Summer 2000/Volume 4. No. 3

Editors’ Comments

table of contents 2 Tom Janisse, MD; Lee Jacobs, MD Permanente Abstracts 5 Abstracts of articles authored or coauthored by Permanente clinicians. Original Research 13 Effect of “Time Famine” on Women’s Self-Care and Household Health Care. Nancy Vuckovic, PhD The author introduces her concept of “time famine” and ties together two elements of contemporary culture: time pressure and pill-taking. She finds evidence that one effect of time pressure is increased use of medicines. 21 Psychiatric Disorders and Functional Disability in Patients with Fibromyalgia. Arne Beck, PhD; George Breth, MD; Rob Hays, MD; Colleen Miller, RNP

On the Cover This study describes the prevalence of current psychiatric disorders and functional disability among a Dr Mohamed Osman, a sample of patients attending a fibromyalgia group clinic in the Rheumatology Department at Kaiser physician with Group Permanente Colorado. Health Cooperative, was born in Somalia; his life Clinical Contributions there is a major influence 29 Management of Libido Problems in Menopause. Jeanne L. Leventhal, MD in his art. Dr Osman, a This article reviews the causes and treatment of the common decrease in sexual activity and satisfaction self-taught artist, credits experienced by many menopausal women. Causes include physiologic changes, depression, decreased his medical knowledge sexual functioning of the partner, and individual cultural or psychological factors. Treatment, which includes with enhancing his art. counseling and medications, needs to be individualized according to the specific identified etiologic factors. His work has appeared in group and solo exhibi- 35 Likelihood That a Woman Will Have No Major Risk Factors At the Time of First tions. A Friday Walk, Myocardial Infarction or Stroke. acrylic, recalls Dr Diana B. Petitti, MD; Stephen Sidney, MD; Charles P. Quesenberry, Jr, PhD; Arthur L. Klatsky, MD Osman’s life in Somalia: A substantial minority of women who experience a first heart attack or stroke do not have known major risk a family heads to the factors, as here documented from Kaiser Permanente hospitalization databases. Age differences in presence golden white beach of the of individual risk factors were also noted, with smoking more prevalent in younger women and hyperten- Indian Ocean, a luxury of sion more prevalent in older women. The data have implications both for clinical evaluation of women with living near a coast. More symptoms and with respect to screening needs for all women. of Dr Osman’s paintings can be seen on pages 8, 39 Kaiser Permanente Medicine 50 Years Ago: The Gynecological Cancer Detection Clinic. 59, and 80. Wilson Footer, MD; Commentary by Steven A. Vasilev, MD, MBA The reprinted 56-year-old article by an early Kaiser Permanente physician shows that Permanente Medicine in the 1940s was clearly on the cutting edge of early diagnosis of gynecologic cancers. The described clinic was one of the few in operation at the time. Dr Vasilev’s accompanying current Commentary authoritatively reviews the history of this topic. He details major technological advances over the past half century as well as ongoing limitations. He points out the needs for more education and more universal application of this If you would like cornerstone of preventive medicine in women’s health. to submit art for consideration Soul of the Healer for the cover of 8 “Dream.” Mohamed Osman, MD The Permanente Journal, 47 In the Shadow of Obesity—Part 1. Eric Blau, MD, FACP please use the following guidelines… 56 Women in Medicine—A Living History. Kate Scannell, MD Send us a high-quality 59 “Life on Mars.” Mohamed Osman, MD color photograph of your art no smaller than 4”x5” 80 “Parental Respect.” Mohamed Osman, MD and no larger than 8”x10”. Portrait orientation is preferred. Health Systems 60 Commentary: Women’s Health—It’s More Than Ob-Gyn. Jill M. Steinbruegge, MD Dr Jill Steinbruegge presents a must-read personal viewpoint on women’s health and concludes by presenting a challenge for the Permanente family in improving “the gender balance among our Permanente workforce and leadership.” 61 Commentary: Kaiser Permanente—Recognizing the Importance of Women. Rhoda Nussbaum, MD Mission... This commentary by Dr Rhoda Nussbaum—a Permanente physician from Northern California and a The Permanente respected national leader in women's health—provides an excellent introduction to the Health Systems’ Journal is written and articles on this subject. published by the clinicians of the 62 Studies of Women’s Health Care: Selected Results. Rhoda Nussbaum, MD Permanente Medical Groups and KFHP to Dr Nussbaum reports on the studies that the Women’s Health Task Force in Northern California has promote the delivery of undertaken to better understand the desires and underlying values of the women members in their region. superior health care 68 Proposed Care Management for Women with Estrogen Deficiency: through the principles Identification, Risk Stratification, and Treatment. Philip J. Tuso, MD, FACP and benefits of Permanente Medicine. Dr Philip Tuso from Southern California describes an information technology process for identifying women who have estrogen deficiency and assist in their management.

External Affairs 74 The Heart of a True Partnership: Dr Oliver Goldsmith Receives Where to find The “Winning Spirit Award for Partnership.” Deidre S. Lind Permanente Journal... A full-text version is With the support of The Southern California Permanente Medical Group (SCPMG) Medical Director, Oliver available on our Web site Goldsmith, MD, a Kaiser Permanente patient and physician teamed up to create a very successful program (www.kaiserpermanente.org/ to improve the care of breast cancer patient. Dr Goldsmith was honored by WIN ABC, a national non-profit permanentejournal.html). organization, with the Winning Spirit Award for Partnership. In addition, copies of the 76 We Have Come a Long Way: Women’s Health at the Turn of the Millennium. Journal are available in M. Jean Gilbert, PhD Kaiser Permanente libraries Programwide. M. Jean Gilbert, former Director of Cultural Competence for the Southern California Region, writes about women’s health care leading up to the new millennium. She discusses the possibilities for the coming decades, and she reviews Kaiser Permanente’s Women’s Healthcare Program. 82 Women’s Health and Federal Policy. Joanne L. Hustead, JD; Donald W. Parsons, MD

Don Parsons, MD, Permanente Federation’s Associate Executive Director of Health Policy and Joanne L. If you have any questions Hustead JD, Director of Legal and Public Policy at the National Partnership for Women and Families, regarding distribution of discuss women’s heath on the federal level. They look at past, present, and future legislation. this journal, please contact Amy Eakin at (503) 813-2623, or Book Reviews e-mail: [email protected] 84 Reviews of literature important to Permanente clinicians.

Announcements How to Contact The 89 Information on topics of interest for Permanente clinicians. Permanente Journal… E-mail us at [email protected] CME Call us at (503) 813-4387 95 Complete this form to receive Category 1 Credit. Fax us at (503) 813-2348

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The Permanente Journal / Summer 2000 / Volume 4 No. 3 Editors’ Comments

A Tribute to Women Tom Janisse, Editor-in-Chief editors’ comments You are holding the first of two Women’s Health issues; the second will be published in the Fall. There was such a large response to our call for articles that the Editorial Team decided to publish the best articles in two successive issues. As you read these research studies, programs, initiatives, and systems innovations, and view the paintings, photographs and other visuals, you will learn much that is transferable to all of your patients. We are privileged as an organization to have women so prominent and successful in the fields of clinical medicine, research and leadership to be able to present such exemplary knowledge, practice, and wisdom. This will be of great benefit to ourselves, our members, and our communities both local and national. Congratulations to the women we feature and to the women we serve. Women’s Health Center The concept of “Women’s Health” as a realizable future alternative to conventional health care for women exists only by understanding several key components and by achieving a new perspective. Primarily, enhanced care for women will not be achieved by erecting a new building to house a Women’s Health Center. Neither will it be achieved through an institutional icon; through advances in technology; through tertiary services; through expanded well-analyzed data sets; through singular or insular treatment approaches delivered by an impersonal scientist; or through advancements in traditional medical science. Clinicians will, however, be more sensitive to women and will exhibit enhanced commu- nication and relationship skills. In our process to describe the future, we must first ask women what they want and listen to them, before we mistakenly build a future on the basis of our current assumptions about them from a biomedical model. What women have suggested so far in focus groups of members, in meetings of clinicians, and in the recent literature looks and sounds alternative. A spectrum of approaches and activities are necessary from convenience to holism. Focus first on common needs and concerns. Deliver services close to home, in one place. Don’t make a woman drive all over town to each specialist’s office. Care should be multidisciplinary and delivered or coordinated as much as possible at one visit in a women’s health module. For example, just as two surgeons from different departments arrange their time to perform an operation and look into the belly together, two specialists could arrange a visit to look into a woman’s health concern together. In a variation of this scenario, some would even prefer a group setting with other women to socialize and exchange stories and advice. And it is important to remember that women’s health begins when they are young girls. Compartmentalizing their care within department boundaries is artificial and better serves providers of care than recipients. Kaiser Permanente has been developing the “capability” of delivering advanced women’s health care for several years. This capability—a connected set of activities and competencies—resides in our integrated system and in people and processes. It represents a women’s health “center” that exists in many sites; through many services; in many relationships; and in the attitudes, perspectives, and interpersonal skills of many clinicians and ancillary providers. This will be a center “without walls” as exemplified by the personal health knowledge a registering medical assistant will have by accessing a woman’s electronic medical record in any facility. The woman, as individual, will be “the center” of her health care. The center will not be a structure into which The woman, as she seeks service. It will be a primary care center rather than a tertiary care center. A primary care doctor and team will individual, will be lead the coordination of her care. She will not receive expert medical advice at the end of a long string of visits that have “the center” of ignored psychological, social, behavioral, familial, or environmental factors. These will be assessed initially as “emo- her health care. tional vital signs” and be taken with the physical vital signs. When clinicians recommend that geriatric women go to the local health club for exercise, we will recognize their loss of dizziness, improved balance, less painful knees, and normalizing blood sugar as advanced health care practice rather than an off-handed suggestion about which medical science doesn’t concern itself. We will recognize that the social encounter she had with several other elderly women was one of the most potent components in improving her physiology, because she learned that others have similar maladies and that they have overcome them with simple methods they taught her. As well, she will be versed in self-care through easily available education, materials, printed and electronic resources that are readily accessible, carefully researched, and reader-friendly. Clinicians will consider alternative options and will recognize cultural diversity and preferences. Similarly, quick referral by her primary care physician to an acupuncturist for relief of chronic nasal congestion, or to a massage

2 The Permanente Journal / Summer 2000 / Volume 4 No. 3 editors’ comments

therapist for lumbar strain, or to a naturopath for an herbal tea to help her sleep will become common practice and be recognized as advances in women’s health care. As we continue to develop the women’s health center capability as a program, and it becomes increasingly recognized, the women in our preferred market segments will stay with our system, and others will join us. Because these women make many of the health care decisions for their family, we gain their husbands and children as members. These women will influence other women with whom they are friends, in their neighborhoods, in their churches, in their gatherings, and in their workplaces. Women will also influence their husbands, fathers and sons to appreciate a more holistic, balanced approach to their treatment. In this discovery and creation process, impersonal medical care will become personal health care. ❖

Women’s Health: Permanente Medicine Lee Jacobs, MD, Associate Editor, Health Systems I was reminded again at a recent Infectious Disease meeting of the global importance of women’s health. The continued increasing AIDS incidence for women in the United States is striking. Especially alarming is the worldwide statistic that out of 16,000 new HIV infections each day in 1997, 40% were women. How about the fact that the cumulative number of children orphaned by AIDS worldwide is 11.2 million? How discouraging is it to see the continued high incidence of perinatal transmission of HIV from mother to infants in other countries when we know that with treatment it is preventable? We have documented evidence that breast-feeding increases the transmission of HIV to infants, but third-world mothers are placed in a Catch-22 since the death rate from diarrhea is so very high if they don't breast-feed. Certainly women's health in the United States and around the world, especially related medical, social and ethical issues, deserve special attention. For that reason we are dedicating the next two issues of The Permanente Journal to this very important topic. It is not just a popular topic-of-the-month. No, it is right at the core of Permenante Medicine as we are always seeking to better understand the evidence-based approach to the care of a population of people. Too often the women’s health focus in the community is based solely on economics. Such is not the case for Permanente. In the Health Systems section of this edition, we present several articles on women’s health that are represen- tative of the type of work that is taking place throughout Kaiser Permanente. Dr Jill Steinbruegge shares personal observations on women’s health and then presents the challenge to Permanente Medical Groups to address the gender gap in leadership. Dr Rhoda Nussbaum’s introductory commentary and her article summa- rizing the work of the Women’s Health Task Force in Northern California sets the agenda for the articles that follow. Dr Philip Tuso’s article on an estrogen replacement anchors this issue with articles on breast cancer and mobile mammography to follow in the second part of the series on women's health issues which will appear in Fall 2000 edition of The Permanente Journal. I hope you enjoy your reading of the work that your Permanente colleagues are doing. As always, we invite your articles and comments for future publication. ❖

Coming in the next issue ... Focus on Women’s Health—Part 2

Uterine Artery Embolization for the Treatment of Uterine Fibroids Perimenopausal Mood Problems Sex Differences in Coronary Hospitalizations Mobile Mammography: Providing Service to the Hard-to-Reach Woman Improving Breast Care In the Shadow of Obesity—Part 2 ... and more

The Permanente Journal /Summer 2000 / Volume 4 No. 3 3 Letters to the Editor

To the Editor.—I enjoyed reading the Spring 2000 issue of the Journal, especially the Editor’s Comments. I would like to speak in more detail about another article on page 57 entitled “Emergency Contraception Research and Demonstration Project.” As a member of the Ethics Committee at Kaiser Permanente Santa letters to the editor Clara, I think a more accurate description of the effects of the hormones administered to the patients in the study is necessary. Attempts at contraception after intercourse with hormone therapy could potentially block the sperm’s passage through the cervix, prevent sperm migration to the ovum in the distal Fallopian tube, or prevent sperm capacitation (cleavage to and penetration of the ovum). Studies show that, at peak phase during ovulation, it takes an average of 90 seconds for the sperm to penetrate the cervix and another four to five minutes to reach the distal Fallopian tube with capacitation following a short time later. Due to the usual delay in taking emergency contraceptive pills (ECP) none of these potential effects would take place in a timely fashion. Use of the hormones would, however, increase the transport time of the embryo to the uterine cavity by reducing tubal motility and prevent implantation of the embryo into the uterine wall. Wyeth’s data on the estrogenic component of the ECPs do not demonstrate any convincing evidence that ECPs prevent ovulation in this situation. In spite of ACOG’s recent change in terminology, conception takes place at fertilization, usually in the distal tube, and not at implantation. I agree that ECPs will reduce the number of unplanned pregnancies from unprotected intercourse but what the patient has the right to know is that this is not a contraceptive but an abortifacient effect of ECPs. As with other medications, procedures, and treatments, the patient has a right to—and we have a legal and ethical obligation to—informed consent. Dave Hammons, MD Kaiser Permanente, Santa Clara, CA

In Reply.—Dr Hammons correctly describes the several mechanisms of action of hormonal EC. These mechanisms are described in the Provider Service Manual, in the patient information brochure, and in the Healthphone script developed by the Project. The Provider Service Manual contained the following statement (p. 4) about these mechanisms of action: “….since some people will consider interference with a fertilized, not yet implanted egg as an induced abortion, the potential mode of action must be made clear to all members who might elect this treatment.” (p. 4) and the following recommendations to providers (p. 6) about counseling: “Due to various definitions of pregnancy and abortion, the mode of action should be clearly explained to members as part of their decision-making process.” (p. 6) In the patient brochure, the statement below follows the description of the mechanisms of action of ECPs: “Because a fertilized egg may be prevented from growing by this treatment, ECPs are considered an abortion by some people. If you would not use a treatment that would interfere with an already fertilized egg, then ECPs may not be a good choice for you.” Finally, providers who considered ECPs to be abortion were permitted to opt out of providing of ECPs. The EC Research and Demonstration Project was grounded in respect for differences in beliefs about abortion, and took seriously the obligation to provide information about ECPs that would permit informed decision-making. Diana Petitti, MD Kaiser Permanente, Pasadena, CA

4 The Permanente Journal /Summer 2000 / Volume 4 No. 3 permanente abstracts Permanente Abstracts

An HMO Survey on Mass Customization of ber, mental illness of a household member). Healthcare Delivery for Women RESULTS: More than 45% of the women reported Thompson M, Nussbaum R. Womens Health Issues 2000 that their first pregnancy was unintended, and 65.8% Jan-Feb;10(1):10-9. reported exposure to two or more types of child- A telephone survey of 1000 randomly selected hood abuse or household dysfunction. After women members of Kaiser Permanente examined adjustment for confounders (marital status at first preferences for care delivery. The majority of women pregnancy and age at first pregnancy), the strongest under age 55 years (80%) were interested in sched- associations between childhood experiences and uling evening or Saturday appointments, and half unintended first pregnancy included frequent psy- (50%) of them were willing to switch doctors for this chological abuse (risk ratio [RR], 1.4; 95% confidence option. Although most (57%) said that physician gen- interval [CI], 1.2-1.6), frequent physical abuse of the der “did not matter,” women who preferred to see a mother by her partner (RR, 1.4; 95% CI, 1.1-1.7), and female physician but were seeing a male were sig- frequent physical abuse (RR, 1.5; 95% CI, 1.2-1.8). nificantly less satisfied than women whose Women who experienced four or more types of abuse preferences were matched. Half (51%) of women during their childhood were 1.5 times (95% CI, 1.2- were open to receiving health education in group 1.8) more likely to have an unintended first pregnancy classes. Information on when care is preferred, by during adulthood than women who did not experi- whom, and in what setting sets the stage for mass ence any abuse. customization strategies. CONCLUSIONS: This study indicates that there may be Reprinted with permission from the Jacobs Institute of Women’s a dose-response association between exposure to Health, Womens Health Issues 2000 Jan-Feb;10(1):10-9. childhood abuse or household dysfunction and un- intended first pregnancy in adulthood. Additional Unintended Pregnancy among Adult Women research is needed to fully understand the causal Exposed to Abuse or Household Dysfunction pathway of this association. During Their Childhood Copyrighted 1999, American Medical Association. Dietz PM, Spitz AM, Anda RF, Williamson DF, McMahon PM, Santelli JS, et al. JAMA 1999 Oct 13;282(14):1359-64. Osteoporosis: Risk Factor Prevalence and CONTEXT: Studies have identified childhood sexual Drug and Densitometry Utilization and physical abuse as a risk factor for adolescent Binstock M. Obstet Gynecol 2000 Apr 1;95(4 Suppl pregnancy but the relationship between exposure to 1):S50. childhood abuse and unintended pregnancy in adult- OBJECTIVE: To evaluate the prevalence of selected hood has, to our knowledge, not been studied. risk factors for postmenopausal osteoporosis, use of OBJECTIVE: To assess whether unintended pregnancy bone protective medications, and utilization of bone during adulthood is associated with exposure to psy- densitometry (DXA). chological, physical, or sexual abuse or household METHODS: Computerized records on demographics, dysfunction during childhood. medications dispensed, diagnostic/procedure sum- DESIGN AND SETTING: Analysis of data from the Ad- mary lists, and radiology files for 33,662 women more verse Childhood Experiences Study, a survey mailed than age 50 years who were current members of a to members of a large health maintenance organiza- health maintenance organization were merged and tion who visited a clinic in San Diego, CA, between analyzed. August and November 1995 and January and March RESULTS: Overall, 4733 (14%) women had recently 1996. The survey had a 63.4% response rate among been dispensed one or more bone protective medi- the target population for this study. cations: estrogens conjugated, 4625 (13.7%); all other PARTICIPANTS: A total of 1193 women aged 20 to 50 estrogens, 578 (2%); alendronate, 240 (1%); calcito- years whose first pregnancy occurred at or after age nin, 499 (1%); etidronate disodium, 58 (1%); 20 years. raloxifene, 82 (<1%); tamoxifen, 445 (1%). There were MAIN OUTCOME MEASURE: Risk of unintended first 14,668 (44%) who had one or more selected risk fac- pregnancy by type of abuse (psychological, physi- tors: current cigarette smoking, 7607 (23%); weight cal, or sexual abuse; peer sexual assault) and type of less than 125 lb, 3522 (11%); high-dose steroid use, household dysfunction (physical abuse of mother by 81 (<1%); on thyroid replacement, 3227 (9.6%); her partner, substance abuse by a household mem- chronic renal failure, 221 (1%); vertebral fractures,

The Permanente Journal / Summer 2000 / Volume 4 No. 3 5 208 (<1%); fracture of pelvis, 88 (<1%); femoral neck bacco dependency are needed to correct this situa- fractures, 240 (1%); on antiseizure medication, 177 tion. Long-term use of nicotine has been linked with (<1%); and on benzodiazepam or lithium, 1145 (3%). self-medicating efforts to cope with negative emo- Bone protective drug use was 17% in those with risk tional, neurobiological, and social effects of adverse permanente abstracts factors and 13% in those with none. Prior DXA was childhood experiences. performed in 2.0% of those with risk factors and in OBJECTIVE: To assess the relationship between ad- 1% of those without risk factors. verse childhood experiences and five smoking CONCLUSIONS: In this population (probably not unlike behaviors. other populations), despite high prevalence of os- DESIGN: The ACE Study, a retrospective cohort sur- teoporosis risk factors, DXA screening utilization is low vey including smoking and exposure to eight (<2%), as is use of bone protective medications (14%). categories of adverse childhood experiences (emo- Reprinted with permission from the American College of Obstetricians tional, physical, and sexual abuse; a battered mother; and Gynecologists Obstet Gynecol, 2000 April; 95(4 Suppl 1):S50. parental separation or divorce; and growing up with a substance-abusing, mentally ill, or incarcerated Diagnosis of Symptomatic Postmenopausal household member), conducted from August to No- Women by Traditional Chinese Medicine vember 1995 and January to March 1996. Practitioners SETTING: A primary care clinic for adult members of a Zell B, Hirata J, Marcus A, Ettinger B, Pressman A, large health maintenance organization in San Diego, CA. Ettinger KM. Menopause 2000 Mar-Apr;7(2):129-34. PARTICIPANTS: A total of 9215 adults (4958 women OBJECTIVE: To learn more about the way that practi- and 4257 men with mean [SD] ages of 55.3 [15.7] and tioners of traditional Chinese medicine (TCM) 58.1 [14.5] years, respectively) who responded to a diagnose women who have menopausal symptoms. survey questionnaire, which was mailed to all pa- DESIGN: We assembled a cohort of 23 postmeno- tients one week after a clinic visit. pausal women who had hot flushes and who were MAIN OUTCOME MEASURES: Smoking initiation by age otherwise healthy. Each woman was examined inde- 14 years or after age 18 years, and status as ever, pendently by nine practitioners of TCM on the same current, or heavy smoker. day. Examination consisted of medical history and RESULTS: At least one of eight categories of ad- physical examination. Diagnoses were recorded and verse childhood experiences was reported by 63% counted. of respondents. After adjusting for age, sex, race, RESULTS: The most frequent diagnosis made by the and education, each category showed an increased practitioners of TCM was kidney yin deficiency, which risk for each smoking behavior, and these risks were was the diagnosis made after 168 of 207 visits (81%); comparable for each category of adverse childhood 23 women seen by nine TCM practitioners. Practitio- experiences. Compared with those reporting no ners showed good agreement regarding presence of adverse childhood experiences, persons reporting kidney yin deficiency: in 12 women (52%), this diag- five or more categories had substantially higher risks nosis was made by eight of nine practitioners; in 16 of early smoking initiation (odds ratio [OR], 5.4; 95% women (70%), seven of nine practitioners made this confidence interval [CI], 4.1-7.1), ever smoking (OR, diagnosis; and in all 23 women (100%), at least five 3.1; 95% CI, 2.6-3.8), current smoking (OR, 2.1; 95% of nine practitioners made this diagnosis. CI, 1.6-2.7), and heavy smoking (OR, 2.8; 95% CI, CONCLUSIONS: Practitioners of TCM who diagnose 1.9-4.2). Each relationship between smoking behav- postmenopausal women with vasomotor symptoms ior and the number of adverse childhood are likely to make a diagnosis that includes kidney experiences was strong and graded (P < .001). For yin deficiency. any given number of adverse childhood experiences, recent problems with depressed affect were more Adverse Childhood Experiences and Smoking common among smokers than among nonsmokers. During Adolescence and Adulthood CONCLUSIONS: Smoking was strongly associated with Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, adverse childhood experiences. Primary prevention Williamson DF, et al. JAMA 1999 Nov 3;282(17):1652-8. of adverse childhood experiences and improved treat- CONTEXT: In recent years, smoking among adoles- ment of exposed children could reduce smoking cents has increased and the decline of adult smoking among both adolescents and adults. has slowed to nearly a halt; new insights into to- Copyrighted 1999, American Medical Association.

6 The Permanente Journal / Summer 2000 / Volume 4 No. 3 permanente abstracts

Efficacy, Safety and Immunogenicity of Neonatal Assisted Ventilation: Predictors, Heptavalent Pneumococcal Conjugate Vaccine Frequency, and Duration in a Mature in Children. Northern California Kaiser Managed Care Organization Permanente Vaccine Study Center Group Wilson A, Gardner MN, Armstrong MA, Folck BF, Escobar Black S, Shinefield H, Fireman B, Lewis E, Ray P, Hansen JR, et al. GJ. Pediatrics 2000 Apr;105(4 Pt 1):822-30. Pediatr Infect Dis J 2000 Mar;19(3):187-95. OBJECTIVE: Reference data are lacking on the fre- OBJECTIVE: To determine the efficacy, safety and quency and duration of assisted ventilation in neonates. immunogenicity of the heptavalent CRM197 pneu- This information is essential for determining resource mococcal conjugate vaccine against invasive disease needs and planning clinical trials. As mortality becomes caused by vaccine serotypes and to determine the uncommon, ventilator utilization is increasingly used effectiveness of this vaccine against clinical episodes as a measure for assessing therapeutic effect and quality of otitis media. of care in intensive care medicine. Valid comparisons METHODS: The Wyeth Lederle Heptavalent CRM197 require adjustments for differences in a patient’s (PCV) was given to infants at 2, 4, 6 and 12 to 15 baseline risk for assisted ventilation and prolonged months of age in a double-blind trial; 37,868 chil- ventilator support. The aims of this study were to de- dren were randomly assigned 1:1 to receive either termine the frequency and length of ventilation (LOV) the pneumococcal conjugate vaccine or meningo- in preterm and term infants and to develop models coccus type C CRM197 conjugate. The primary study for predicting the need for assisted ventilation and outcome was invasive disease caused by vaccine length of ventilator support. serotype. Other outcomes included overall impact METHODS. We performed a retrospective, popula- on invasive disease regardless of serotype, effec- tion-based cohort study of 77,576 inborn live births tiveness against clinical otitis media visits and at six Northern California hospitals with level-three episodes, impact against frequent and severe otitis intensive care nurseries in a group-model managed media and ventilatory tube placement. In addition care organization. The gestational age-specific fre- the serotype-specific efficacy against otitis media quency and duration of assisted ventilation among was estimated in an analysis of spontaneously drain- surviving infants was determined. Multivariable re- ing ears. gression was performed to determine predictors for RESULTS: In the interim analysis in August 1998, 17 assisted ventilation and LOV. of the 17 cases of invasive disease caused by vaccine RESULTS. Of 77,576 inborn live births in the study, serotype in fully vaccinated children and five of five 11,199 required admission to the neonatal intensive partially vaccinated cases occurred in the control care unit, and of these, 1928 survivors required ven- group for a vaccine efficacy of 100%. Blinded case tilator support. The proportion of infants requiring ascertainment was continued until April 1999. As of assisted ventilation and the median LOV decreased that time 40 fully vaccinated cases of invasive dis- markedly with increasing gestational age. In addi- ease caused by vaccine serotype had been identified, tion to gestational age, admission illness severity, all but one in controls for an efficacy of 97.4% (95% five-minute Apgar scores, presence of anomalies, male confidence interval, 82.7 to 99.9%), and 52 cases, all sex, and white race were important predictors for but three in controls in the intent-to-treat analysis for the need for assisted ventilation. The ability of the an efficacy of 93.9% (95% confidence interval, 79.6 models to predict need for ventilation was high, and to 98.5%). There was no evidence of any increase of significantly better than birth weight alone with an disease caused by nonvaccine serotypes. Efficacy for area under the receiver operating characteristic curve otitis media against visits, episodes, frequent otitis of .90 versus .70 for preterm infants, and .88 versus and ventilatory tube placement was 8.9, 7.0, 9.3 and .50 for term infants. For preterm infants, gestational 20.1% with P < 0.04 for all. In the analysis of sponta- age, admission illness severity, oxygenation index, neously draining ears, serotype-specific effectiveness anomalies, and small-for-gestational age status were was 66.7%. significant predictors for LOV, accounting for 60% of CONCLUSION: This heptavalent pneumococcal con- the variance in the length of assisted ventilation. For jugate appears to be highly effective in preventing term infants, oxygenation index and anomalies were invasive disease in young children and to have a significant predictors but only accounted for 29% of significant impact on otitis media. the variance.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 7 soul of the healer

“Dream” by Mohamed Osman, MD An expression of a content, quasi happy face in a sleeping woman voyaging through space and time.

8 The Permanente Journal / Summer 2000 / Volume 4 No. 3 permanente abstracts

CONCLUSIONS. Considerable variation exists in the uti- the male patient base in 1996, reflecting the more fre- lization of ventilator support among infants of closely quent occurrence of UTI in uncircumcised males (132 related gestational age. In addition, a number of medi- episodes) than in circumcised males (22 episodes) and cal risk factors influence the need for, and length of, the larger number of hospital admissions in uncircum- assisted ventilation. These models explain much of cised males (38) than in circumcised males (four). The the variance in LOV among preterm infants but ex- incidence of UTI in the first year of life was 1:47 (2.15%) plain substantially less among term infants. in uncircumcised males, 1:455 (.22%) in circumcised Reproduced by permission of Pediatrics, 2000 Apr;105(4 Pt 1):822- males, and 1:49 (2. 05%) in females. The odds ratio of 30. Copyright 2000. UTI in uncircumcised:circumcised males was 9.1:1. CONCLUSIONS. Newborn circumcision results in a 9.1- Newborn Circumcision Decreases Incidence fold decrease in incidence of UTI during the first year and Costs of Urinary Tract Infections of life as well as markedly lower UTI-related medical During the First Year of Life costs and rate of hospital admissions. Newborn cir- Schoen EJ, Colby CJ, Ray GT. Pediatrics 2000 Apr;105(4 Pt 1):789-93. cumcision during the first year of life is, thus, a valuable OBJECTIVE: To assess the effect of newborn circum- preventive health measure, particularly in the first three cision on the incidence and medical costs of urinary months of life, when uncircumcised males are most tract infection (UTI) during the first year of life for likely to be hospitalized with severe UTI. patients in a large health maintenance organization. Reproduced by permission of Pediatrics, Vol 105, 789-93, Copy- SETTING. Kaiser Permanente Medical Care Program right 2000. of Northern California (KPNC). PATIENTS. The population consisted of members of The Highly Protective Effect of Newborn KPNC. The study group consisted of a cohort of 28,812 Circumcision Against Invasive Penile Cancer infants delivered during 1996 at KPNC hospitals; of Schoen EJ, Oehrli M, Colby Cd, Machin G. Pediatrics the 14,893 male infants in the group, 9668 (64.9%) 2000 Mar;105(3):E36. were circumcised. A second cohort of 20,587 infants OBJECTIVE: We determined the relation between new- born in 1997 and monitored for 12 months was ana- born circumcision and both invasive penile cancer lyzed to determine incidence rates. (IPC) and carcinoma in situ (CIS) among adult male DESIGN. Retrospective study of all infants consecu- members of a large health maintenance organization. tively delivered at 12 facilities. SUBJECTS AND METHODS: Circumcision status was as- OUTCOME MEASURES. Diagnosis of UTI was deter- certained by a combination of pathology reports, mined from the KPNC computerized database using medical record review, and questionnaires for 213 the International Classification of Diseases, Ninth adult male members of a large prepaid health plan Revision code for inpatients and KPNC Outpatient who were diagnosed with IPC or CIS. Summary Clinical Record codes for outpatients. A RESULTS: Of 89 men with IPC whose circumcision sample of 52 patient charts was reviewed to confirm status was known, two (2.3%) had been circumcised the International Classification of Diseases, Ninth as newborns, and 87 were not circumcised. Of 118 Revision and KPNC Outpatient Summary Clinical men with CIS whose circumcision status was known, Record codes and provide additional data. 16 (15.7%) had been circumcised as newborns. RESULTS. Infants <1 year old who were born in 1996 CONCLUSIONS: Our results confirm the highly protec- had 446 UTIs (292 in females; 154 in males); 132 (86%) tive effect of newborn circumcision against IPC and of the UTIs in males occurred in uncircumcised boys. the less protective effect against CIS. The mean total cost of managing UTI was two times as Reproduced by permission of Pediatrics, Vol 105(3), E36, Copy- high in males ($1111) as in females ($542). This higher right 2000. total cost reflected the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared Optimizing Treatment of Dyslipidemia in with females (7.5%); mean age at hospitalization for Patients with Coronary Artery Disease in the UTI was 2.5 months old for uncircumcised boys and Managed-Care Environment (the Rocky 6.5 months old for girls. In 1996, total cost of managing Mountain Kaiser Permanente Experience) UTI in uncircumcised males ($155,628) was ten times Merenich JA, Lousberg TR, Brennan SH, Calonge NB. Am higher than for circumcised males ($15,466) despite the J Cardiol 2000 Feb 10;85(3A):36A-42A. fact that uncircumcised males made up only 35.1% of Rocky Mountain Kaiser Permanente has taken aggres-

The Permanente Journal / Summer 2000 / Volume 4 No. 3 9 sive steps to ensure optimal treatment of all modifiable eligible members of a large not-for-profit health main- cardiac risk factors, especially low-density lipoprotein tenance organization who responded to a 1997 survey. (LDL) cholesterol, in patients with coronary artery dis- We tested associations among demographic, treatment,

ease. In this article, we are presenting (1) the basic and psychometric variables with mean 1997 HbA1c val- permanente abstracts rationale for our approach, (2) the critical steps translat- ues. The Problem Areas in Diabetes (PAID) instrument ing philosophy into practice, and (3) justification for all was used to assess the emotional effect of living with health plans to pursue a similar course. The continuum diabetes, and the Short Form 12 Physical Function Scale of physician-directed disease management systems that was used to assess the effect of physical limitations on have evolved in our region—one administered by car- daily activities. Based on differences between and within diology nurses in the perihospitalization period and the treatment groups, we built models to predict glycemic other by pharmacists in the long-term, outpatient set- control for subgroups of subjects who were using insu- ting—is then detailed. Although the relatively short lin alone and those who were using insulin in duration that our comprehensive systems have been in combination with an oral hypoglycemic agent. place precludes any assessment of their impact on car- RESULTS: Younger age, lower BMI, and increased emo- diac death, coronary artery disease events, or coronary tional distress about diabetes (according to the PAID artery disease procedure rates, the improvements in scale) were all significant predictors (P < 0.05) of worse intermediate surrogate outcomes are promising. Virtu- glycemic control. However, except among individuals

ally all surveyed patients participating in our with an HbA1c level of > 8.0 who were receiving com- management systems have been “very” or “extremely” bination therapy, only ~10% of the variance in glycemic satisfied with their experience. The LDL-cholesterol control could be predicted by demographic, treatment, screening rate in the approximately 2500 participants or psychometric characteristics. in the programs to date has reached 97%. Of these CONCLUSIONS: Personal characteristics explain little patients, 84% have LDL cholesterol <130 mg/dL and of the variation in glycemic control in insulin-using 48% <100 mg/dL, and only 15% of those few with LDL adults with type 2 diabetes. Possible explanations cholesterol >130 mg/dL (2.5% overall) are currently not are that the reduced complexity of control in type 2 receiving lipid-lowering therapy. The proportions of diabetes makes the disease less sensitive to personal patients on aspirin/antiplatelet and beta-blocker therapy factors than control in type 1 diabetes, that health- after myocardial infarction are 97% and 92%, respec- related behavior is less driven by personal and tively. The lipid-screening and treatment rates, especially, environmental characteristics among older individu- represent significant improvement from our own als, or that, in populations exposed to aggressive baseline, and compare favorably with outcomes from glycemic control with oral hypoglycemic agents and other practice settings. In conclusion, health mainte- nurse care managers, personal differences become nance organizations have tremendous incentive and the largely irrelevant. unique opportunity and ability to develop systems to Copyrighted by the American Diabetes Association. better manage large numbers of individuals with coro- nary artery disease. The Treatment of Anxiety Disorders in a Reprinted from the American Journal of Cardiology, Merenich JA; Primary Care HMO Setting Lousberg TR; Brennan SH; Calonge NB, Optimizing treatment of Price D, Beck A, Nimmer C, Bensen S, Psychiatr Q 2000 dyslipidemia in patients with coronary artery disease in the man- Spring;71(1):31-45. aged-care environment (the Rocky Mountain Kaiser Permanente Anxiety disorders are common, yet under diag- experience), 36A-42A, Copyright 2000, with permission from nosed, in primary care settings. Many patients with Excerpta Medica Inc. anxiety and other psychiatric disorders do not seek care in mental health care settings. An integrated Predictors of Glycemic Control in Insulin- primary care/mental health model offers one ap- Using Adults with Type 2 Diabetes proach to improving outcomes for patients with Nichols GA, Hillier TA, Javor K, Brown JB. Diabetes Care anxiety disorders. This model has been researched 2000 Mar; 23(3):273-7. for the treatment of depression with positive results OBJECTIVE: To determine the characteristics that in- but has not been well studied for the treatment of fluence glycemic control among insulin-using adults anxiety disorders. We describe the results of care for with type 2 diabetes. a cohort of adult patients with Generalized Anxiety RESEARCH DESIGN AND METHODS: We studied all 1333 Disorder (GAD) and clinically significant anxiety sec-

10 The Permanente Journal / Summer 2000 / Volume 4 No. 3 permanente abstracts

ondary to Major Depressive Disorder (MDD) treated California, between July 1995 and June 1996 (N = in an integrated model. Compared to a matched co- 2,076,303), the authors estimated the prevalence, hort of adults treated in a primary care setting with average annual costs per person, and percentage of usual care, the intervention cohort experienced sig- total direct medical expenditures attributable to each nificantly improved reduction in symptoms of anxiety of 25 chronic and acute conditions. Ordinary least at six months. The intervention cohort also was sig- squares regression was used to adjust for age, gen- nificantly more satisfied with care. der, and comorbidities. The costs attributable to the 25 conditions accounted for 78 percent of the health The Cost-Effectiveness of Mind-Body Medicine maintenance organization’s total direct medical ex- Interventions pense for this age-group. Injury accounted for a higher Sobel DS. Prog Brain Res 2000;122:393-412. proportion (11.5 percent) of expenditures than any Evidence is mounting that addressing the psycho- other single condition. Three cardiovascular condi- social needs of patients makes economic and health tions—ischemic heart disease, hypertension, and sense. If there were a drug or surgical procedure that congestive heart failure—together accounted for 17 could reduce ambulatory care visits, decrease post- percent of direct medical expense and separately surgical length of stay, reduce c-section rates, or accounted for 6.8 percent, 5.7 percent, and 4.0 per- decrease death rates from cancer, this medical inter- cent, respectively. Renal failure ($22,636), colorectal vention would be widely accepted and utilized with cancer ($10,506), pneumonia ($9499), and lung can- little hesitation. The beliefs and biases that delay and cer ($8612) were the most expensive conditions per retard the use of psychosocial interventions need to person per year. be challenged (Engel, 1977; Williamson et al, 1991). Copyright © 2000 by Medical Care Research and Review (MCR). This brief review of mind-body interventions sug- Reprinted by Permission of Sage Publications, Inc. gests that health care providers can ill afford to treat patients simply as disordered machines whose health Controlled Trials of CQI and Academic can be restored with physical or chemical interven- Detailing to Implement a Clinical Practice tions alone. Indeed, a burgeoning interest in Guideline alternative and complementary medicine with a fo- for Depression cus on non-drug, non-surgical interventions as well Brown JB, Shye D, McFarland BH, Nichols GA, Mullooly as the exploding field of lay literature and self-help JP, Johnson RE. Jt Comm J Qual Improv 2000 groups suggests that many patients are ready, will- Jan;26(1):39-54. ing, and even demanding that mind-body health BACKGROUND: The release of the Agency for Health Care techniques be considered as part of health care (Fried- Policy and Research (AHCPR)’s Guideline for the Detec- man et al, 1997). While the health care system cannot tion and Treatment of Depression in Primary Care created be expected to address all the psychosocial needs of an opportunity to evaluate under naturalistic conditions people, clinical intervention can be brought into bet- the effectiveness of two clinical practice guideline imple- ter alignment with the emerging evidence on the mentation methods: continuous quality improvement health and cost-effectiveness of mind-body interven- (CQI) and academic detailing. A study conducted in 1993- tions. Mind-body medicine is not something separate 1994 at Kaiser Permanente Northwest Division, a large, or peripheral to the main tasks of medical care but not-for-profit prepaid group practice (group-model) HMO, should be an integral part of evidence-based, cost- tested the hypotheses that each method would increase effective, quality health care. the number of members receiving depression treatment Reprinted from Sobel DS, Progressive Brain Research, Copyright and would relieve depressive symptoms. 2000, 393-412, with permission from Elsevier Science. METHODS: Two trials were conducted simultaneously among adult primary care physicians, physician assis- The Cost of Health Conditions in a Health tants, and nurse practitioners, using the same guideline Maintenance Organization document, measurement methods, and one-year fol- Ray GT, Collin F, Lieu T, Fireman B, Colby CJ, low-up period. The academic detailing trial was Quesenberry CP, et al. Med Care Res Rev 2000 randomized at the clinician level. CQI was assigned to Mar;57(1):92-109. one of the setting’s two geographic areas. To account In this retrospective cohort analysis of all adults for intraclinician correlation, both trials were evalu- who were members of Kaiser Permanente, Northern ated using generalized equations analysis.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 11 RESULTS: Most of the CQI team’s recommendations pulmonary disease, cerebral vascular accident, can- were not implemented. Academic detailing increased cer, diabetes, anxiety, or need for wound care were treatment rates, but—in a cohort of patients with prob- eligible for random assignment to intervention (n = able chronic depressive disorder—it failed to improve 102) or control (n = 110) groups.

permanente abstracts symptoms and reduced measures of overall functional INTERVENTION: The control and intervention groups status. received routine home health care (home visits and CONCLUSIONS: New organizational structures may be telephone contact). The intervention group also had necessary before CQI teams and academic detailing access to a remote video system that allowed nurses can substantially change complex processes such as and patients to interact in real time. The video system the primary care of depression. New research and treat- included peripheral equipment for assessing cardiop- ment guidelines are needed to improve the ulmonary status. management of persons with chronic or recurring major MAIN OUTCOME MEASURES: Three quality indicators depressive disorder. (medication compliance, knowledge of disease, and © Joint Commission: Journal on Quality Improvement. Oakbrook ability for self-care); extent of use of services; degree Terrace, IL: Joint Commission on Accreditation of Healthcare Or- of patient satisfaction as reported on a three-part scale; ganizations, 2000, 39-54. Reprinted with permission. and direct and indirect costs of using the remote video technology. Outcomes of the Kaiser Permanente Tele- RESULTS: No differences in the quality indicators, Home Health Research Project patient satisfaction, or use were seen. Although the Johnston B, Wheeler L, Deuser J. Sousa KH; Arch Fam average direct cost for home health services was $1830 Med 2000 Jan;9(1):40-5. in the intervention group and $1167 in the control CONTEXT: Level of acuity and number of referrals group, the total mean costs of care, excluding home for home health care have been escalating exponen- health care costs, were $1948 in the intervention group tially. As referrals continue to increase, health care and $2674 in the control group. organizations are encouraged to find more effective CONCLUSIONS: Remote video technology in the home methods for providing high-quality patient care with health care setting was shown to be effective, well cost savings. received by patients, capable of maintaining quality OBJECTIVE: To evaluate the use of remote video tech- of care, and to have the potential for cost savings. nology in the home health care setting as well as the Patients seemed pleased with the equipment and the quality, use, patient satisfaction, and cost savings from ability to access a home health care provider 24 hours this technology. a day. Remote technology has the potential to effect DESIGN: Quasi-experimental study conducted from cost savings when used to substitute some in-person May 1996 to October 1997. visits and can also improve access to home health SETTING: Home health department in the Sacramento, care staff for patients and caregivers. This technology CA, facility of a large health maintenance organization. can thus be an asset for patients and providers. PARTICIPANTS: Newly referred patients diagnosed as Copyrighted 2000, American Medical Association. having congestive heart failure, chronic obstructive

A Simple Way Some say that art is a complicated way of saying very simple things, but we know that art is a simple way of saying very complex things. Jean Cocteau, 1889-1963, French filmmaker, dramatist, poet and novelist

12 The Permanente Journal / Summer 2000 / Volume 4 No. 3 By Nancy Vuckovic, PhD

original research Effect of “Time Famine” on Women’s Self-Care and Household Health Care

The experience of “time famine” in contemporary American culture af- Qualitative Research Methodology fects women’s decisions about self-care and their use of pharmaceutical agents Forty households residing in and near a for self-medication. This paper examines the manner in which time demands midsized city in the southwestern United shape women’s interpretations of medicine efficacy and drive increases in medi- States (Table 1) were studied for 18 months cation use for themselves as well as for their children. Like other timesaving to observe actions and interactions of fam- commodities, medicines appear to shift the time-power differential in favor of ily members, who were formally and individuals, placing them in control of how time is spent. When there is “no time informally interviewed about their beliefs to be sick,” allopathic medicines become timesaving devices that enable women and practices concerning use of medications to fulfill responsibilities at work or at home while attending to sick children or and to ascertain the families’ domestic re- while being ill themselves. Medicines are used to “beat the clock” by increasing sponse to illness. Questionnaires, self-care women’s capacity to be productive. diaries, and medicine inventories were also used to learn about household self-medi- Introduction individuals to be contacted almost anywhere cation practices in each participating Lack of time is a plague of industrialized, at any time, and fax machines and electronic household.20 The University of Arizona In- prosperous societies. It manifests as the mail discourages people from claiming that stitutional Review Board approved the acceleration of activities in all facets of life1-4 they “didn’t get the message in time.” Even project, and informed consent was obtained and as a reorientation of time sense that for employees who do not have as much from all participants. places ever-increasing emphasis on the flexibility in how or where they do their All interviews were audiotaped and tran- present and on the short-term future.4-6 This work, changes in the marketplace have in- scribed for analysis. Codes were inserted chronic shortage of time, which I refer to creased the demand for overtime labor; into the transcript by The Ethnograph text- as “time famine,” is endemic in the con- consequently, work time is increasingly be- analysis software program (Scolari/Sage, temporary United States. Americans are ing extended into personal time.7,10 Thousand Oaks, California) to identify re- acutely aware of time pressures in their lives sponses to specific questions and to flag and have become preoccupied with time, Time Famine themes that emerged from analysis of mul- its passage, and the lack of it.7-10 Time famine adversely affects quality of tiple responses. Segments of text coded for life not only by reducing leisure time but a given topic were reviewed to identify re- Time as a Scarce Resource also by attacking physical health. By increas- sponse patterns. Assumptions drawn from In the United States, economic well-be- ing the level of “stress” in people’s daily this process were tested in consultation with ing and social status are linked to temporal lives, scarcity of time has been implicated a group of colleagues who read a sample notions of speed. Americans have long been as a causal agent in acute and chronic ill- of the transcripts. Participants were assigned characterized as a restless, hurried people nesses, including gastric ulcers, headache, and pseudonyms for this report. driven toward achieving ever-increasing even cancer.1,12-14 Studies of household health Qualitative methods (eg, in-depth inter- efficiency and progress.11 indicate that time shortage may negatively views) allowed participants to describe By enabling people to engage in a wider affect health when preventive health be- beliefs and experiences in their own words range of activities, modern technology ac- haviors, such as adequate rest or proper and to make associations they felt were rel- celerates the pace at which people live. In nutrition and sanitation, are foregone.15-19 evant as they described events and turn, this more hectic pace acts as a catalyst Less has been written about the ways in experiences. Because qualitative methods for social changes that encourage Americans which time pressure or time allocation affects effectively elicit the participant’s perspec- to believe that they should be engaged in household response to illness. This paper tive, these methods are particularly useful productive activity every moment of the day. examines how time famine in contemporary for defining the range and variability of The vicious cycle is thus completed: The ef- United States culture affects women’s deci- beliefs, behaviors, and experiences of study ficiency enabled by new products places new sions about self-care and about use of populations as well as the natural language and greater pressure on consumers to be- pharmaceutical agents for self-medication. In people use to discuss these issues. come more efficient. Access to high-speed this respect, by altering the timing of profes- Although this type of in-depth ethno- computers, e-mail, and fax machines means sional care and the magnitude of graphic research is generally incompatible that lack of productivity can no longer be self-treatment, time famine directly affects the with large sample sizes, it offers richness of blamed on slow equipment or on the postal frequency and severity of symptoms that ulti- information that cannot usually be obtained service. Pagers and cellular phones allow mately prompt women to visit their physicians. by more superficial inquiries, whether quali-

NANCY VUCKOVIC, PhD, is an investigator at the Kaiser Permanente Center for Health Research, and Principal Investigator of CACAM study. E-mail: [email protected]

The Permanente Journal / Summer 2000 / Volume 4 No. 3 13 tative or quantitative. Extended study “in the field” of their role as primary agents in the household pro- enables researchers to gather data by various means duction of health and as principal providers of domestic

original research and to corroborate findings by comparing data from health care.21-24 Research in the United States indicates ... scarcity of time multiple on-site sources. In addition, when data are that despite changes in gender roles related to wage has been collected through repeated contacts over time, par- and domestic labor, women are still the primary deci- implicated as a ticipants also may feel less need to “impress the sion-makers regarding purchase and administration of causal agent in researcher” and may thus offer information that more medicine and are usually the adults responsible for acute and chronic accurately reflects reality. the care of sick children.7,25 The women studied were illnesses ... To learn about households’ health care behavior, all mothers of young children and had an acute sense this inquiry primarily observed women in recognition of time famine. Making arrangements to meet with

Table 1. Demographic characteristics of adult women in 40 households surveyed in study

Households insured Households with Households without by Arizona Health private health any health Cost Containment insurance (n=18) insurance (n=18) Systema (n=4)

Mean age (years) 34 36 26

Ethnicity

White 72% 72% 25%

Mexican American 11% 22% 50%

African American -- 6% --

Otherb 17% -- 25%

Mean number of children 2.06 1.94 1.25

Highest educational level attained

Some high school or graduated 39% 39% 75%

Some college or graduated 61% 61% 25%

Employment status

Wage earner 61% 61% 25%

Homemaker 39% 39% 75%

Annual income

≥$30K 69% 39% --

$20-29K 25% 33% --

<20K 6% 28% 100%

a Arizona’s Medicaid Program and the State of Arizona’s health care program for persons who do not qualify for Medicaid. b Includes Native Americans and Asian Americans.

14 The Permanente Journal / Summer 2000 / Volume 4 No. 3 original research

these informants opened my eyes to the importance Primary Care Physician Commentary: Women’s Health Choices of time and timing in American culture. I had to be Today’s American women are frequently caught between competing prompt, and—at least initially—my visits needed to priorities of home, family care, and the workplace, leaving little time for be scheduled and to the point. Even after I estab- personal needs—especially when illness strikes, as this article illustrates. lished relationships with these women, dropping in By direct linkage of “time famine” and women’s health choices, Nancy for visits or spending time together beyond the inter- Vuckovic leaves open many implications for health care. view was problematic because of their work and family Women tend to postpone their own health care and are prone to burn- schedules. I soon became aware that time pressures out in caring for chronically ill family members. As clinicians, we may be also played a salient role in their self-medication deci- able to positively affect the whole family unit by seizing the opportunity sions. Having “no time to be sick” emerged as an issue to speak to these caregivers as they accompany ill family to clinic and by early in my research on pharmaceutical practice in US encouraging them to attend to needs for personal time and health care. households and remained an issue of repeated dis- This article can help us to be more understanding when confronted cussion for the subsequent months of field work. with expectations for quick fixes such as inappropriate antibiotics so we This paper describes the lives and reports words of can address the whole problem. We should consider whether our clinical women who were my principal informants in this behavior ameliorates time famine or reinforces women’s sense of the study of self-medication practices. Nonetheless, evi- “clock as enemy” by our prescribing practices, compressed appointment dence suggests that the experiences of the women schedules, and long waiting room times. One can speculate whether in this study are representative of more pervasive much use of alcohol, tobacco, and even caffeine is also a manifestation time famine that also affects male parents as well as of time famine as women fortify themselves for what can feel like a 7 persons of either gender who do not have children. treadmill into a dark tunnel. Results – Donna Strain, MD Internal Medicine, NWP Impatience with Illness An outcome of the American cultural ideal of Women who have jobs outside the home often feel progress and productivity is impatience with ill- that they cannot afford to take time off from work ness26,27—not merely reluctance to be uncomfortable, when they are sick because time off for illness means but a practical need to keep the household and work- lost income—and sometimes jeopardizes job secu- place running that fuels this expectation of rity. If a woman takes time off for her own illness, productivity. Multiple responsibilities—jobs, child less sick leave remains available for when her chil- care, home management, and social commitments— dren are sick and need to be cared for at home. As a allow women little time to “give in” to illness.19,28 The result of these pressures, women continue to go to women in the present study measured their own pro- work unless their symptoms are debilitating. ductivity by activity in their household as well as in Maureen’s story is one example of such behavior. their workplace. Summarizing the feelings of other She told me, “If I call in sick to work, man I’m sick! women, Gloria said: “I don’t enjoy being sick. I don’t I’m really sick—and I’ve only ever called in, well, like it slowing me down. It takes a lot to keep me when I had that food poisoning. I thought I was home from work. Because of guilt. I don’t ever want going to die. And then, yeah, I called in sick.” to be in a situation where I’m wondering ‘Well, I can be at work. I know I could.’ I want to know that Increased Use of Medications when I’m in bed, I really belong there. And that no When women “have no time to be sick,” medi- “You know I’ll go one can question that and that I’m not questioning it. cines provide a way to keep them going. As Teresa to work until I You know I’ll go to work until I really can’t. Until it said, “If I have a headache, I’ll go get a Tylenol be- really can’t. Until becomes just physically insane to be there.” cause I got to keep going. I’ve got to fix dinner and it becomes just Another woman, Karen, explained her situation with clean the house and take care of the kids and do physically insane a laugh—and with a phrase I often heard during my laundry. I don’t have time to sit on the couch and go, to be there.” conversations with her and other women: “I don’t have ‘Oh, I really feel bad.’” time to be sick—not with three kids!” She continued: Response to illness becomes more aggressive when “No, I don’t do much of that [ie, being sick]. There’s time demands create pressures to keep going. Women always something to be done. There is. If I’m really reach for medicinal solutions to alleviate symptoms feeling bad, I’ll go to bed early. But it’s a rare day that quickly and to prevent them from becoming worse. I would actually sit down and do nothing.” This practice results in increased medicine use over-

The Permanente Journal / Summer 2000 / Volume 4 No. 3 15 Primary Care Physician Commentary: A Lure and a Snare more responsibility. So I treat my symptoms sooner.” Women acknowledged that they relied more on original research Expansion of workplace opportunities for women since World War II has proved a lure and a snare. Alhough attracted to the promise of satis- medical solutions to treat symptoms when time com- fying jobs and of gaining parity with men in professional status and income, mitments prohibited rest or relaxation. Penny talked women with occupations have mostly retained their traditional domestic about consciously assessing her day before deciding roles. They go to work but remain caregivers and what some call “CEOs whether to take a pain reliever or allergy medicine. of the home.” Particularly when households become dependent on double She explained that on a work day, she might reason incomes, women can be trapped by economics. Finding sufficient time to that “I’ve got a lot of stuff to do” and consequently run a household and to be a mother and spouse can seem impossible take medicine to relieve symptoms quickly. Other even without the additional role in the workplace. informants described a similar thought process. Gloria In this article, Nancy Vuckovic introduces her concept of “time famine” said: “If it was a weekend and I was feeling bad and and ties together two elements of contemporary culture: time pressure I knew I was just going to be able to just basically and pill-taking. From interviews with women done in the course of pre- hang around and maybe cook a few meals and what paring a doctoral dissertation, she finds evidence that one effect of time not, I’m less apt to take something than if I’ve got to pressure is increased use of medicines. Her subjects attribute this to at- be at work and be on top of it, you know. That’s tempts to save time three ways: 1) avoid time-consuming office visits; 2) when I’ll start taking the Dristan or, you know, carry shorten the course of illness; and 3) treat symptoms that threaten to inter- the Pepto-Bismol with me if my stomach’s a little fere with performance of job or household activities. Moreover, use of upset. Yeah, [I] definitely [take] more [medications] medicine in children is described as a way to keep them in daycare when when I’m working.” they might otherwise be home with a parent forced to miss work. Other researchers have noted a higher incidence of Vuckovic’s discovery that many women feel hounded by demands for medicine use among women than among men29 but their time is familiar to those of us practicing primary care. Among our often look for answers in different morbidity rates patients are many whose disease seems broadly related to time-pressure, between genders30 or in gender difference in percep- loss of personal time, and work/home life imbalance, or whose dedication tion of illness.31 Such reports indicate that women may to work leads to neglect of personal health. Clinicians of both genders be more aware of bodily symptoms because they gen- contend with similar time pressures in our own lives. Vuckovic’s article erally have more experience with hormonal changes helps us complete our picture of the dilemma by describing medicine use (in addition to the extensive changes they experience among women who generally seek to avoid office treatment. Readers will during pregnancy) and that women therefore may gain empathy for these women. The bibliography contains references that identify symptoms and signs of health problems be- contribute more fully to understanding the impact of time pressure in con- fore men do.32 However, the present study suggests temporary culture. that feeling a lack of time to be ill leads women to What are some ways this article can help us in Permanente practice? downplay their illnesses and to “keep going” despite • Explain the motivation for some medicine-seeking behavior having minor—and sometimes major—physical symp- • Remind us that loss of time constitutes a significant burden of toms. The study shows that this tendency to downplay illness illness does not reduce women’s consumption of • Lead us to directly address time pressure and time manage- medicine and in fact may increase it. ment with patients • Encourage us to streamline our processes to reduce the time Entitlement to Health Care members invest in obtaining medical care Anthropological studies of entitlement to health care – Arthur D. Hayward, MD show that women often forego medical care for them- Internal Medicine, NWP selves when scarce household resources are allocated preferentially to the care of children or male wage earners.19,33 These findings hold true for the women all, even among women who voice a preference to in this study, for whom time as well as money can avoid medicines as much as possible.20 Claire ex- be in short supply. plained: “I don’t think I got sick less often [before I For example, when Claire’s husband and children had children], but when I got sick, I got really sick. suffered from a round of intestinal “flu” during the Because I would probably not treat it. And now I winter, they stayed at home to recuperate. Claire there- know I can’t afford that. There are three other people fore stayed home to care for them, missing two days depending on me in my house, plus my job. It af- of work. Later, when Claire herself had the upset fects my household, my husband, my children. Just stomach and diarrhea which had caused her other

16 The Permanente Journal / Summer 2000 / Volume 4 No. 3 original research

family members to stay home, she took two doses of what I do, and if they [ie, my children] are sick and I an antidiarrheal agent and went to work. She ex- feel like I have to be away from work, I feel guilty plained, “I just didn’t want to miss any more work.” about leaving my work there for other people to Although willing to By saying that they “do not have time” to be ill, do....So, if they [ie, the children] wake up with a take their children women not only forfeit medical care but also relin- temp[erature], I give them some Tylenol and then we to the doctor when 34 quish the sick role as a legitimate way to refrain go to school and we pray that the temperature doesn’t necessary, women from productive labor. go up during the day and that they don’t call me.” are reluctant to go Daycare workers confirmed that parents commonly to the doctor No Time for Professional Care use medicines to mask symptoms such as cough or themselves When their ability to meet responsibilities became high fever in an attempt to keep the child in atten- because “it’s just threatened by physical symptoms, women quickly dance. High rates of disease prevalence in some daycare too time- responded to these symptoms by taking medicines facilities may be due in part to this practice.36-38 consuming.” that can relieve symptoms—or, at least, that can mask Parental aggressiveness in treating children’s illness them. However, the demands of their lives some- with medications may vary by day of the week. For times caused women to postpone curative therapy, example, if the child becomes ill on Wednesday, his such a seeing a doctor, until the illness became se- or her parents may try to keep the child in daycare vere. One woman explained that she postponed or school until the weekend by using medications treatment of her urinary tract infection because “I that mask the symptoms. Over the weekend, medi- was so busy taking care of the family that I couldn’t cation use may be reduced in response to the allow myself to be sick.” increased time available for rest and home care. If The motivations for choosing self-medication in both strategies fail to produce a cure by Monday, a preference to seeing a health care practitioner are doctor’s visit may be scheduled.24 complex and may include lack of money, conflicting medical ideology, negative experiences, or fear.20 Expectations that Medications Must Act Quickly Another important factor driving women’s decisions Their quickened pace of life causes Americans to to avoid clinic visits for themselves is unwillingness favor commodities (people as well as products) that to invest the time necessary to obtain professional respond quickly to the demands of a given situation care.35 Although willing to take their children to the and that work efficiently to optimize productivity. A doctor when necessary, women are reluctant to go mentality of time famine alters expectations such that to the doctor themselves because “it’s just too time- punctuality and the ability to “get to the point” be- consuming.” Often this time is not willingly spent, come valued traits not only of employees, but also especially when other options are available to allevi- of family, friends, and even inanimate products. The ate symptoms. Thus, self-medication is popular in same reasoning that leads people to expect punctu- part because it is less time-consuming than profes- ality from people leads them to expect promptness sional care. A multitude of medicines are available from medicines. When applied to medications, ex- from stores that are nearer to home than the doctor’s pectations of punctuality and quick access manifest office and that are open at all hours. Many women as demand for rapid transformation from illness to feel that if their self-medication efforts solve a medi- health. If “instant gratification” (ie, fast relief) is not cal problem and thereby avoid a visit to the doctor, forthcoming, individuals may consume greater then the relatively small time and money invested amounts and varieties of medications. are worthwhile. For example, Lydia routinely doubled the dosage of ibuprofen that she took for headaches. She said, Time Regulation and Children’s Illness “If it says one tablet, I take two ... I want pain relief When conflicts arose between the need to care for immediately.” Other women also reported that they a sick child and the need to go to work, some women became impatient when medicines failed to achieve medicated their children to make them comfortable a desired effect after a short time. Mercy said, “I should and to mask symptoms so that the children could feel better in about ten minutes. And if not, I’ll just continue to attend school or daycare. Claire explained take more.” the decision-making process she used when one of Fast-acting medicines and those which treat sev- her children became ill during the workweek: eral symptoms in a single dose are valued for their “I’m responsible for what I do at my work, and I like efficiency. Product efficiency was the reason Mercy

The Permanente Journal / Summer 2000 / Volume 4 No. 3 17 gave: “I like the Contact best. It takes care of about improve time management dominate the market and 50,000 symptoms.” Multisymptom drugs are an en- captivate the minds and wallets of Americans.39 These

original research capsulation of Linder’s simultaneous consumption, commodities of efficiency—ranging from microwave ie, consumption of more than one product simulta- ovens to drive-through pharmacies, day planners to neously in an effort to achieve maximum use of time.1 disposable diapers—all share one attribute: By buy- In this way, multisymptom medications represent a ing them, consumers hope to also buy time. Efficiency and the single product opportunity to engage in polyphar- Commodities offer consumers the illusion of buying need to be macy. Preparations that treat a variety of symptoms time, not only because the products permit users to productive at all times has been are valued for their ability to adapt to the situation at do things faster but also because these products en- extended to the hand because they can be used at one time for one able individuals to do several tasks at the same most leisurely of illness and at another time to treat a different illness. time—a phenomenon described as “multitasking.” In leisure times: Multisymptom products promote time efficiency by this way, equipped with car phone and fax machine, sleep. eliminating the need to buy specific medicines each an executive can begin the workday while driving to time a family member gets sick. her office. A parent at home can wash clothes and cook dinner while helping her child download infor- Sleeping Efficiently mation from a local library. The side effects of allergy and cold medicines con- Medicines possess such time-management attributes taining antihistamines can be both undesired and in that they enable consumers to increase their pro- desired. When productivity is important, the sleepi- ductive time by eliminating the “downtime” caused ness these medicines produce is experienced as a by illness, behavioral difficulties, or “bothersome” negative side effect. The same sleep-enhancing quality biological functions. Certain products, such as “non- becomes a positive side effect at night, when sleep drowsy” formulations of medicines, allow a person is desirable. Because sleep is viewed as a time when to treat symptoms and still care for children or func- the body rejuvenates and heals itself, women in the tion on the job. In yet another way, products study expressed their belief that sleeping well could formulated to care for multiple symptoms promise help a person overcome illness more quickly. On to simultaneously accomplish more than one task by occasion, the sleep-inducing effect of cold and al- treating several symptoms at once. Medicines have lergy medicines was so desired that women took become commodities that make consumers more products with antihistamines even when they did not efficient; and in doing so, medicines have joined the have symptoms that generally indicate use of these ranks of other time-management products. products. Women recognized that they could regu- Women’s participation in the labor force often re- late side effects through deliberate choice of particular sults in increased medicine use, both by women and medicines at particular times of the day. Teresa said, by their children.7 Increased demands on women’s “When I go to bed is when I usually notice my back time cause them to treat illness sooner or to take has hurt all day ... It’s real tight, and it’s hard to relax medications for symptoms that she might not other- to get it to stop hurting. And everybody else is snor- wise treat. Similarly, the need to get to work prompts ing and you’re just like, ‘I’ve go to get to sleep or I women to medicate their children’s symptoms more won’t be able to function tomorrow.’ I’ll get up and aggressively so that the children can remain in daycare pop a couple of Tylenol.” or school. Limits on maternal time also lead mothers Efficiency and the need to be productive at all times to rely on medicines in lieu of spending time com- has been extended to the most leisurely of leisure forting a sick child. Taking time off work because of times: sleep. A daytime filled with efficient productiv- a child’s illness is often frowned upon by employers, ity leads to the expectation that sleep must also come and this disapproval threatens women’s job security efficiently. This “colonization” of sleep time as pro- and ultimately the welfare of their families. In this ductive time leads Americans to medically overcome kind of environment, it is financial necessity—not the insomnia which threatens to make their nights lack of concern for children—that motivates aggres- unproductive.1 People resort to drugs in order to avoid sive use of medicines. losing time because of an uncooperative body. Implications for Clinical Practice Medicines as Timesaving Devices In addition to creating and exacerbating illness, time- Products and services designed to save time and induced stress drives impatience with symptoms and

18 The Permanente Journal / Summer 2000 / Volume 4 No. 3 original research

desire for fast-acting treatment. The need for quick increasing a person’s capacity to be productive. Like relief prompts greater and more frequent use of medi- other timesaving commodities, consumers find medi- cine and thus raises the risk of overmedication, cations appealing because they seem to shift the adverse drug reactions, and a tendency for people to time-power differential in favor of individuals, plac- self-medicate for nonpathological conditions. Low- ing them in control of how time is spent. ❖ ered tolerance for discomfort can also lead people to A related version of this article was published as: Vuckovic N. rely on medications instead of seeking longer-term, Fast relief: buying time with medications. Med Anthropol Q behaviorally oriented strategies. Use of vitamins, laxa- 1999;13(1):51-68. tives, and antacids to counteract poor eating habits Acknowledgments: I would like to thank Louise Williams, PhD, for is one example of this strategy. her enthusiasm, encouragement, and generous editorial contri- The self-care practices described in this paper may butions to the revision of this manuscript. affect the timing of professional care as well as the stage at which patients are initially seen for their ill- References ness. As described above, patients may view 1. Linder SB. The harried leisure class. New York: Columbia self-medication as more expedient than seeking pro- University Press; 1970. 2. Kern S. The culture of time and space. Boston (MA): Harvard fessional care. This behavior may be appropriate for University Press; 1983. self-limiting illnesses but can be harmful when ap- 3. O’Malley M. Keeping watch: a history of American time. New plied to more serious conditions. Further, these York: Viking Penguin; 1990. self-medication strategies can mask symptoms and 4. Rifkin J. Time wars: the primary conflict in human history. thus complicate diagnosis when patients finally seek New York: Holt; 1987. 5. Jeanniere A. The pathogenic structures of time and modern medical care. societies. In: Time and the Philosophies. Aguessy H., editor. Because use of over-the-counter (OTC) medications London: The Benham Press; 1977. p 107-23. for symptomatic relief is so common, patients may 6. Keyes R. Timelock: how life got so hectic and what you can not remember whether they used some products or do about it. New York: HarperCollins Publishers; 1991. may not consider them to be “medication.” Health 7. Hochschild AR. The time bind: when work becomes home and home becomes work. New York: Metropolitan Books; 1997. care professionals must therefore query patients about 8. Carpenter ES. Children’s health care and the changing role of their use of specific drugs so that patients report their women. Med Care 1980 Dec;18(12):1208-18. medication use as accurately as possible. In addi- 9. Robinson JP. The time squeeze. Am Demogr 1990;12(2):30-3. tion, some patients are reluctant to report their 10. Schor JB. The overworked American: the unexpected self-care activities, because they fear being ridiculed decline of leisure. New York: Basic Books; 1992. 11. Tocqueville A. Democracy in America. The Henry Reeve text or chastised for taking inappropriate action. A as revised by Francis Bowen. Bradley P, editor. New York: AA nonjudgmental approach to asking questions about Knopf; 1945. medication use may help alleviate these patients’ 12. Brown BB. Between health and illness: new notions of concerns. stress and the nature of well being. New York: Houghton Mifflin; 1984. A final consideration for clinical practice: Desire 13. Plotnikoff NP, Murgo A, Faith R, Wybran J, editors. Stress for fast relief may prompt some patients to ask for and immunity. Boca Raton (FL): CRC Press; 1991. particular pharmaceuticals even when use of that 14. Zerubavel E. Hidden rhythms: schedules and calendars in Self-medication medication is clinically inappropriate. More than one social life. Chicago: University of Chicago Press; 1981. strategies can mask participant in the present study told me about hav- 15. Backett K. Taboos and excesses: lay health moralities in symptoms and thus middle class families. Sociol Health Illn 1992;14(2):255-74. complicate ing demanded antibiotics to speed relief from a cold. 16. Berman P, Kendall C, Bhattacharyya K. The household diagnosis when production of health: integrating social science perspectives on Conclusion patients finally micro-level health determinants. Soc Sci Med 1994 seek medical care. In our current cultural environment, use of medi- Jan;38(2):205-15. 17. Cosminsky S, Mhloyi M, Ewbank D. Child feeding practices cine becomes one way to make the best of what is in a rural area of Zimbabwe. Soc Sci Med 1993 Apr;36(7):937-47. perceived to be the unchangeable, taken-for-granted 18. David S. Health expenditures and household budgets in phenomenon of time famine. When women have rural Liberia. Health Transit Rev 1993 Apr;3(1)57-76. “no time to be sick,” medications act as time-saving 19. Graham H. Women, health and the family. Brighton, Sussex devices that enable women to fulfill responsibilities (UK): Wheatsheaf Books; 1984. 20. Vuckovic N. You do what you have to do: Cultural and at work or at home while attending to sick children socio-cultural influences on self-medication behavior in the or while being ill themselves. Over-the-counter and United States [dissertation]. Tucson (AZ): Univ. of Arizona; 1995. prescription drugs are used to “beat the clock” by 21. Browner C. Women, household and health in Latin America.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 19 Soc Sci Med 1989;28(5):461-73. differences in health perceptions and their predictors. Soc Sci 22. Graham H. The concept of caring in feminist research: the Med 1993 Feb;36(4):419-27. original research case of domestic service. Sociology 1991;25(1):61-78. 31. MacIntyre S. Gender differences in the perception of 23. Hibbard J, Pope C. Women’s roles, interest in health and common cold symptoms. Soc Sci Med 1993 Jan;36(1):15-20. health behavior. Women’s Health 1987;12(2):67-84. 32. Saltonstall R. Healthy bodies, social bodies: men’s and 24. Querubin MP, Tan ML. Old roles, new roles: women, women’s concepts and practices of health in everyday life. Soc primary health care, and pharmaceuticals in the Philippines. In: Sci Med 1993 Jan;36(1):7-14. McDonnell K, editor. Adverse effects: women and the 33. Morsy S. Sex roles, power and illness in an Egyptian village. pharmaceutical industry. Toronto Ont.: Women’s Educational Am Ethnol 1977;36:137-50. Press; 1986. p 175-86. 34. Parsons T. The Social System. Glencoe (IL): Free Press. 1951. 25. Clark L. Women’s domestic health work in poverty: a 35. Leibowitz A. Substitution between prescribed and over-the- comparison of Mexican-American and Anglo households counter medicines. Med Care 1989 Jan;27(1):85-94. [dissertation]. Tucson (AZ): Univ. of Arizona; 1992. 36. Daum RS, Granoff DM, Gilsdorf J, Murphy T, Osterhom MT. 26. Vuckovic N, Nichter M. Changing patterns of pharmaceutical Haemophilus influenzae type b infections in day care attendees: practice in the United States. Soc Sci Med 1997 May;44(9):1285-302. implications for management. Rev Infect Dis 1986 Jul- 27. Young JH. Patent medicines and the self-help syndrome. In: Aug;8(4):558-67. Risse GB, Numbers RL, Leavitt JW, editors. Medicine without 37. Super CM, Keefer CH, Harkness S. Child care and infectious doctors: home health care in American history. New York: respiratory disease during the first two years of life in a rural Science History Publications; 1977. p 95-116. Kenyan community. Soc Sci Med 1994 Jan;38(2):227-9. 28. Litman TJ. Health care and the family: a three-generational 38. Henderson FW, Giebink GS. Otitis media among children in analysis. Med Care 1971 Jan-Feb;9(1):67-81. day care: epidemiology and pathogenesis. Rev Infect Dis 1986 29. Johnson R, Pope C. Health status and social factors in Jul-Aug;8(4):533-8. nonprescribed drug use. Med Care 1983 Feb;21(2):225-33. 39. Berry LL. Market to the perception. Am Demogr 30. Anson O, Paran E, Neumann L, Chernichovsky D. Gender 1990;12(2):32.

The Most Beautiful Verb in the World After the verb ‘To love,’ ‘To help’ is the most beautiful verb in the world. Baroness Bertha Von Suttner, 1843-1914, author and peace activist, winner of the 1905 Nobel Peace Prize

20 The Permanente Journal / Summer 2000 / Volume 4 No. 3 By Arne Beck, PhD; George Breth, MD;

original research Psychiatric Disorders and Functional Disability Rob Hays, MD; in Patients with Fibromyalgia Colleen Miller, RNP

OBJECTIVE: The objective of this study was to describe the prevalence of current psychiat- ric disorders and functional disability among a sample of patients attending a fibromyalgia group clinic in the Rheumatology Department at Kaiser Permanente Colorado. METHODS: A sample of 184 patients, 92% of whom were women, were given question- naires at the beginning of the group clinic. Questionnaires included items on demographics, Patients with work disability, and history of trauma and abuse. Also included were the following instruments: fibromyalgia pose a challenge to the Illness Intrusiveness Scale, the Fibromyalgia Impact Questionnaire, and the Quick Psychodi- health care agnostics Panel. practitioners RESULTS: Most patients reported a history of trauma (74.7%) or abuse (53.5%). Major de- because the pression (34.2%), anxiety (29.9%), and panic disorders (17.4%) were prevalent in this sample. condition affects Symptoms of bipolar disorder were present in 59.2% of patients. In addition, a high level of psy- multiple aspects chiatric comorbidity was evident: 64.1% of the patients met DSM-IV criteria for two or more diag- of physical as noses. These patients also reported clinically significant functional impairment (especially in the well as life domains of active recreation, health, and work) and were most negatively affected by fatigue, psychological lack of restfulness at waking, and stiffness. function. CONCLUSIONS: Baseline assessment of this patient sample confirmed clinicians’ suspicion of clinically significant psychiatric and functional disability and led to the addition of a clinical psychologist to the group clinic to target and intervene with patients who had psychiatric disor- ders. We conclude that treatment effectiveness for fibromyalgia can be enhanced by collaboration between rheumatologists and behavioral medicine specialists.

Introduction fibromyalgia. Moreover, the care provided to these Fibromyalgia—a condition characterized by patients is often fragmented: typically, they see a vari- chronic widespread pain with multiple tender points, ety of different specialists (ie, rheumatologists, fatigue, sleep disturbances, and clinically significant neurologists, orthopedic specialists, mental health pro- functional impairment—is often associated with viders) in addition to their primary care physician, often psychiatric comorbidity.1-3 The prevalence of with no practitioner managing their overall care. fibromyalgia in the general population has been Most patients diagnosed with fibromyalgia by their estimated to range from 2% among 20-year-old per- primary care physician at Kaiser Permanente (KP) sons to 8% among 70-year-old persons, and the in Colorado are referred to a rheumatologist. Be- condition affects approximately 3.7 million Ameri- cause of the volume of fibromyalgia patients seen cans.4-6 The overwhelming majority of individuals there—fibromyalgia is the second most prevalent suffering from fibromyalgia are women. condition seen at the KP Colorado Rheumatology Although some treatments have been shown effec- Department—and because of the difficulties in pro- tive for fibromyalgia (eg, medications to improve sleep, viding care to these patients within the traditional exercise, some complementary therapies),7-16 no cure office-visit model, the rheumatologists developed a has yet been found. Patients with fibromyalgia pose a fibromyalgia group clinic that was implemented in challenge to health care practitioners because the con- 1998. The group clinic consists of one four-hour dition affects multiple aspects of physical as well as session that includes education about fibromyalgia psychological function. For this reason, the tradition- and its diagnosis; behavioral guidelines for restor- ally brief medical office visit is often inadequate to ative sleep, relaxation, and exercise; and treatment address the needs of patients affected with such as medications and physical therapy. Because

ARNE BECK, PhD (top left), is the Research and Development Director at Kaiser Permanente in the Colorado Region. He has been with KP since 1991. Dr Beck is an Assistant Clinical Professor in the Department of Biometrics and Preventive Medicine at the University of Colorado Health Sciences Center. GEORGE BRETH, MD (top right), is the Chief of Rheumatology with the Colorado Permanente Medical Group (CPMG), where he has practiced since 1985. Dr Breth is an Assistant Clinical Professor in the Department of Medicine at the University of Colorado Health Sciences Center. ROB HAYS, MD, MA (bottom left), is a Rheumatologist with the CPMG, where he has practiced since 1991. Dr Hays was Chief of Rheumatology at Saint Joseph Hospital in Denver from 1992-1998. He is an Assistant Clinical Professor in the Department of Medicine at the University of Colorado Health Sciences Center. COLLEEN MILLER, RNP (bottom right), is a Nurse Practitioner with KP in the Colorado Region. She has been with KP since 1990. Ms Miller is the present Chairperson of the Rocky Mountain Chapter of the Arthritis Foundation, where she has taught fibromyalgia self-help classes for a number of years.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 21 Kaiser Permanente Employment Status APGAR Social Support: 7 (good) Fibromyalgia Assessment Have job outside home Date: 04/04/00 Y Presently working ‘usual’ job Y Exercise in past 6 months PID: Y Presently unemployed Gender: Female N Declared medically disabled Y Suffered severe emotional trauma Age: 26 N Applying for medical disability Y Has been abused Session: Follow-up N Fibromyalgia caused job change original research Illness Intrusiveness Fibromyalgia Impact Stress Management How does illness interfere with your: 1 Physical Functioning Score 4 Health Biggest Source of Stress 5 Diet 5 Days felt good last week ___ Marriage 5 Work 4 Nights restful sleep last week ___ Family 6 Active Recreation 0 Days missed work _x_ Work/School 2 Passive Recreation 3 How did pain interfere with job ___ Finances 2 Financial Situation 1 How bad has pain been _x_ Health 4 Relation w/spouse 7 How tired have you been _x_ Other 5 Sex Life 7 How you feel when you wake up 3 Family relations 5 How bad is stiffness How do you handle stress: 4 Other social functions 2 How tense have you felt ___ Ignore it 2 Self expression/improvement 2 How depressed have you felt _x_ Talk to spouse 1 Religious expression Scale: 0-Best to 10-Worst ___x Exercise 1 Community/Civic improvement ___x Relaxational exercises Scale: 1-Not very much to 7-Very ___x Alcohol/drugs Much ___x Yoga ___ Prayer ___x Other QPD Results RESULTS TEST REFERENCE RANGE Within range Out of range Depression 12 0-10 Anxiety 15 0-10 Panic Disorder 0 0-8 OCD 4 0-5 Bulimia 0 0-4 Somatization 12 0-11 Notes: - Rule out bipolar disorder before treating depression. - Depression Score is out of range, but patient does not appear to meet formal diagnostic criteria for major depression or dysthymia. - Anxiety Score is out of range, but patient does not appear to meet formal diagnostic criteria for generalized anxiety disorder. - Patient may be prone to somatization.

Depressive Symptoms: Anxiety Symptoms: - depressed mood - excessive anxiety or worry - weight gain - worried about multiple things - insomnia - restless, keyed up - agitation - easily fatigued - fatigue, loss of energy - difficulty concentrating - poor concentration - muscle tension - thinks about death - sleep disturbance - easily startled - frequent cold, clammy hands or feet - frequent stomach aches - frequent hot flushes or chills - frequent heart racing or pounding - frequent “lump in throat” - frequently feels out of breath - frequent dizziness or lightheadedness - frequent sweating Figure 1: Rheumatologist-designed format for organizing results of fibromyalgia assessment.

22 The Permanente Journal / Summer 2000 / Volume 4 No. 3 original research

the course of the condition is greatly affected by When patients arrived for the group clinic, they the presence of psychiatric disorders and by the were given a questionnaire assessing demographics, patient’s initial level of functional impairment, as- job-related disability, history of trauma and abuse, sessment of these two domains among patients fibromyalgia-related functional status, intrusiveness attending the group clinic became a primary goal of the illness, and psychiatric disorders. for the rheumatology providers. Questionnaires were contained in a Point-of-View To understand the prevalence of psychiatric disor- Survey Systems (Denver, Colorado) “box”—a hand- ders and functional impairment in patients with held tablet about the size of a book, equipped with a fibromyalgia and to develop treatment plans more liquid crystal display (LCD) screen displaying ques- closely tailored to individual patient clinical status, tions and a keypad with numeric and true/false we administered a patient questionnaire at the be- buttons for entering responses. Questionnaires re- ginning of the clinic. We were particularly interested quired a mean of 15 to 20 minutes to complete. After in screening for psychiatric disorders, because the each questionnaire was completed, the Point-of-View rheumatology clinical staff expressed their belief (and box was placed on a docking station connected to a the medical literature about fibromyalgia suggests) printer; questionnaire results were immediately sum- that psychiatric disorders are common among pa- marized and printed in an easy-to-read format tients with fibromyalgia and greatly affect these designed by the rheumatologists to highlight key find- patients’ ability to manage their condition and to ings and to allow rapid assessment of symptom achieve successful treatment outcomes. severity and to assist with individualized treatment planning (Figure 1). The rheumatologists and nurs- Methods ing staff reviewed these results to develop care plans Study Setting for patients and to assess any serious psychopathol- The fibromyalgia group clinic is facilitated by a rheu- ogy that warranted referral to the mental health matologist and by a nurse or nurse practitioner. The department. Data were stored in the Point-of-View purpose of this clinic is to inform patients about the boxes until they could be downloaded to a micro- diagnosis and treatment of fibromyalgia, to suggest computer for later analysis. and develop self-management strategies, and to pro- vide a forum for questions and answers. During part Measurement Instruments of the clinic, a physical therapist educates patients Measurement instruments were selected by the about exercise, and a psychologist provides infor- rheumatologists after they reviewed the most widely mation about stress management. The fibromyalgia used measures of condition-specific functional sta- group clinic was envisioned as a more efficient ap- tus as described in the rheumatology literature. The proach to educating and supporting patients while psychiatric assessment tool was chosen by the first avoiding the unnecessarily duplicative care that re- author (AB) on the basis of his extensive experience sults within the traditional office-visit model. with its use in primary as well as specialty care set- Originally designed as three separate two-hour ses- tings. The measures, self-administered by patients sions over a period of three months, the clinic format using the Point-of-View box, included the following: was revised to consist of one four-hour session. This • Illness Intrusiveness Scale.17 This scale measures change was based on patients’ preference to mini- the degree to which an illness interferes with major mize the number of trips to the rheumatology clinic. life domains, including diet, work, active and pas- Group size has ranged from 15 to 30 patients. sive recreation, financial situation, relationship with significant other, sex life, family relations, other so- Study Subjects and Data Collection cial relations, self-expression/self-improvement, The data for this study were obtained from a variety religious expression, and community and civic in- of validated self-report measures administered to 184 volvement. Items are scored from 1 (not very much patients attending the fibromyalgia group clinic be- interference) to 7 (very much interference). tween November 1998 and August 1999. Patients had • Fibromyalgia Impact Questionnaire.18 This instru- been referred to a rheumatologist by their primary ment was designed to measure the impact of care physician, who made the initial diagnosis of fibromyalgia on instrumental activities of daily living fibromyalgia; the rheumatologist scheduled the patient (eg, shopping, meal preparation, household chores, for the group clinic after confirming the diagnosis. walking several blocks, driving a car). This instrument

The Permanente Journal / Summer 2000 / Volume 4 No. 3 23 also measures common symptoms associated with depression specified by the Quick Psychodiagnos- fibromyalgia, including nights of restful sleep, pain, fa- tics Panel and answer “True” to at least four of the

original research tigue (in general and at waking), depression, and anxiety. following items, including the first item: The Quick • Quick PsychoDiagnostics Panel.19 This instrument 1. There have been periods in my life lasting PsychoDiagnostics is an automated tool for diagnosing and assessing a WEEK OR MORE when I was so excited Panel screens the severity of psychiatric disorders. This part of the or “hyper” that people thought I was not patients for nine test required about 6.2 minutes to complete using my normal self, or I got myself into real mental disorders according to the Point-of-View box. Diagnostic items are displayed trouble. DSM-IV diagnostic on the screen in a true/false response format, and During these periods when I was “hyper” or excited, criteria. patients respond by pressing response buttons la- 2. I needed far less sleep than usual. beled “True” and “False.” When a patient completes 3. I talked so much or so quickly that the test, the Point-of-View box is placed on a dock- people had trouble stopping me or ing station connected to a printer, and a diagnostic understanding me. report is printed automatically. The computer-gener- 4. My thoughts were racing through my ated report resembles a blood chemistry report (lower head, and I could not slow them down. half, Figure 1). Patient data are also stored electroni- 5. I was so distracted by everything that I cally in a database that can be accessed for subsequent could not keep myself on one track. analysis (eg, to create aggregate reports). 6. I did reckless things that I would not The Quick PsychoDiagnostics Panel screens patients normally do (like having promiscuous sex for nine mental disorders according to DSM-IV diag- or going on spending sprees). nostic criteria: major depression, dysthymic disorder, 7. I felt I could do anything or that I had bipolar disorder, generalized anxiety disorder, panic special powers. disorder, obsessive-compulsive disorder (OCD), bu- Some of these bipolar-type symptoms also appear to limia nervosa, alcohol and/or other substance abuse, be common in fibromyalgia patients and may be asso- and somatization disorder. The “lab report” provides ciated with sleep disturbance. The test also identifies 1) numeric scores that indicate severity of symptoms, patients who may be at risk for suicide. The second 2) a specific psychiatric diagnosis, and 3) a list of the page of the report lists the symptoms that led to the symptoms that led to the diagnosis. The algorithm diagnosis. The validity of the Quick PsychoDiagnostics for ruling out bipolar disorder does not provide a Panel has been described elsewhere.19 DSM-IV diagnosis, because the diagnosis requires an Additional questionnaire items asked about work- interview by a trained clinician. The algorithm re- related disability, family support, participation in quires that patients report at least eight symptoms of exercise programs during the past six months, history

70

60 59.2

50

40 34.2 29.9 30

Percentage of patients Percentage 20 17.4

10 3.8 2.7 0 Depression Bipolar Anxiety Generalized Panic Obsessive- disorder secondary to anxiety disorder compulsive depression disorder disorder

Figure 2: Diagnostic data for 184 patients attending

24 The Permanente Journal / Summer 2000 / Volume 4 No. 3 original research

of trauma and abuse, sources of stress, stress manage- had two or more diagnoses, suggesting a high level ment behaviors, and past and current medication use. of psychiatric comorbidity. In addition to diagnoses, results were obtained Results describing the mean symptom severity scores for Mean age of patients in the sample was 48.8 years several disorders (Figure 4). These scores reflect the (SD = 12.2), and 92% were female. More than one actual number of symptoms reported by the patient fifth (20.7%) of the patients reported that they cur- for any given diagnostic category. Mean scores for Most patients rently were receiving medical disability benefits, and depression (12.8) and anxiety (14.1) were within a (61.4%) had two or 11.4% indicated that they were applying for these clinically significant range. Similar to the finding of more diagnoses, benefits. More than one third (35.9%) of the patients high levels of comorbidity among psychiatric diag- suggesting a high level of psychiatric indicated that fibromyalgia caused them to change noses, Figure 5 shows a large percentage of patients comorbidity. jobs. Past trauma and abuse were prevalent: 74.7% (76.1%) with clinically significant psychiatric symp- responded affirmatively to the question, “Have you toms in two or more diagnostic categories. Therefore, ever been in a severe accident, suffered the loss of a even when they did not meet DSM-IV criteria for a child, spouse, or suffered severe emotional trauma diagnosis, most patients reported multiple clinically from some other life event?”, and 53.5% responded significant symptoms—most commonly, a combina- affirmatively to the question, “Have you ever been tion of depression and anxiety. abused (emotionally, physically, or sexually)?”. Illness Intrusiveness and Fibromyalgia Impact Psychiatric Diagnoses and Symptom Severity Figure 6 shows mean illness intrusiveness scores across Figure 2 shows the percentage of patients meeting the 13 different dimensions assessed. Ten of the 13 DSM-IV criteria for diagnostic categories assessed by mean scores were higher than the midpoint score of the Quick PsychoDiagnostics Panel. The most com- 3.5, indicating that patients reported at least moderate mon diagnoses were major depressive episode interference of fibromyalgia with most domains of func- (34.2%) and anxiety secondary to depression (29.9%). tion. Areas of highest reported impact were active Panic disorder was also prevalent (17.4%). The Quick recreation (5.74), health (5.33), and work (5.21). PsychoDiagnostics Panel generated a note suggest- Results from the Fibromyalgia Impact Questionnaire ing to clinicians that they rule out bipolar disorder (Figures 7 and 8) showed that patients had the high- for 59.2% of the patients. est mean levels of functional impairment in ability to Figure 3 shows the percentage of patients who had do yard work (2.24), walk several blocks (1.77), and multiple DSM-IV diagnoses. Most patients (61.4%) do vacuuming (1.69). More pronounced impairment

50

40 38.6

30 ... patients reported at least 21.2 20 19 moderate interference of

Percentage of patients Percentage fibromyalgia with 10 8.7 9.8 most domains of function. 2.7 0 None One Two Three Four Five

No. of diagnoses per patient

Figure 3: Multiple diagnoses (depression, dysthymia, generalized anxiety disorder, anxiety secondary to depression, panic disorder, obsessive-compulsive disorder, bipolar disorder) seen in 184 patients attending fibromyalgia group clinic.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 25 was evident for items associated with symptoms of results, which are nonetheless consistent with other fibromyalgia: on a scale of 1 (best) to 10 (worst), reports describing a history of trauma and abuse original research The finding of self- mean scores for these domains ranged from 5.68 (for among fibromyalgia patients.20-25 reported bipolar- type symptoms in interference of fibromyalgia with job) to 8.05 (for Our findings regarding psychiatric disorders are also more than half of fatigue). Poor scores were reported also for feeling generally consistent with other published research find- 1-3,21 our patient sample rested at waking (7.89) and stiffness (7.87). More- ings. In particular, depression among fibromyalgia was somewhat over, patients reported that during the past week, on patients might be expected, because considerable unexpected. average, they felt good 2.08 days, had 1.84 nights of overlap exists between fibromyalgia symptoms and restful sleep, and missed 2.08 days of work. symptoms of depression (eg, fatigue and sleep distur- bance). Of particular note was the high level of Discussion psychiatric comorbidity—the most common being a Baseline questionnaire results for our sample of combination of mood and anxiety disorders. Because fibromyalgia patients showed a high prevalence of the Quick PsychoDiagnostics Panel assessed multiple past trauma and abuse, major depression and anxi- psychiatric disorders, we were able to gain a more ety disorders, and clinically significant functional comprehensive picture of the range and severity of disability. Detailed histories of trauma and abuse were psychiatric impairment in our patient sample. not obtained from patients; instead, single question- The finding of self-reported bipolar-type symptoms naire items were used to ascertain this information. in more than half of our patient sample was somewhat Therefore, caution must be used in interpreting these unexpected. As discussed earlier, substantial overlap may exist between symptoms of sleep disturbance as- 16 14.1 sociated with fibromyalgia and bipolar symptoms. 14 12.8 However, the rheumatologists expressed their clinical 12 impression that bipolar disorder is fairly common among 10 fibromyalgia patients and complicates treatment—and 8 that, therefore, the bipolar-type symptoms reported in 6 4.1 responses to the Quick PsychoDiagnostics Panel may 4 identify some patients who truly have bipolar disorder. 2 0.6 Nonetheless, the definitive diagnosis of this disorder

Mean symptom severity score symptom severity Mean 0 can be made only after a more in-depth interview by a Depression Anxiety Panic Obsessive- trained mental health clinician. compulsive The patients in our study sample had clinically sig- disorder nificant levels of functional disability that appeared to Figure 4: Symptom severity scores for 184 patients attending fibromyalgia group clinic. be widespread across most life domains and that most severely affected performance of physical activities 40 such as doing yard work and walking several blocks. 32.6 Notably, work-related function was substantially im- paired. About one third of the sample were either 30 receiving or applying for disability benefits, and, on 23.9 average, patients had been absent from work more than two days during the prior week. The most com- 20 16.3 14.7 monly reported symptoms associated with this disability included fatigue, lack of restful sleep, and stiffness. 10 8.2 Percentage of patients Percentage 4.3 Clinical Implications of Findings Our findings of substantial current psychiatric dis- 0 orders as well as a history of trauma and abuse among None One Two Three Four Five fibromyalgia patients underscored these patients’ need No. of clinically significant symptom scores for behavioral health services. As a result, the rheu- Figure 5: Number of clinically significant symptom severity scores (depression, anxiety, matology and behavioral health departments formed panic disorder, obsessive-compulsive disorder, somatization) for 184 patients attending a stronger collaboration to make behavioral health fibromyalgia group clinic. services more readily accessible to fibromyalgia pa-

26 The Permanente Journal / Summer 2000 / Volume 4 No. 3 original research

mean score: 1 = low, 7 = high 7 This study 5.74 suggests the 6 5.33 5.21 4.59 importance of a 5 4.27 3.84 4.13 4.07 3.97 3.84 multidisciplinary 4 3.46 3.48 team approach to 3 2.37 treating 2 fibromyalgia. 1 0 h t k n n n e e s s t n t lt ie r o io o s if n n n o en a d o ti t ti ou l io io e si e w ea ea a p ex at t m es m h r r tu s s l la e r ve ec ec si h re re ov p l r r l it y l r ex o e e a il ia p s v iv iv ci w c m u in t ss n ip am so i o y ac a a h f r , gi it p in s e on li n f n h si re u io ot s m at re el p om r ex c lf- se Figure 6: Illness intrusiveness scores for 184 patients attending fibromyalgia group clinic.

tients. A psychologist is now present at the group References clinics to discuss stress and stress reduction with the 1. Wolfe F, Hawley DJ. Psychosocial factors and the fibromyalgia patients. The psychologist also reviews printouts of syndrome. Z Rheumatol 1998;57 Suppl 2:88-91. 2. Offenbaecher M, Glatzeder K, Ackenheil M. Self-reported Quick PsychoDiagnostics Panel results, identifies pa- depression, familial history of depression and fibromyalgia tients with high-risk profiles, conducts more detailed (FM), and psychological distress in patients with FM. Z assessment with these patients (eg, obtains more thor- Rheumatol 1998;57 Suppl 2:94-6. ough information about trauma and abuse history, 3. Kurtze N, Gundersen KT, Svebak S. The role of anxiety and depression in fatigue and patterns of pain among subgroups of possibly diagnoses posttraumatic stress disorder, con- fibromyalgia patients. Br J Med Psychol 1998 Jun;71(Pt 2):185-94. firms a diagnosis of bipolar disorder) and plans more 4. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The intensive, individualized intervention (eg, cognitive prevalence and characteristics of fibromyalgia in the general behavioral therapy, referral to a psychiatrist for medi- population. Arthritis Rheum 1995 Jan;38(1):19-28. 5. Smith WA. Fibromyalgia Syndrome. Nurs Clin North Am 1998 cation evaluation). Dec;33(4):653-69. The results from this study suggest the importance of a multidisciplinary team approach to treating fibromyalgia. This approach is supported by other In the past week, were you able to: published research.7,8,26,27 0 = Almost always 2.5 2.24 1 = Most times As an important next step, follow-up surveys should 2 = Occasionally 2 1.77 be conducted to assess changes in fibromyalgia pa- 1.69 3 = Never tients’ psychiatric symptoms and functional status six 1.37 1.42 1.5 1.18 1.26 months to one year after they attend the group clinic. 1.06 1.13 0.94 The goal of this follow-up would be to identify factors 1 that improve the health of fibromyalgia patients or that 0.5

inhibit this improvement. Such findings will enable us score Questionnaire to modify the group clinic to better meet the needs of 0 s s s s r fibromyalgia patients and to increase the likelihood of op ry ls e m d k d rk a h d ea u e c n o c S n ish u b lo w a improved outcomes in this patient population. ❖ u m d ac e d e re V k l b r la a sh a ra a riv o p a M e isit frie y D Acknowledgments: Supported by the Kaiser Permanente D re W v V o P se D Garfield Memorial Fund Depression Initiative and an Unre- alk stricted Educational Grant from Eli Lilly & Company. Scott W Rosenberg, MS, of Point-of-View Survey Systems, Inc, provided Figure 7: Response scores for 184 patients answering Fibromyalgia Impact Questionnaire. programming assistance.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 27 original research Depression 6.01

Tension 7.086

Stiffness 7.87

Rested at waking 7.89

Fatigue 8.05

Pain 7.2

Illness-related interference with job 5.68

0246810 1 = best; 10 = worst Figure 8: Distribution of symptoms reported by 184 patients answering Fibromyalgia Impact Questionnaire. 6. Gordon S, Morrison C. Fibromyalgia and its primary care impact questionnaire: development and validation. J Rheumatol implications. Medsurg Nurs 1998 Aug;7(4):207-13, 216. 1991 May;18(5):728-33. 7. Sim J, Adams N. Physical and other non-pharmacological 19. Shedler J, Beck A, Bensen S. Practical mental health interventions for fibromyalgia. Baillieres Best Pract Res Clin assessment in primary care: validity and utility of the Shedler Rheumatol 1999 Sep;13(3):507-23. Quick PsychoDiagnostics Panel (QPD Panel). J Fam Pract 2000 8. Berman BM, Swyers JP. Complementary medicine treatments Jul;49(7):614-21. for fibromyalgia syndrome. Baillieres Best Pract Res Clin 20. Walker EA, Keegan D, Gardner G, Sullivan M, Bernstein D, Rheumatol 1999 Sep;13(3):487-92. Katon WJ. Psychosocial factors in fibromyalgia compared with 9. Sandstrom MJ, Keefe FJ. Self-management of fibromyalgia: the rheumatoid arthritis: II. Sexual, physical, and emotional abuse role of formal coping skills training and physical exercise and neglect. Psychosom Med 1997 Nov-Dec;59(6):572-7. training programs. Arthritis Care Res 1998 Dec;11(6):432-47. 21. Walker EA, Keegan D, Gardner G, Sullivan M, Katon WJ, 10. Gowans SE, deHueck A, Voss S, Richardson M. A random- Bernstein D. Psychosocial factors in fibromyalgia compared with ized, controlled trial of exercise and education for individuals rheumatoid arthritis: I. Psychiatric diagnoses and functional with fibromyalgia. Arthritis Care Res 1999 Apr;12(2):120-8. disability. Psychosom Med 1997 Nov-Dec;59(6):565-71. 11. Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer JF, 22. McBeth J, Macfarlane GJ, Benjamin S, Morris S, Silman AJ. McIntosh MJ et al. A meta-analysis of fibromyalgia treatment The association between tender points, psychological distress, interventions. Ann Behav Med 1999 Spring;21(2):180-91. and adverse childhood experiences: a community-based study. 12. Buckelew SP, Conway R, Parker J, Deuser WE, Read J, Witty Arthritis Rheum 1999 Jul;42(7):1397-404. TE et al. Biofeedback/relaxation training and exercise 23. Goldberg RT, Pachas WN, Keith D. Relationship between interventions for fibromyalgia: a prospective trial. Arthritis Care traumatic events in childhood and chronic pain. Disabil Rehabil Res 1998 Jun;11(3):196-209. 1999 Jan;21(1):23-30. 13. Keel PJ, Bodoky C, Gerhard U, Muller W. Comparison of 24. Alexander RW, Bradley LA, Alarcon GS, Triana-Alexander M, integrated group therapy and group relaxation training for Aaron LA, Alberts KR et al. Sexual and physical abuse in women fibromyalgia. Clin J Pain 1998 Sep;14(3):232-8. with fibromyalgia: association with outpatient health care utilization and pain medication usage. Arthritis Care Res 1998 14. Singh BB, Berman BM, Hadhazy VA, Creamer P. A pilot Apr;11(2):102-15. study of cognitive behavioral therapy in fibromyalgia. Altern Ther Health Med 1998 Mar;4(2):67-70. 25. Aaron LA, Bradley LA, Alarcon GS, Triana-Alexander M, 15. Mason LW, Goolkasian P, McCain GA. Evaluation of Alexander RW, Martin MY et al. Perceived physical and emotional trauma as precipitating events in fibromyalgia. multimodal treatment program for fibromyalgia. J Behav Med 1998 Apr;21(2):163-78. Associations with health care seeking and disability status but not pain severity. Arthritis Rheum 1997 Mar;40(3):453-60. 16. Nicassio PM, Radojevic V, Weisman MH, Schuman C, Kim J, 26. Turk DC, Okifuji A, Sinclair JD, Starz TW. Interdisciplinary Schoenfeld-Smith K et al. A comparison of behavioral and educational interventions for fibromyalgia. J Rheumatol 1997 treatment for fibromyalgia syndrome: clinical and statistical significance. Arthritis Care Res 1998 Jun;11(3):186-95. Oct;24(10):2000-7. 27. Strobel ES, Wild J, Muller W. Interdisziplinäre 17. Devins GM, Edworthy SM, Guthrie NG, Martin L. J gruppentherapie für die fibromyalgie. [Interdisciplinary group Rheumatol 1992 May;19(5):709-15. therapy for fibromyalgia]. Z Rheumatol 1998 Apr;57(2):89-94. 18. Burckhardt CS, Clark SR, Bennett RM. The fibromyalgia

28 The Permanente Journal / Summer 2000 / Volume 4 No. 3 By Jeanne L. Leventhal, MD

clinical contributions Management of Libido Problems in Menopause

Presented at the Conjoint Annual Meeting of the American Soci- 45-59 Years 60-74 Years 75+ Years ety for Reproductive Medicine and the Canadian Fertility and Andrology Society 32nd Annual Postgraduate Program, Toronto, 40% 38% Canada, September 25-26, 1999, and published as a course hand- out to participants. 35% 30% Sexuality and Aging 23% 25% Menopausal and postmenopausal women can ex- 19% perience decreases in both libido, orgasm, and 20% 16% frequency of coitus—most commonly because of physi- 15% ologic changes due to menopause, less commonly due 8% 10% to depression or marital discord (Figure 1). The differ- 3% ential diagnosis in women who are seen for sexual 5% difficulties during the climacteric is challenging, espe- 0% cially when symptoms such as decline in libido and/ Completely Impotent Moderately Impotent Reproduced by permission of the author and publisher from: Jacoby S. Great sex: what's age got to do with it? [Results of 8 or persistent dyspareunia occur simultaneously with AARP/Modern Maturity Sexuality Survey conducted by NFO Research, Inc]. Modern Maturity 1999 Sep-Oct:41-5, 91. depression and marital discord. Estrogen, with or with- Figure 2. Importance by age (N=635) out androgen, can ameliorate the physiologic changes of menopause affecting sexuality. Depression can be postmenopausal women) can further affect the treated with psychotherapy, with or without antide- sexual experience.1,2 The psychological impact of pressant drugs. Marital discord is best treated with these sexual changes is varied and can be very couples therapy. The marital difficulties can either be disturbing to women and to their partners. the cause or the consequence of changes in sexual Although the ratio of dysthymia and depression activity. In the latter case the marital discord resolves is as high as 2:1 in women versus men, many of with the return of regular coital activity. these women are not treated for this depression The physiologic changes of menopause affect- and thus enter the menopausal years with untreated ing sexual response are largely mediated by depressive illness.3-5 Depression can itself cause de- estrogen. The most notable effect is on orgasmic creased libido as well as marital problems and can response: Altered nerve function due to the complicate any sexual problems arising from meno- hypoestrogenic state of menopause may delay cli- pause. In addition, hot flushes and consequent toral reaction time and result in slow or absent nonrestorative sleep can complicate all these clini- The physiologic orgasmic response. This effect, along with delayed cal situations. changes of or absent vaginal secretion, diminished orgasmic Medication and illness in the postmenopausal years menopause platform (ie, decreased or absent congestion in the can affect sexuality and can complicate existing physi- affecting sexual outer third of the vagina), and painful uterine con- ologic changes associated with menopause.6 The newer response are tractions (in some 60- to 70-year-old forms of antidepressant medication, ie, selective sero- largely mediated tonin reuptake inhibitors (SSRIs), may cause slowed by estrogen. The most notable effect or absent orgasm and can reduce or eliminate libido Interpersonal is on orgasmic Psychological in some women. Illness can decrease desire or simply response. make sexual activity inadvisable, given illness-associ- ated lack of energy or anatomic difficulties.7 Sexual Function In about one third of couples, male sexual dys- at Menopause function contributes to decreased frequency of coitus (Figure 2); the remaining two thirds of couples are affected by physiologic factors of menopause (Fig- Sociocultural Biological ure 3).8 The psychological aspects of aging are less a factor in decreased coital activity than the physiologic Figure 1. Factors impacting changes in sexual function effects of aging and the way couples adjust to those at menopause changes. Couples may choose to include alternatives

JEANNE L. LEVENTHAL, MD, has been with Northern California Kaiser Permanente since 1985. She is currently the Regional Director of the Northern California Kaiser Psychiatry Women’s Health Project, as well as a regional champion for Best Practices in Menopause, Postpartum Depression, Premenstrual Syndrom, and Libido and Menopause. E-mail: [email protected]

The Permanente Journal / Summer 2000 / Volume 4 No. 3 29 to genital-genital contact if the male partner is hav- Clinical View of Sexual Functioning ing erectile problems; increased nonpenile stimulation Davidson16 divided sexual functioning into behav- may be helpful for women who have delayed re- ior and potency, whereas Sarrel and Whitehead8

clinical contributions sponse; and couples may develop a more flexible divided sexual functioning into the desire phase, attitude toward their sexuality.10 excitement phase, orgastic phases, and dyspareunia. Sexual problems are numerous in the US popula- Both are useful ways to view sexual functioning when tion and increase with aging. The scientific literature evaluating perimenopausal and postmenopausal indicates, however, that sexual problems in elderly women. These classifications are shown in Table 1.9,16 people are often anatomic or physiologic in nature,11,12 whereas sexual problems in younger people tend to Sex and Menopause: Studies on Etiology of be more psychological and sociocultural.13 Because Decreased Coitus of the complexity of sexual problems in postmeno- Sexual research on sexual functioning during the pausal women, gynecologists and primary care climacteric has been studied for 30 years. This re- physicians have a central role in expediting the dif- search has approached the issue from different points ferential diagnosis and treatment (Figure 4).14,15 of view, including biologic, psychiatric, anthropologic, and sociologic. The two main conclusions are that 35.0% decreasing sexual activity in a woman results in part 30.9% 30.9% from decreasing sexual functioning of her male part- 30.0% ner and in part from anatomic and physiologic changes associated with her menopause. The repre- 23.0% 25.0% sentative studies are summarized in Table 2.17-25 The 18.5% 20.0% 17.4% large majority of these studies found a decrease in coitus and sexual interest of greater than 40% within 15.0% a few years of the menopause. 9.0% 10.0% Physiologic Changes at Menopause and Their 5.0% Effect on Sexuality Hormones affect sexual arousal through sensory 0.0% perception, central as well as peripheral nerve trans- Touch Loss of Vaginal Secondary Primary Vaginismus Impaired Clitoral Dryness Non- Non- mission and discharge, peripheral blood flow, and Sensation Orgasmic Orgasmic capacity to develop muscle tension. Impairment of Reproduced by permission of the author and publisher from: Sarrel PM, Whitehead MI. Sex and menopause: defining the issues. Maturitas 1985 Sep;7(3):217-24.9 this mechanism can lead to diminished sexual re- Figure 3. Specific problems reported by women at a London menopause clinic (N=178) sponsiveness, dyspareunia, decreased sexual activity, decline in sexual desire, and sexual aversion. Decreasing estrogen affects the integrity of female reproductive tract tissues. Decreased vaginal lubrica- Decline in Decline in Physical Health Androgen Levels tion and atrophic vaginitis result in dyspareunia. Decline in Decreased blood flow to the reproductive organs Sexual Activity Decline in results in diminished vasocongestion. Progressive is- Desire chemia, thinning of the barrier layers of skin and Sexual Function mucous membrane tissue, loss of subcutaneous fat, and Aging and a shrinking introitus are among many changes Delayed Orgasm which occur in the genital structures as a result of Fear of Sexual or Anorgasmia Relations hypoestrogenemia. Extragenital effects include loss of pelvic muscle tone, decreased intraurethral pres- Adapted and reproduced by permission of the authors and publishers from: Sherwin BB, sure, a smaller bladder, and thinning of the mucous Belfand MM. The role of androgen in the maintenance of sexual functioning in Dyspareunia and oophorectomized women. Phychosom Med 1987 membrane lining of the bladder and urethra. These Vulvar/Vaginal Atrophy Jul-Aug;49(4):397-40914; and Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen effects have been found to be somewhat ameliorated Decline in replacement in postmenopausal women dissatisfied with estrogen-only therapy. Sexual by continuing sexual activity despite no estrogen re- Estrogen Levels behavior and neuroendocrine responses. J Reprod Med 1998 Oct;43(10):847-56.15 placement. Women who were sexually active had Figure 4. Process of aging less atrophy than those who were not.26 In general,

30 The Permanente Journal /Summer 2000 / Volume 4 No. 3 clinical contributions

the health of the vaginal tissues decline in the ab- The evidence that testosterone affects libido in women sence of estrogen stimulation, despite sexual activity. draws from clinical research on women who have lost The physiology of the sexual response changes with ovarian testosterone production.33,34 The best known of Decreasing sexual prolonged hypoestrogenemia. These changes include that research was done by Sherwin35, who examined activity in a diminished and slowed clitoral reaction time, dimin- mood, memory, and libido before and after surgical woman results in ished or absent secretion by the Bartholin glands, oophorectomy in the absence of preexisting depres- part from delayed or absent vaginal secretion, decreased vagi- sive illness. With regard to testosterone and libido, decreasing sexual nal length, and decreased transcervical width as well Sherwin35 found that in surgically menopausal women, functioning of her as possible painful uterine contractions in women aged women receiving estrogen-testosterone preparations male partner and in part from 60 years to 70 years. Lack of estrogen decreases blood reported higher levels of sexual desire and arousal and anatomic and flow to the genitalia, and one study found a 50% in- higher frequency of sexual fantasies compared with physiologic crease in vulvar blood flow measured women treated postoperatively with estrogen alone or changes associated ultrasonographically when estradiol treatment was with placebo. Other research on replacement therapy with her initiated.27 Ovarian steroids affect nerve cell growth, in postmenopausal women described use of estrogen menopause. proliferation, transmission time, and rate of discharge versus estrogen-testosterone and found that libido im- along nerve fibers. A hypoestrogenemic state results proved in the combined treatment group only.36-39 in altered nerve function. Possible clinical manifesta- Evidence shows that to the degree loss of testosterone tions of change in peripheral nerve function in affects libido in postmenopausal women, testosterone postmenopausal women are numbness, itching, cloth- replacement can improve libidinal functioning.40,41 ing intolerance, increased 2-point discrimination Moreover, hormone replacement therapy itself can threshold, paresthesia, loss of clitoral reaction sensa- decrease libido through the effect of different forms of tion, and decreased capacity for orgasm.28,29 Ovarian estrogen on sex-hormone-binding globulin (SHBG).42 steroids can also affect neurotransmitters centrally, al- In this circumstance, estrogen replacement stimulates though this topic is beyond the scope of this article. production of SHBG and thus results in reduced levels All these changes affect desire, mainly through aver- of free estradiol and free testosterone. These reduc- sion. A postmenopausal patient’s experiences of tions can cause return of hot flushes and dyspareunia persistent dyspareunia, postcoital bleeding, delayed as well as decrease in libido. The increase in SHBG can or absent lubrication, and delayed or absent orgasm be ameliorated by prescribing a combined testosterone affect her motivation for sexual intercourse. Pain can and estrogen preparation, by changing to an estrogen cause vaginismus, a conditioned response to painful preparation that does not stimulate SHBG as greatly, or coitus. Lack of sexual relations due to physiologic by prescribing testosterone along with the estrogen change may then be further complicated by the effect preparation the patient is already on. of this condition on the marital relationship. Decline in sexual relations may cause a couple to respond or Table 1. Views of Sexual Function from a Clinical Perspective: Comparison of Published Studies cope in ways that lead to further decline in coitus and further deterioration of the marital relationship. Behaviors associated with libido or sexual motivation: sexual desire, sexual fantasies, and Testosterone and Libido satisfaction or pleasure Davidson16 Androgen levels in postmenopausal women decline over time. The impact of this decline on libido de- Potency: pelvic vasocongestion, orgasmic pends on the woman’s inherent biologic sensitivity to contractions, and possible extragenital responses testosterone, her sexual history, and many other fac- Desire phase: loss of desire or sexual aversion tors. Half of postmenopausal women continue to secrete appreciable amounts of testosterone from their Excitement phase: touch sensation impairment, ovaries, whereas the other half of postmenopausal loss of clitoral sensation, vaginal dryness, and urinary incontinence women have negligible ovarian production of test- Sarrel and Whitehead9 osterone.30 In postmenopausal women who still secrete Orgasmic phase: primary or secondary testosterone, testosterone levels may be approximately 31 50% lower than in premenopausal, younger women. Dyspareunia: vaginal dryness, vaginismus as Postmenopausal ovarian stromal tissue secretes test- conditioned response to painful penetration osterone but little to no androstenedione.32

The Permanente Journal / Summer 2000 / Volume 4 No. 3 31 Libido and the Psyche For depression or anxiety disorders to be the cause of Physiologic problems must always be treated de- decrease in libido, onset of the psychiatric illness must spite presence of psychiatric illness, because these two be established and correlated with the onset of sexual clinical contributions For depression or factors can have an indistinguishably intertwined im- symptoms. Depression and anxiety in women may di- anxiety disorders to pact on libido and coital activity. Dyspareunia-related rectly affect libido and sexual response through loss of be the cause of decrease in frequency of coitus can be the primary desire and also may affect the woman’s sexual partner in decrease in libido, cause of marital problems and can present as a mari- that he stops initiating sexual relations. Libido can be onset of the tal problem when in fact physiologic problems of affected by marital stress as well as by accumulated an- psychiatric illness menopause are the cause of the change in libido. Lack ger between the couple. Both these factors should be must be established of libido due to low testosterone levels can induce the taken into account when evaluating decrease in libido.13 and correlated with same type of marital conflict, a circumstance that can However, the chronicity of the coital problem and of the the onset of sexual in turn mislead physicians into diagnosing a psycho- libidinal problem is a critical aspect of determining the symptoms. logical problem as the cause of the lack of libido. cause of decreasing libido and frequency of coitus.

Table 2. Epidemiological Studies of Sexual Complaints in the Menopausal Female

53% decrease in coitus Kinsey et al, 195317 48% decrease in orgasm

University Menopause Clinic in Bologna Five times as many postmenopausal women as premenopausal women had ceased having coitus Bottiglioni et al, 198218 Postmenopausal women reported coitus less satisfying, decline in orgasmic frequency, 79% decrease in sexual interest

McCoy et al, 198519,20 85% decrease in sexual interest

Sarrel and Whitehead, 19859 39% decrease in sexual interest

250 black women in Lagos 40% increase in dyspareunia within one to three years of 21 Bajuliye and Sarrel, 1986 menopause and 47% loss of sexual desire; by nine years postmenopausal, 70% had ceased sexual activity compared with 10% of their premenopausal partners

800 Swedish women Extensive medical, psychiatric, and psychologic evaluation Hällström et al, 197322 181 postmenopausal women had: marked decline in sexual interest, a decline in capacity for orgasm, an increase in dyspareunia, and a decrease in coital activity

448 Swiss women Keep and Kellerhals et al, 197423 Menopause led to a decrease in the frequency of sexual activity, decrease in the quality of the sexual experience; greatest decline was among the lower social classes

Longitudinal study of menopause in Sweden 52% decrease in sexual interest Hällström, 197724 20% decrease in orgasm frequency Decrements related to menopause and not to aging

Hällström and Samuelsson, 199025 33% decrease in sexual interest

32 The Permanente Journal /Summer 2000 / Volume 4 No. 3 clinical contributions

Many perimenopausal and postmenopausal women of sexual desire was highly correlated with former have untreated dysthymia, a new episode of depres- sexual activity. An additional finding was that antici- sion, or an untreated anxiety disorder. Because of pation of declining desire predicted decline in desire. the high prevalence of these untreated psychiatric Sexual scripts may require people to adapt to the For marital illnesses, the likelihood of psychiatric comorbidity in challenges of aging. Geriatric problems with health, problems to be the cause of decrease postmenopausal women is high.43 pulmonary function, cardiovascular function, and in libido, the Many types of medication used to treat psychiatric mobility may all affect a woman’s ability to have 7 marital problems illness can lead to a decrease in libido or orgasm. sexual relations. Degree of comfort with alternative must precede the This issue will be reviewed in another article on the modes of sexual interaction may also affect her abil- decrease in libido newer forms of antidepressant medication. Because ity to have continued sexual relations.46 and must be prevalence of depression and anxiety disorders is somewhat long- higher in women than in men and often remains Summary standing. untreated, the probability of a comorbid psychiatric Coital and libidinal change can be singularly caused disorder developing in midlife patients is high. Con- by anatomic and physiologic change associated with sequently, evaluation for problems of libido requires the climacteric—by psychiatric illness, by marital dis- in-depth evaluation for depression and anxiety as cord, or by a combination of all these factors. The well as for marital discord. ideal treatment for women in midlife is complete Psychological barriers to continued sexual function- evaluation of the factors affecting sexuality and use ing can also exist. Women who did not find sex of a combined treatment approach to ameliorate these pleasurable before menopause may look forward to factors. Use of such an individualized approach can ceasing sexual activity after menopause. Women with enable the women in midlife to continue to have a problems in their marital relationships may have re- satisfying sexual life, should they choose to do so. ❖ sentment toward their spouses, and menopause may give these women permission to decline sex. Some women were raised to believe that sexual relations References 1. Goldstein MK, Teng NN. Gynecologic factors in sexual end at a certain age, and altered body image due to dysfunction of the older woman. Clin Geriatr Med 1991 atrophic changes can impact libido. Consideration of Feb;7(1):41-61. these factors is necessary for understanding libido 2. Sarrel PM. Sexuality and menopause. Obstet Gynecol 1990 and the psyche.44 For marital problems to be the cause Apr;75(4 Suppl):26S-30S; discussion 31S-35S. of decrease in libido, the marital problems must pre- 3. Weissman MM, Klerman GL. Sex differences and the epidemiology of depression. Arch Gen Psychiatry 1977 cede the decrease in libido and must be somewhat Jan;34(1):98-111. long-standing. 4. Weissman MM, Klerman GL. Gender and depression. Trends Neurosci [TINS] 1985 Sep;8(9):416-20. Cultural issues 5. Nolen-Hoeksema S. Sex differences in unipolar depression: evidence and theory. Psychol Bull 1987 Mar;101(2):259-82. Cultural issues too can affect a woman’s view of 6. Deamer RL, Thompson JF. The role of medications in geriatric herself and thus can affect her psyche as well as sexual function. Clin Geriatr Med 1991 Feb;7(1):95-111. her libido. Societal attitudes toward sex in midlife 7. Mooradian AD. Geriatric sexuality and chronic diseases. Clin affect behavior.12 A woman’s value as a sexual per- Geriatr Med 1991 Feb;7(1):113-31. son increases or decreases postmenopausally 8. Great sex: what’s age got to do with it? [Results of AARP/ 12 Modern Maturity Sexuality Survey conducted by NFO Research, according to the society in which she lives. In a Inc]. Modern Maturity 1999 Sep-Oct:41-5, 91. Nigerian study, most of the older women became 9. Sarrel PM, Whitehead MI. Sex and menopause: defining the sexually abstinent.21 In contrast, older women in al- issues. Maturitas 1985 Sep;7(3):217-24. most 25% of primitive societies were seen as less 10. Barber HR. Sexuality and the art of arousal in the geriatric inhibited, became more sexually active, and were woman. Clin Obstet Gynecol 1996 Dec;39(4):970-3. 11. Pfeiffer E, Verwoerdt A, Davis GC. Sexual behavior in more attractive to young men. Thus, societal con- middle life. Am J Psychiatry 1972 Apr;128(10):1262-7. 21 text can substantially affect women’s libido. 12. Sarrel PM. Sexuality in the middle years. Obstet Gynecol Previous sexual functioning has also proved to be Clin North Am 1987 Mar;14(1):49-62. a predictor of future sexual functioning. Koster and 13. Frank E, Anderson C, Rubinstein D. Frequency of sexual 45 dysfunction in “normal” couples. N Engl J Med 1978 Jul Garde examined sexual wellness in Danish women 20;299(3):111-5. aged 40, 45, and 51 years by in-person interview and 14. Sherwin BB, Gelfand MM. The role of androgen in the by questionnaire and found that current frequency maintenance of sexual functioning in oophorectomized women.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 33 Psychosom Med 1987 Jul-Aug;49(4):397-409. Tresquerres JAF. Testosterone and 17 beta-oestradiol secretion 15. Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen of the human ovary. II. Normal postmenopausal women, replacement in postmenopausal women dissatisfied with postmenopausal women with endometrial hyperplasia and estrogen-only therapy. Sexual behavior and neuroendocrine postmenopausal women with adenocarcinoma of the endometrium. Maturitas 1997 Jan;2(1);7-12.

clinical contributions responses. J Reprod Med 1998 Oct;43(10):847-56. 16. Davidson JM, Gary GD, Smith ER. The sexual 32. Longcope C, Hunter R, Franz C. Steroid secretion by the psychoendocrinology of aging. In: Meites J, editor. Neuroendo- postmenopausal ovary. Am J Obstet Gynecol 1980;138:564-8. crinology of aging. New York. Plenum Press; 1983. p. 221-58. 33. Plouffe L Jr, Cohen DP. The role of androgens in meno- 17. Institute for Sex Research. Sexual behavior in the human pausal hormone replacement therapy. In: Lorrain J, Plouffe L Jr, female. Alfred C. Kinsey [and others]. Philadelphia: Saunders; 1953. Ravnikar V, Speroff L, Watts N, editors. Comprehensive 18. Bottiglioni F, De Aloysio D. Female sexual activity as a management of menopause. New York: Springer-Verlag; 1994. p. 297-308. [Clinical perspectives in obstetrics and gynecology] function of climacteric conditions and age. Maturitas 1982 Apr;4(1):27-32. 34. Sherwin BB. Impact of progestins on mood and cognition in 19. McCoy N, Culter W, Davidson JM. Relationships among women [abstract]. Presented at the: North American Menopause Society, Chicago, IL, September 26-28, 1996. sexual behavior, hot flashes, and hormone levels in perimenopausal women. Arch Sex Behav 1985 Oct;14(5):385-94. 35. Sherwin B. Changes in sexual behavior as a function of plasma sex steroid levels in post-menopausal women. Maturitas 20. McCoy NL, Davidson JM. A longitudinal study of the effects 1985 Sep;7(3):225-33. of menopause on sexuality. Maturitas 1985 Sep;7(3):203-10. 21. Bajulaiye O, Sarrel PM. A survey of perimenopausal 36. Cardozo L, Gibb DM, Tuck SM, Thom MH, Studd JW, Cooper DJ. The effects of subcutaneous hormone implants symptoms in Nigeria. In: Notelovitz M, van Keep PA, editors: The climacteric in perspective. Proceedings of the Fourth during climacteric. Maturitas 1984 Mar;5(3):177-84. International Congress on the Menopause, held at Lake Buena 37. Cardozo L, Gibb DM, Studd JW, Tuck SM, Thorn MH, Vista, Florida, October 28-November 2, 1984. Lancaster, Boston: Cooper DJ. The use of hormone implants for climacteric MTP Press Limited; 1986. p. 161-75. symptoms. Am J Obstet Gynecol 1984 Feb 1;148(3):336-7. 22. Hällström T. Mental disorder and sexuality in the climacteric: 38. Burger HG, Hailes J, Menelaus M, Nelson J, Hudson B, a study in psychiatric epidemiology. Goteborg: Esselte studium; Balazs N. The management of persistent menopausal symptoms 1973. [Reports from the Psychiatric Research Centre, St. Jörgen’s with oestradiol-testosterone implants: clinical, lipid and Hospital; 6. Scandinavian University Books] hormonal results. Maturitas 1984 Dec;6(4):351-8. 23. Keep PA van, Kellerhals JM. The impact of socio-cultural 39. Burger H, Hailes J, Nelson J, Menelaus M. Effect of factors on symptom formation. Some results of a study on combined implants of oestradiol and testosterone on libido in ageing women in Switzerland. Psychother Psychosom postmenopausal women. Br Med J (Clin Res Ed) 1987 Apr 1974;23(1-6):251-63. 11;294(6577):936-7. 24. Hällström T. Sexuality in the climacteric. Clin Obstet 40. Graziottin A. Loss of libido in the postmenopause. Gynaecol 1977 Apr;4(1):227-39. Menopausal Med 2000 Spring;8(1):9-12. 25. Hällström T, Samuelsson S. Changes in women’s sexual 41. Davis SR. Androgen treatment in women. Med J Aust 1999 desire in middle life: the longitudinal study of women in Jun 7;170(11):545-9. Gothenburg. Arch Sex Behav 1990 Jun;19(3):259-68. 42. Nachtigall LE, Raju U, Banerjee S, Wan L, Levitz M. Serum 26. Masters WH, Johnson VE. Human sexual response. Boston: estradiol-binding profiles in postmenopausal women undergo- Little, Brown; 1966. ing three common estrogen replacement therapies: associations with sex hormone-binding globulin, estradiol, and estrone 27. Sarrel PM. Progestogens and blood flow. In: Proceedings of the Consensus Development Conference on Progestogens, levels. Menopause 2000 Jul-Aug;7(4):243-50. Naples, 1988. Int Proc J 1989;1(101):226-71. 43. In: Jensvold MF, Halbreich U, Hamilton JA, editors. Psychopharmacology and women: sex, gender, and hormones. 28. Rauramo L. Estrogens and psychic function. In: van Keep Washington DC: American Psychiatric Press; 1996. PA, Lauritzen C, editors. Ageing and estrogens; workshop conference in Geneva, October 5-6, 1972. Sponsored by the 44. Barbach L. Sexuality through menopause and beyond. International Health Foundation, Geneva. Basel, New York: Menopause Manage 1996 Nov-Dec;5(5):18-21. [Originally Karger 1973. [Frontiers of human research, v. 2] published in: The pause: positive approaches to menopause by 29. Sarrel L, Sarrel P. Sexual turning points: the seven stages of Lonnie Barbach. Copyright © Lonnie Barbach, 1993. Dutton Signet/Penguin Books.] adult sexuality. New York: MacMillan; 1984. 45. Koster A, Garde K. Sexual desire and menopausal 30. Lucisano A, Acampora MG, Russo N, Maniccia E, Montemurro A, Dell’Acqua S. Ovarian and peripheral plasma development. A prospective study of Danish women born in 1936. Maturitas 1993 Jan;16(1):49-60. levels of progestogens, androgens and oestrogens in postmeno- pausal women. Maturitas 1984 Jul;6(1):45-53. 46. Bachmann GA. Sexual issues at menopause. Ann N Y Acad Sci 1990;592::87-94; discussion 123-33. 31. Botella-Llusia J, Orio-Bosch A, Sanchez-Garrido F,

Our Contemporary World Everything, absolutely everything in our contemporary world, has been tailed to the measure of men. Eva Peron, 1919-1952, First Lady of Argentina, women’s suffrage and social activist

34 The Permanente Journal /Summer 2000 / Volume 4 No. 3 By Diana B. Petitti, MD;

Stephen Sidney, MD; clinical contributions Likelihood That a Woman Will Have No Charles P. Quesenberry, Jr, PhD; Major Risk Factors At the Time of First Arthur L. Klatsky, MD Myocardial Infarction or Stroke

This article describes an analysis of data from a case-control study of myocardial infarc- tion (MI) and ischemic stroke in women aged 45-74 years who had been inpatients at any of 10 Kaiser Permanente Northern California (KPNC) facilities from November 1991 to November 1994. Information on major risk factors for ischemic stroke (ie, diabetes, hypertension, and smoking) and MI (ie, diabetes, hypertension, smoking, and hypercholesterolemia) known at the time of the MI event was obtained at patient interviews. The percentage of patients and controls who had MI or The presence or stroke and one, two, three, or (for MI) four major risk factors was calculated along with the odds absence of risk ratio and 95% confidence intervals for stroke according to the number of major risk factors. factors can In 25.8% of women with incident ischemic stroke and 17.5% of women with incident MI, no influence major risk factors for the disease were identified at time of hospital admission. Among women with physicians’ incident stroke, absence of major risk factors was associated with younger age; among women with MI, assessment of absence of major risk factors was associated with older age, although the changes with age were not disease probability as well as their statistically significant in this group. Among women who had only one of these major risk factors at decisions about presentation, hypertension was seen significantly more often with increasing age, whereas among women diagnostic testing who had stroke or MI, smoking was the risk factor seen significantly less often with increasing age. in people who The data show that a substantial minority of female patients with incident stroke and MI present with have no identified major risk factors at the time of their MI event. symptoms of MI or Introduction woman with risk factors but may be reasonably fore- stroke. Epidemiologic research over the last three decades gone in the woman without risk factors. has elucidated a number of important risk factors for Largely absent from the literature on cardiovascular myocardial infarction (MI) and stroke. That hyperten- epidemiology is information on the likelihood that a sion, diabetes, and cigarette smoking increase the risk person will not have any risk factors when they are first of both MI and ischemic stroke is now well estab- seen with cardiovascular disease. Information about lished.1,2 These factors are associated with an increased cardiovascular disease and risk factors in women is risk for MI and stroke in women as well as in men.3 particularly sparse, because women have not been the High levels of total serum cholesterol are an estab- subject of intensive epidemiologic investigation until Largely absent lished risk factor for MI in both men and women,1 but recently. The present analysis of data from a previously from the literature the question of whether high cholesterol increases the completed study was done to answer the question: What on cardiovascular risk for stroke remains controversial.2 is the likelihood that women with a confirmed diagno- epidemiology is For persons with MI and stroke, recognition and iden- sis of MI or stroke have no identified major risk factors information on the tification of risk factors is an important part of clinical when they present with the condition? likelihood that a care because postevent efforts to prevent recurrent dis- person will not have any risk ease are increasingly focused on management of these Methods factors when they Case Ascertainment and Classification risk factors. The presence or absence of risk factors can are first seen with influence physicians’ assessment of disease probability The methods used for case ascertainment and clas- cardiovascular as well as their decisions about diagnostic testing in sification have been described in detail elsewhere.4,5 disease. people who present with symptoms of MI or stroke. A Briefly, an attempt was made to identify all fatal and 40-year-old woman with vague chest pain who also nonfatal strokes and MIs in women aged 45-74 years smokes, has hypertension, and serum cholesterol level who had been inpatients in any of 10 medical cen- of 300 mg/dL is more likely to have coronary disease ters of Kaiser Permanente Northern California (KPNC) than a normotensive nonsmoker with a cholesterol level from November 1991 to November 1994. Sources for of 180 mg/dL who has the same kind of chest pain. case ascertainment included hospital admission and Given the probability of coronary artery disease, tread- discharge records, emergency department logs, and mill testing is a reasonable diagnostic choice in the payments for out-of-plan hospitalizations.

DIANA B. PETITTI, MD (not pictured) is the Director of Research and Evaluation for Kaiser Permanente’s Southern California Division, where she has been since 1993. She is a recognized expert on hormones and disease. E-mail:[email protected] STEPHEN SIDNEY, MD, MPH (right, top), is the Associate Director for Clinical Research at the Division of Research in Oakland, California and a Consultant at the University of California School of Public Health. E-mail [email protected] CHARLES P. QUESENBERRY, JR, PhD (not pictured) has spent 14 years with the Division of Research in Oakland, where he currently works as a biostatistician. E-mail: [email protected] ARTHUR L. KLATSKY, MD, is a Senior Consultant in Cardiology for The Permanente Medical Group, Inc. (TPMG) in Oakland, and is an Associate at the Division of Research. He is also an Associate Editor for The Permanente Journal. E-mail: [email protected]

The Permanente Journal / Summer 2000 / Volume 4 No. 3 35 Stroke was defined as the new onset of rapidly devel- trols were selected at random from among all female oping symptoms and signs of loss of cerebral function members of the Kaiser Permanente Medical Care Pro- with no apparent cause other than that of vascular ori- gram. If the first potential control could not be located,

clinical contributions gin. Patients who had a history of cerebrovascular declined to participate, or spoke a language other than disease were excluded. Details of our protocol for veri- English or Spanish, an attempt was made to enroll the fying the diagnosis of stroke and for subclassifying stroke second potential control and, if necessary, the third. by type appear in our prior publication.5 The present analysis includes only stroke classified as ischemic. Information Sources Diagnostic criteria for myocardial infarction were Eligible patients and controls were interviewed in adapted from those of the American Heart Associa- person by trained interviewers using a standardized tion Council on Epidemiology.6 These criteria use instrument. If a study subject had died or was unable presence or absence of chest pain, results of cardiac to communicate verbally, an attempt was made to in- enzyme measurement, and electrocardiograms to clas- terview a proxy. Interview questions pertained to an Hypertension, sify events as definite, probable, or suspect MI or not index date, which was the date of symptom onset for diabetes, and MI. Consistent with other epidemiologic studies of MI each case and matched control. current smoking based on these criteria, we included events catego- Hypertension, diabetes, and current smoking were were considered rized as definite or probable MI. considered major risk factors for ischemic stroke. These major risk factors for ischemic For each patient, an attempt was made to interview three factors plus hypercholesterolemia were consid- stroke. These three one control, matched by year of birth as well as medi- ered major risk factors for MI. factors plus cal facility at which care was usually received. To obtain Family history was not considered as a major risk hypercholesterolemia one interviewed control per case, three potential con- factor because it is not generally described as a ma- were considered Table 1. Number and percentage distribution of major risk factors for myocardial infarctiona and major risk factors b for MI. ischemic stroke in patients and controls and age-adjusted odds ratios by number of risk factors Myocardial infarction Ischemic stroke

Number (%)Age-adjusted Number (%) Age-adjusted No. of major odds ratio odds ratio risk factors Patients Controls (95% CI) Patients Controls (95% CI)

0 93 (17.5) 269 (49.4) 1.0 (referent) 105 (25.8) 240 (56.9) 1.0 (referent)

1 225 (42.3) 197 (36.1) 3.3 (2.4, 4.5) 185 (45.5) 145 (34.4) 3.0 (2.2, 4.1)

HBP only 69 (13.0) 71 (13.0) 2.6 (1.7, 3.9) 97 (23.8) 84 (19.9) 2.7 (1.8, 3.9)

DM only 37 (7.0) 14 (2.6) 7.2 (3.7, 29 (6.9) 12 (2.8) 5.5 (2.7, 11.3) 14.0)

Smoking only 75 (14.1) 54 (9.9) 4.3 (2.8, 6.7) 59 (14.5) 49 (11.6) 2.8 (1.8, 4.3)

High cholesterol 44 (8.3) 58 (10.6) 2.1 (1.3, 3.3) ------only

2 171 (32.1) 73 (13.4) 6.8 (4.7, 9.7) 111 (27.3) 35 (8.3) 7.4 (4.7, 11.5)

3 37 (7.0) 6 (1.1) 17.9 (7.3, 43.8) 6 (1.5) 2 (0.5) 6.7 (1.3, 33.8)

4 6 (1.1) 0 (0.0) Inestimable ------

All 532 545 407 422

a Major risk factors for myocardial infarction are hypertension, diabetes, smoking, and high cholesterol level. b Major risk factors for ischemic stroke are hypertension, diabetes, and smoking. Note: Due to rounding, percentages do not total 100.0.

36 The Permanente Journal /Summer 2000 / Volume 4 No. 3 clinical contributions

jor risk factor, and because no standard definition of Table 1 shows the distribution of ischemic stroke and positive family history exists for either stroke or MI. MI among patients and controls according to number Other risk factors for MI, stroke, or both (eg, of major risk factors along with age-adjusted odds ra- homocysteinemia and fibrinogen levels, markers of tios for stroke and MI in women who had one, two, response to chronic inflammation) were not assessed three, or (for MI) four major risk factors. Also shown and could not be examined as risk factors. are the age-adjusted odds ratios for ischemic stroke and Hypertension was defined as a “yes” to a question MI in women with only one major risk factor according Among women about use of medication for high blood pressure. Dia- to the risk factor. The odds ratios for both stroke and with stroke, 25.8% betes was defined as a “yes” to a question asking about MI increased according to the number of major risk had no major risk use of insulin or pills for diabetes. Women who stated factors. For women with one major risk factor, odds factors identified that they had been told by a physician that they had a ratios were highest in women with diabetes for both at the time of the high cholesterol level were classified as having hyper- ischemic stroke and MI, although the 95% confidence incident event. Among women cholesterolemia. We did not use measured levels of limits for these estimates overlapped. with MI, 17.5% cholesterol, because data were missing for a large per- Among women with stroke, 25.8% had no major had no major centage of subjects. A study subject was defined as a risk factors identified at the time of the incident event. identified risk nonsmoker if she answered “no” to the question, “Have Among women with MI, 17.5% had no major identi- factors. you ever smoked cigarettes?”; if she answered “yes” to fied risk factors. this question, she was categorized as a current regular Table 2 shows the percentage distribution of major smoker on the basis of her answer to the question, risk factors for ischemic stroke by age for patients only. “On [index date], were you still smoking regularly?” The percentage of patients with incident stroke who had (Regularly means at least five cigarettes per week, al- no major risk factors decreased with age, but the change most every week.) On the basis of this information, with age was not statistically significant (p = 0.08). study subjects were classified as having one, two, three, Table 3 shows the percentage distribution of major or (for MI) four major risk factors. risk factors for MI by age for patients only. The per- centage of patients with incident MI who had no Analysis major risk factors increased with age, but the change The exposure odds ratio was used to estimate rela- with age was not statistically significant (p = 0.15). tive risk of ischemic stroke and MI in women with Table 2. Number and percentage distribution of major risk factorsa one, two, three, or (for MI) four major risk factors. for ischemic stroke in women with incident ischemic stroke by age Odds ratios for stroke and MI were estimated sepa- at event rately for each major risk factor among women with only one risk factor. The percentage of patients with No. (%) of women one, two, three, or (for MI) four major risk factors was No. of major risk also calculated by age in three categories (age 45-54 factors Age 45-54 yr Age 55-64 yr Age 65-74 yr years, age 55-64 years, age 65-74 years). The statistical significance of changes in the percentage of cases with 0 24 (35.8) 29 (21.0) 52 (25.7) no major risk factors by age was examined using the 1 26 (38.8) 65 (47.1) 94 (46.5) chi-square statistic. A probability value less than 0.05 was considered statistically significant. HBP only 8 (11.9) 29 (21.0) 60 (29.7)

Results DM only 6 (9.0) 9 (6.5) 14 (6.9) Of 758 women who had confirmed diagnoses of ischemic stroke, 407 patients and 422 controls remained Smoking only 12 (17.9) 27 (19.6) 20 (9.9) for analysis after we excluded women on the basis of patient or physician refusal, proxy interviews, and self- 2 14 (20.9) 42 (30.4) 55 (27.2) reported history of cerebrovascular disease at time of 3 3 (4.5) 2 (1.4) 1 (0.5) interview. Of 685 women who had confirmed diag- noses of definite or probable MI, 532 patients and 545 Total 67 138 202 controls remained for the analysis after we excluded a women on the basis of patient or physician refusal, Major risk factors for ischemic stroke are hypertension, diabetes, and smoking. proxy interview, and self-reported coronary heart dis- Note: Due to rounding, percentages do not total 100.0. ease at time of interview.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 37 Among patients with only one risk factor, the per- have no major risk factors identified at the time of centage of patients with only hypertension increased their event. significantly with age for patients with stroke (p < The pattern of risk factors among women with only Knowing about the clinical contributions 0.01) and for patients with MI (p < 0.01); the percent- one major risk factor is also of interest. For women epidemiologic age of patients whose only risk factor was smoking who had MI or stroke, cigarette smoking decreased associations decreased significantly with age (p < 0.05). with increasing age as a single risk factor, whereas between major risk hypertension increased with increasing age as a single factors and disease Discussion may lead risk factor in these women. physicians to Epidemiologic research has identified several major Unfortunately, we have no comparable data about men. expect that women risk factors for ischemic stroke and MI in women. Our Similar analyses of risk factors with incident disease could with disease will analysis of data from a large case-control study in not be identified for either men or women. Information have major risk women confirms that the risk of both MI and stroke is on major risk factors was derived from self-report, and factors, although substantially higher in women with these well-recog- the study results should be interpreted recognizing this we have no proof nized major risk factors, whether alone or in limitation. More important, the absence of identified major of this speculation. combination. Knowledge of the relation between these risk factors does not mean that the woman had no risk factors and disease is important for designing pro- factors; occurrence of a clinical event may prompt clini- grams aimed at preventing the diseases. cal testing that leads to a previously unrecognized Clinicians see patients—not cases and controls. diagnosis of hypertension, diabetes, or hypercholester- Knowing about the epidemiologic associations be- olemia. Thus, the present analysis should not be tween major risk factors and disease may lead interpreted to mean that no major risk factors were present physicians to expect that women with disease will at the time of the incident event, only that no major risk have major risk factors, although we have no proof of factors had been identified at that time. An increase in this speculation. Our data show that a substantial mi- rate of screening for dyslipidemia and/or hypertension nority of female patients with incident stroke and MI might change these percentages. Finally, some risk fac- tors were not considered here. These risk factors include a Table 3. Distribution of major risk factors for myocardial infarction family history of heart disease or stroke; obesity; among women with incident myocardial infarction by age at event dyslipidemias other than hypercholesterolemia; No. (%) of women hyperhomocysteinemia; and others. No. of major risk This study found that the absence of identified major factors Age 45-54 yr Age 55-64 yr Age 65-74 yr risk factors is not uncommon in women patients with incident stroke and MI. Among patients with only 0 16 (13.1) 29 (16.0) 48 (21.0) one identified major risk factor, the pattern of major risk factors changed with age. ❖ 1 48 (39.3) 74 (40.9) 103 (45.0) References HBP only 9 (7.4) 18 (9.9) 42 (18.3) 1. Labarthe DR. Coronary Artery Disease. In: Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge. Gaithersburg, Maryland: Aspen Publishers, Inc: 1998. p 43-68. DM only 7 (5.7) 11 (6.1) 19 (8.3) 2. Labarthe DR. Stroke. In: Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge. Gaithersburg, Smoking only 28 (23.0) 29 (16.0) 18 (7.9) Maryland: Aspen Publishers, Inc: 1998. p 73-89. 3. Wenger NK, Speroff L, Packard B. Cardiovascular health and High cholesterol disease in women. N Engl J Med 1993;329:247-56. 4 (3.3) 16 (8.8) 24 (10.5) only 4. Petitti DB, Sidney S, Quesenberry CP, Bernstein A. Ischemic stroke and use of estrogen and estrogen/progestogen as hormone replacement therapy. Stroke 1998;29:23-8. 2 43 (35.2) 65 (35.9) 63 (27.5) 5. Sidney S, Petitti DB, Quesenberry CP. Myocardial infarction and the use of estrogen and estrogen-progestogen in postmeno- 3 11 (9.0) 13 (7.2) 13 (5.7) pausal women. Ann Intern Med 1997;127:501-8. 6. Gillum RF, Fortmann S, Prineas RJ, Kottke TE. International diagnostic criteria for myocardial infarction and acute stroke. 4 4 (3.3) 0 (0.0) 2 (0.9) (Prepared for the Committee on Criteria and Methods, Council on Epidemiology, American Heart Association). Am Heart J Total 122 181 229 1984;108:150-8.

a Major risk factors for ischemic stroke are hypertension, diabetes, smoking, and high cholesterol level. Acknowledgments: This research was supported by a grant (R01- Note: Due to rounding, percentages do not total 100.0. HL-47043) from the National Heart, Lung, and Blood Institute.

38 The Permanente Journal /Summer 2000 / Volume 4 No. 3 By Wilson Footer, MD

Commentary by Steven A. Vasilev, MD, MBA clinical contributions Kaiser Permanente Medicine 50 Years Ago: The Gynecological Cancer Detection Clinic

From the Department of Obstetrics and Gynecology, Permanente presence of carcinoma confined to the squamous epi- Hospitals, Oakland and Richmond, California. Reprinted from the thelium at the periphery of invasive carcinoma of the Permanente Foundation Medical Bulletin. 1944 Oct;2(4):165-74. 5,6,7,8 cervix. Since then Schiller has repeatedly empha- If we had no means The greatest problem with which we are confronted sized that carcinoma of the cervix can be diagnosed of attacking this in the practice of gynecology is startlingly evident from before invasion occurs and has introduced the proce- scourge, it would the fact that “among white women cancer is the lead- dure of staining the cervix with an aqueous solution of be discouraging ing cause of death by a considerable margin for the iodine to reveal suspicious areas requiring biopsy. He enough to know as 20-year period from 35-54 years of age. A study of the has also shown that cases adequately treated in the a certainty that 14 current statistics indicates that, if present conditions of preinvasive stage are 96% curable.7 percent, or one in mortality remain unchanged, cancer will take as its toll Graves9, during nine months experience with the every seven, of the by death 14 out of every 100 women.”1 If we had no Schiller test, discovered three early cases of cancer of women in the prime of life are means of attacking this scourge, it would be discourag- the cervix, all of which, however, had had contact going to die from ing enough to know as a certainty that 14 percent, or bleeding. He believed that cancer of the cervix passes this disease. one in every seven, of the women in the prime of life through a period in its life history during which it is are going to die from this disease. The fact that this theoretically 100% curable and concluded that “pa- situation persists (in spite of knowledge that we can tients must repeatedly be on our examining tables who cure 96% of certain very malignant tumors, specifically without impairment of health, and often without symp- those of the cervix) is the greatest condemnation of the toms, harbor a disease which at the same time is present lay and professional handling of cancer. invisible to the keenest eye and intangible to the most Bowen2 reported two cases of “precancerous derma- sensitive touch.” Of the 18 cases reported by Stevenson toses” that had been present 19 and four years without and Scipiades10 two are known to have developed becoming invasive but which showed the cytological invasive carcinoma after three and eight years. changes found in undoubted cancers. Although the il- Wollmer11 stated that “It becomes evident that there lustrations of his second case have been used to are neither symptoms nor clinical findings on which demonstrate what is now called Bowen’s disease, the to base the diagnosis of cervical carcinoma in the early lesion had not become invasive. In fact Bowen cred- stage.” In one group of 35 normally menstruating ited Wende3 with demonstrating what had been women in whom he removed the entire cervical mu- suspected by others, namely, that these intraepithelial cosa he found one unsuspected epidermoid carcinoma. changes could progress to true malignancy. Schottlander In another group of 24 patients with cervicitis and and Kermauner4 have been credited with observing the erosion he found one more unsuspected carcinoma. Commentary By Steven A. Vasilev, MD, MBA The Gynecologic Cancer Detection Clinic, one of a very few in that era, was established in the face of The Gynecologic no efficacious screening modalities for cervical cancer, a potentially lethal disease that was rampant at Cancer Detection the time. Since then, screening for cervical cancer—and more important, screening for the precursors of Clinic, one of a cervical cancer—has undergone a dramatic evolution and is the focus of this commentary. Although very few in that screening programs for ovarian and endometrial cancers also have been proposed, a litany of limitations era, was has prevented adoption of these proposals, and no screening standards have yet been established. established in the face of no Early History and Development of Cervical Cancer Screening efficacious In the early 1940s, Dr George Papanicolaou proposed cytologic evaluation of cervical cells exfoli- screening ated into the vaginal pool. This method of screening for cervical cancer was further refined by Ayre in modalities for 1947 with the introduction of a wooden spatula to physically scrape cells directly from the cervical cervical cancer, a surface. Subsequently, routine practice came to include sampling of the endocervical canal by using potentially lethal disease that was a cotton-tipped applicator, an implement now largely replaced by a cytobrush, whose greater rampant at the abrasiveness produces a tenfold greater yield of endocervical cells. These low-cost technical improve- time. ments occurred after Dr Footer’s experience was published in a 1944 issue of the Permanente Foundation Medical Bulletin. Without these improvements, Footer could not help but conclude that negative results of vaginal smear were not reliable. The relatively low yield of cervical cells from the

The Permanente Journal / Summer 2000 / Volume 4 No. 3 39 Meyer12 maintained that cancer of the cervix can be of cells shed into the vaginal secretions, has been ac- recognized from fragments of superficial epithelium complished by Papanicolaou and Traut14 and verified 15 I have been able to without observing its relation to the underlying con- by Meigs, et al. Theoretically this would permit ap- clinical contributions locate only two nective tissue. This authoritative opinion substantiates plication to the general population without clinics devoted to the the value of cervical scrapings, the removal with a curet examination, that is a mass survey of the entire female early discovery of or similar instrument of the epithelium down to the population for the presence of genital cancer could genital cancer. connective tissue, in the routine study of the cervix to be conducted by having the women send a small detect occult carcinomatous changes. He believed that amount of the vaginal secretion to a central labora- these intraepithelial changes will go on to fatal invasive tory. However, the pitfalls are many and the carcinoma in the absence of treatment. practicability of such a detection program is doubtful. Knight13 reported 17 cases of noninvasive There is now no question that advanced cancer intraepithelial tumors of the cervix with an average age can be diagnosed from individual cells cast off from incidence of 44.1 years among 406 primary squamous the growth and that this method is useful when the cell epitheliomata of the cervix during a 16-year period symptoms cannot be explained by the clinical find- at the Sloane Hospital for Women. He concluded that ings. A cancer of the cervical canal or in an treatment should be just as thorough as when an inva- inaccessible recess of an irregular uterine cavity might sive tumor is being treated. The presence of carcinoma escape discovery by curettage, whereas it could be was completely unsuspected in 11 of his patients. diagnosed from cancer cells found in the smear taken Both of the methods commonly used to diagnose from the upper vagina, cervical canal or endometrial carcinoma of the cervix, namely, biopsy of the full cavity. The danger of relying upon the vaginal smear thickness of the cervix, or curettage of the cervical lies in failure to realize its limitations; all slides made canal and of the surface of the external cervix, have from positive cases do not contain the cancer cells, been shown to provide adequate material for diagno- therefore a negative test is not conclusive. Further- sis. However, the hindrance to their general application more, cancers such as the adenoma malignum of the to the entire population is obvious from a consider- fundus and cervix do not shed cells from which the ation of the skill, time and expense involved. Their diagnosis can be made. use and usefulness are dependent both upon the pa- Finally, the truly early preinvasive carcinomas of tient going to a physician and upon the physician to the cervix theoretically and practically cannot be di- whom she goes. The next step, that of diagnosing the agnosed by this method. This is obvious from a presence of cancer from individual cells and groups consideration of the method of growth and exten-

vaginal pool made it difficult to find “truly early preinvasive carcinomas,” because early dysplastic cells below the surface epthelium are not readily sloughed spontaneously. Thus, despite its labor-intensive nature and higher morbidity, the greater emphasis at the time on visual aids and directed biopsy was understand- able and predominately targeted carcinoma in situ and invasive lesions. Today, direct scraping of the cervix enables cytologic screening for the “truly early preinvasive” lesions or cervical intraepithelial neoplasia (CIN) I-III. Because progression from CIN to invasion usually takes many years, this progression is precisely where early detection and prevention of invasive cancer can make the greatest impact. Success of Modern Screening Tests for Cervical Cancer Notwithstanding Dr Footer’s positive experience with screening by visually directed biopsy, screening by exfoliative cytology (ie, Pap smear) has since been credited with having the greatest impact on reducing both the incidence of cervical cancer and the death rate therefrom. Although never the subject of prospective, randomized studies, large-scale mass screening programs consisting of yearly Pap smears were first instituted during the 1950s in British Columbia. By 1984, the result was a threefold reduction in cervical cancer incidence and fourfold fewer deaths from this disease. The Pap test was quick, simple, associated with low morbidity, and low-cost. Therefore, because of its improved sensitivity compared with the other tests of vaginal cytology, the Pap test evolved as a tool substantially more applicable to mass screening than labor- and cost-intensive visual biopsy screening. Schiller-Lugol staining (recommended by Footer as a screening method) and acetic acid wash—with or without 8-18× magnification via colposcopy—still plays a major role in management of cervical dysplasia. In

40 The Permanente Journal /Summer 2000 / Volume 4 No. 3 clinical contributions

sion of these intraepithelial tumors. The first carcino- phia,17 (where one fundal and three cervical cancers matous changes take place in the basal cells, those were discovered among 976 women) are purely diag- just above the basement membrane, and extend lat- nostic. The patients are referred elsewhere for treatment. erally and gradually upward toward the surface. When This is entirely inadequate because the significance of the surface cells are involved in the typical changes, very early lesions that are neither palpable nor visible is the presence of the cancer could theoretically be di- not generally appreciated. Another inherent defect lies agnosed by the vaginal smear method. But even here in the fact that at these clinics only patients wanting to it must be remembered that the examination by bi- be examined specifically for cancer are seen. As we opsy of all non-staining areas of the cervix is a more have shown in our clinic, it is preferable to examine direct and conclusive approach to the problem as it every woman for cancer rather than restricting our spe- involves the visible portion of the cervix. Differential cial tests to those specifically requesting it. Mortality suction curettage of the cervical canal and endome- from cancer can be reduced only on a large scale. This trial cavity are comparable procedures applicable to presupposes that the public will be made to realize the these hidden areas. In summary it can be said that importance of periodic examinations and that every none of these procedures is universally applicable one of them will be given a complete examination to but that taken together they provide all of the tools detect cancer, regardless of the patient’s complaint. The required by the thorough and inquisitive physician cancer detection clinics should be the center for the to establish the presence or absence of cancer of the dissemination of detailed information to the medical cervix and fundus of the uterus. profession so that every doctor will be able to deter- With the aid of the American Society for the Con- mine which patients require specialized attention. trol of Cancer, the National Cancer Institute (US Public Health Service), and private physicians, I have been Organization of the Cancer Detection Clinic able to locate only two clinics devoted to the early At our Cancer Detection Clinic, which in reality is discovery of genital cancer. intimately a part of the general gynecological clinic, At the Cancer Prevention Clinic at Memorial Hospi- these problems have been largely overcome. In the tal16 in New York during the 25 months from November first place literature is distributed to the women stress- 1, 1940 to January 1, 1943 among 49 malignant tumors ing the importance of periodic examinations and the found, four were of the fundus uteri, six of the cervix fact that early cancer is curable. In regard to this uteri, one of the vulva and two of the ovary. Both the program of lay education it is expected that the old clinic at Memorial Hospital, and the one in Philadel- objection will be raised that it fosters cancer phobia.

the modern paradigm, these tools are used after a screening Pap test alerts the clinician to cytologic abnormal- ity. Subsequent visually directed biopsy using these tools is currently the reference standard for diagnosing and characterizing preclinical cervical dysplasia and microinvasive carcinoma. How has screening affected mortality rates more recently? Unfortunately, despite today’s widespread availability Unfortunately, of low-morbidity cytologic screening, cervical cancer continues to develop in women. The American Cancer despite today’s Society estimates a relatively steady pattern of 16,000 new cases and 5,000 deaths yearly. In addition, the reported widespread incidence of 65,000 new carcinoma in situ cases probably represents severe underreporting of this disease. availability of low- morbidity cytologic Limitations of Cytologic Screening Tests for Cervical Cancer screening, cervical Nearly half the cases of cervical cancer in the United States are diagnosed in women who have never or rarely cancer continues to been screened. Barriers to access to Pap smear testing have been identified and targeted for elimination; however, develop in women. even when available, Pap tests do not always alter the clinical outcome. For example, in Scotland from 1982 to 1991, 63% of women who died of cervical cancer before age 45 years had received Pap tests. In addition, as many as 20% of women with CIS or invasive cervical cancer had normal Pap test results in the preceding year.1 Such reports suggest that Pap tests do not have 100% positive or negative predictive value, especially when used as the sole screening method at a single screening visit. For various reasons, sensitivity and specificity of the Pap test have been estimated only incompletely. However, a false-negative rate of 15% to 20% has been shown in many series of rereviewed Pap tests. A recent meta-analysis2 suggests that the true sensitivity may be substantially lower. Incom- pletely determined specificity and false-positive findings are also of concern.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 41 We have not seen any patients with cancer phobia, occult leucoplakia. The latter appear as pale yellow- In regard to this but many patients have come in to find out if they white in contrast to the dark mahogany brown of the program of lay have cancer or, who in the course of an examination normal staining squamous epithelium. The junction

clinical contributions education it is for some other complaint, have expressed the hope between the two is abrupt. All of the true non-staining expected that the old that they do not have cancer. If it is this doubt and areas are biopsied. In a series of 100 consecutive cer- objection will be curiosity that is usually called cancer phobia, we vixes examined the Schiller test was positive, raised that it fosters should have more of it. We cannot hope to appear non-staining, in 28 (28%). This is of importance be- cancer phobia. We consistent in our beliefs if on the one hand we ex- cause among true non-staining areas we have found have not seen any cuse the present high cancer mortality on the basis 12% to be carcinomas. These figures roughly corre- patients with cancer that the patients come late for treatment and then on spond to Schiller’s7 findings that 25% of the cervices phobia, but many the other hand condemn as neurotics all of those showed occult leucoplakias and that among these there patients have come in to find out if they who try to be examined early. were 4 to 12 percent carcinomas. From Schiller’s find- have cancer or, who The routine examination includes that of the breasts ings, which have been verified in this clinic, it is evident in the course of an and pelvic organs. Patients with suspicious lesions of that from one percent to three percent of women in the examination for the breasts are referred to the surgical service. In the age group seen in a gynecological clinic have definite some other course of the pelvic examination the cervix is cleansed carcinoma of the cervix at the time they are examined. complaint, have and inspected closely. Any gross lesions are photo- It is our opinion that cancer of the cervix in its early expressed the hope graphed in color. Then the lower cervical canal is stage can be treated best when the same person per- that they do not have cleansed by rotating a cotton swab gently to deter- forms the diagnostic procedures, studies the pathological cancer. mine whether the mucosa bleeds easily. If it does, material grossly and microscopically and carries out the suction curettage of the cervical canal is performed; if treatment, whether it be by radium or surgery. This is an insignificant amount of tissue is obtained or if steno- especially true in the very early cases where the lesion sis prevents performing this procedure, a smear is made is a small non-staining area. Such a lesion might not be from material aspirated from the cervical canal. Next included in the biopsy or in the slide. If this slide is the Lugol’s solution is applied generously with a large examined by anyone else the pathological report will well-soaked cotton swab. The excess solution can be deny the presence of malignancy. However, the per- immediately removed by a blotting motion with large son who took the material should promptly realize that cotton applicators. It is important not to rub because the section does not reveal changes compatible with the upper glycogen-containing layers may be rubbed one of the many associated with non-staining areas off, producing non-staining areas simulating those of and consequently that the slide does not contain the

One reason for “failure” of cytologic screening in individual cases (ie, false-negative or positive results) is that dysplastic lesions can spontaneously regress and recur over time. The Pap test can usually show presence or absence of abnormal cells but cannot distinguish between patients with dysplasia who will have spontaneous regression and patients in whom cancer will ultimately develop if treatment is not begun. In addition, a dysplastic lesion might not shed an adequate number of abnormal cells to provide the pathology slide with a sufficient cellular sample. For these reasons, repetitive screening at regular intervals is necessary for optimal clinical effectiveness. A single, isolated, apparently normal Pap test result has less meaning than multiple normal test results, which are associated with a much lower incidence of dysplasia or cancer. The necessary testing interval depends on presence or absence of risk factors, primarily those related to sexual transmission of human papilloma virus (HPV). Other reasons for false test results relate to technical issues. For a Pap smear to be correctly analyzed, an adequate specimen must be collected, the slide must be closely screened for abnormalities, and the abnormali- ties must be appropriately interpreted. Deficiencies in any one of these steps may explain a negative test result for a dysplastic lesion or cervical cancer. Resource Allocation for Maximally Effective Screening of Cervical Cancer Almost 50 years after the Footer report, we still must recognize screening limitations as we develop and select appropriate adjuvant testing modalities. Proposed strategies to improve screening include advances in specimen collection, automated interpretation methods, and adjuvant physical and molecular tests. Although

42 The Permanente Journal /Summer 2000 / Volume 4 No. 3 clinical contributions

Table 1. Age incidence of patients with gynecological cancer (July 1, 1943 to July 1, 1944)

Number of cases Site of cancer Number of cases detected Age range Average age

Cervix uteri

Preinvasive 7 4 30-55 38

Invasive

Stage I, early 3 2 31-44 35

Stage I, late 2 0 43-45 44

Stage II 1 0 44 44

Stage IV 1 0 44 44

7 2 31-45 40

Fundus uteri

Adenocarcinoma 3 1 53-55 54

Ovary

Adenocarcinoma 1 0 35 35

Krukenberg 1 0 19 19

Vulva

Epidermoid 1 0 34 34 carcinoma

not part of the medical lexicon in Footer’s day, cost-effectiveness must be an inherent part of any new tests that augment the Pap test. Cost-effectiveness analysis considers health outcomes as well as the resource costs of health interventions. Going beyond cost-benefit analysis, analysis of cost-effectiveness considers general benefit as given (eg, Footer’s screening methods) and then look for alternatives that are least costly while providing the greatest benefit. Thus, the primary role of cost-effectiveness analysis is to identify the We still must value of alternative interventions for improving health while considering as many costs as possible. recognize screening Analysis is complicated by the elusive nature of determining “total” or “full” costs. Nonetheless, today’s limitations as we adjuvant tests must be measured in terms of both the clinical and economic outcomes they produce. For develop and select example, we have little use for tests that lead to more diagnoses of true lesions that are nonetheless clinically appropriate insignificant. Adjuvant tests used within a specified program should ultimately lead to increased life expect- adjuvant testing ancy by detecting and treating CIN and early-stage cervical cancer. To be useful, adjuvant tests must also modalities. enable stratification of risk so that for patients at low risk for cervical cancer, emphasis may be placed on surveillance and follow-up while treatment (often more costly than surveillance) is emphasized for high-risk patients, who can be expected to benefit most from it. Perhaps the best way to view resource allocation analysis is to compare marginal cost vs marginal benefit, ie, how much additional overall benefit can be derived per additional incremental unit of cost. For the most part, such rigorous analysis of the new Pap-test-enhancing technology is lacking. Ultimately, formal decision

The Permanente Journal / Summer 2000 / Volume 4 No. 3 43 lesion in question. Further sections have to be made cases in which the diagnosis is not yet conclusive), from the block and if these also fail to show the lesion one stage I epidermoid carcinoma in the canal of a the patient must be reexamined and another biopsy The fact that this cervical stump two years after supravaginal hyster- clinical contributions test was directly taken. Failure of the first biopsy to contain the lesion ectomy for “tumors,” one endophytic epidermoid responsible for the can be a very serious matter when the non-staining carcinoma stage I on the anterior lip of a grossly diagnosis in six of area was very small because the chances are that the normal cervix, two stage I grossly diagnosable epi- the 14 cancers of distortion of the cervix as a result of the biopsy and dermoid carcinomas, one stage I adenocarcinoma of the cervix is resulting healing processes will make it difficult to de- the posterior lip, one stage II epidermoid carcinoma indisputable proof termine whether or not the area was actually removed. and one stage IV epidermoid carcinoma. of the value of the To forestall such a situation it is preferable to remove The ages of the seven patients with preinvasive Schiller Lugol test. an adequate wedge of tissue, including the junction of carcinomas were 30, 31, 32, 36, 41, 43 and 55, with the normal and questionable area. After the tissue has an average age of 38 years. One of these patients been removed the application of Lugol’s solution again had malignant changes in a cervical polyp which was to the excised tissue will stain it as before and it can be not suspected before histological study. Another pa- definitely ascertained that the lesion has been removed. tient had a small grossly visible leucoplakia on the It is also important to orient the tissue by placing it on anterior cervical lip. A third patient had a sharply a piece of filter paper, before immersing it in the fixing demarcated raised red granular area on the cervix. solution, in such a way that the epithelium will be sec- These cases cannot be considered as having been tioned perpendicular to the surface. When the detected because they all presented lesions which non-staining area involves a large part of the cervix it should be submitted for histological examination. The may be permissible to remove a small punch biopsy or remaining four cases, however, were discovered en- cervical scraping with the knowledge that if the section tirely as the result of the findings with the Schiller should prove unsatisfactory, plenty of the lesion re- test, which indicated areas requiring biopsy. mains for future study. The ages of the patients with invasive carcinoma were 31, 31, 43, 44, 44, 44 and 45, with an average Review of Cases age of 40 years. One patient (plate I, case 3), a Between July 1, 1943 and July 1, 1944, twenty pa- negress 31 years of age, had had a supravaginal tients with malignancies of the genitalia have been hysterectomy two years previously for “tumors.” For seen in this clinic. These included seven preinvasive the past six weeks she had had post-coital bleed- carcinomas of the cervix (in addition there are five ing. The cervix appeared to have an “erosion”

analysis involving costs as well as defined benefits and utility is likely to help define the best screening program for each patient. Recent and Proposed Improvements to Cervical Cancer Screening Tests Meanwhile, multiple technologic innovations have already been incorporated—albeit somewhat haphaz- ardly—into screening programs. Some of these innovations have a more substantial evidence base and hold greater promise than others. A few of these promising innovations are introduced briefly; many others have been proposed.

ThinPrep® The ThinPrep® method has been introduced to improve the quality of specimen collection. Specimens are placed in a collection fluid that homogenizes and rinses the cells, thus optimizing cell preservation and reducing artifacts that hinder interpretation. Mass screening applications for this method await improvement in handling large quantities of specimens at a reasonable cost.

PAPNET® Because 50,000 to 300,000 cells are held on each slide, rare abnormal events may be missed by routine cytotechnologist screening. PAPNET® is a neural-network computer processing system that digitally screens conventionally prepared slides. The computer is programmed to recognize patterns and can identify abnor- malities based on morphologic characteristics. Areas of concern are reviewed and confirmed by examination

44 The Permanente Journal /Summer 2000 / Volume 4 No. 3 clinical contributions

around the external os. An endocervical suction Among the many faulty concepts regarding cancer, biopsy was taken which showed early invasive epi- one of the most pernicious is the “cancer age” myth, dermoid carcinoma. This was confirmed by biopsies the belief that certain types of cancer appear only of the anterior and posterior lips including the “ero- after the person has attained a certain age. Ordinarily sion.” Both of these contained invasive carcinoma. the cancer age, based purely on a statistical analysis Thus the “erosion” was not the benign lesion it ap- of causes of death, is stated to be from 35 to 55 peared to be. Two of the stage I cases of invasive years. Actually the “cancer age” extends from birth carcinoma were biopsied solely because of non- to death. In any individual, cancer may be found at staining areas. Thus two of the seven cases of any age. In regard to cancer of the cervix, Waters18 invasive carcinoma of the external cervix would not reported a case in a seven-months-old infant and have been diagnosed had it not been for the rou- referred to two other cases at seven months and seven tine use of the Schiller test. The fact that this test years. Hurdon19 mentions cases at 17 and 19 years of was directly responsible for the diagnosis in six of age which were not accurately diagnosed for many the 14 cancers of the cervix is indisputable proof of months because of failure to examine the patients. the value of the Schiller Lugol test. Such fatal delays in diagnosis will not be prevented All of the three adenocarcinomas of the fundus uteri until cancer is suspected and looked for in each and were early growths still circumscribed and essentially every patient. Although we have confirmed Schiller’s confined to the endometrium. One case had no symp- findings with the Lugol’s test and are firmly convinced toms other than those produced by the procidentia. of its value in aiding the discovery of an increasing The diagnosis was made during the curettage routinely number of early cancers of the cervix, the current performed prior to any vaginal plastic operation. Con- literature reflects conflicting opinions regarding its sequently one of the three cases of fundal carcinoma value. Graves9 was enthusiastic, and Henriksen20 used was actually detected prior to the onset of symptoms. the test routinely. On the other hand Hurdon19, The remaining tumors consisted of one adenocar- Marizioff21 and Novak22 considered it practically use- cinoma of the ovary in a patient 35 years old, one less, and Macfarlane23 abandoned the Schiller test after Krukenberg tumor in a 19-year-old girl who was four two thousand examinations. My own opinion is preju- and a half months pregnant, and one epidermoid diced in its favor on the basis of the fact that of the carcinoma of the vulva. All of these lesions were far 14 cases of cancer of the cervix mentioned here, six, advanced when the patients presented themselves or 42.8%, would not have been biopsied had the for treatment. Schiller test been omitted.

of the actual slide. Critics assert that this system produces more ASCUS (atypical cells of uncertain signifi- cance) diagnoses than correct assignments into benign or dysplastic categories and that this result may create a larger problem by increasing costs as well as morbidity.

HPV Testing HPV strain testing has become widely available, both for primary screening and for triaging patients into Ultimately, formal risk groups. However, in young, sexually active women, HPV infection patterns may change over time, analysis involving weakening the clinical significance of a single test result. For most patients, information provided by HPV costs as well as defined benefits testing usually does not lead to changes in case management. The full utility for HPV testing remains unclear, and utility is likely although the best application of the test might be for triage of ASCUS Pap test results. to help define the best screening Speculoscopy program for each Proposed visual methods to improve the Pap test include speculoscopy, which uses 4× to 6× magnification patient of an acetic-acid-stained cervix and a blue light to visualize potentially abnormal areas of the cervix. Study results are interpreted as positive or negative on the basis of presence or absence of white lesions. When used in combination with the Pap test, speculoscopy has been reported to yield a false-negative rate under 3%. Various combinations of speculoscopic screening and Pap testing may be used to identify clinically significant lesions and to triage patients according to whether they need further evaluation, follow-up, or treatment.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 45 In the series of seven cases of preinvasive carcinoma 263:279-367, 1927. 6. Schiller W. Early Diagnosis of Carcinoma of the Cervix, Surg of the cervix there were two in which color photo- Gyn and Obs, 56:210-22, 1933. Cancer detection graphs (Plate I, Case 2), taken before and after the 7. Schiller W. Pathology of the Cervix, Am J Obs and Gyn, 34:430-8, 1937. clinical contributions should be an application of Lugol’s solution, vividly reveal the value integral part of 8. Schiller W. Leucoplakia, Leucokeratosis and Carcinoma of the of this test in pointing out areas in the relatively normal Cervix, Am J Obs and Gyn, 35:17, 1938. every appearing cervix that require biopsy. Biopsies of the 9. Graves, WD. Detection of the Clinically Latent Cancer of the gynecological non-staining areas of these two cases showed definite Cervix. Surg, Gyn and Obs, 56:317-22,1933. examination. 10. Stevenson, CS; Scipiades R. Non-Invasive Potential carcinomatous changes without invasion of the stroma. “Carcinoma” of the Cervix. Surg,Gyn and Obs, 66:822-35, 1938. A detailed report of these and additional cases actually 11. Wollner A. The Early Diagnosis of Cervical Carcinoma, Surg, detected will be published in the near future. Gyn and Obs, 68:147-54, 1939. 12. Meyer R. The Histological Diagnosis of Early Cervical Carcinoma. Surg, Gyn and Obs, 73:129-39, 1941. Conclusions 13. Knight R van D. Superficial Noninvasive Intraepithelial Carcinoma of the cervix uteri can be diagnosed in Tumors of the Cervix. Am J Obs and Gyn, 46:333-49,1943. 14. Papanicolaou GN; Traut HF. Diagnosis of Uterine Cancer by the preinvasive stage and in the early invasive stage Vaginal Smear. New York, Commonwealth Fund,1943. before the appearance of any symptoms and before 15. Meigs VV, et al. Value of the Vaginal Smear in the Diagnosis the development of ulceration or tumor. of Uterine Cancer, Surg, Gyn and Obs, 77:449-61, 1943. 16. L’Esperance E. Cancer Prevention Clinics, The Med Women’s The Schiller (Lugol) test is a definite aid in locating J (Jan) 1944. the optimal site for cervical biopsy. 17. Macfarlane C. Why die from cancer of the uterus? American Cancer detection should be an integral part of ev- Society for the Control of Cancer, The Doctor Speaks on Cancer, ❖ No. 9, 1943. ery gynecological examination. 18. Waters, EG. Carcinoma of the Cervix in a seven-months-old Bibliography infant, Am J Obs and Gyn, 39:1055-57,1940. 1. Statistical Bulletin of the Metropolitan Life Insurance 19. Hurdon E. Cancer of the Uterus. London, Oxford University Company, March 1938, and March 1940. Press, p 35, 1942. 2. Bowen, JT. Precancerous Dermatoses: A Study of Two Cases 20. Henriksen E. Precancerous and carcinoid lesions of the of Chronic Epithelial Proliferation; J Cutan Dis;30:241-55,1912. cervix. Surg, Gyn and Obs, 60:635-44, 1935. 3. Wende: J Cuton Dis, Dec 1908.2 21. Martzloff KH. Cancer of the Cervix Uteri: Recognition of 4. Schottlander J; and Kermauner, E. Das Uteruscarcinom, Early Manifestations, JAMA, 111:1921-5, 1938. Berlin, 1912. From Schiller.6 22. Novak E. Gynecological and Obstetrical Pathology. 5. Schiller W. Untersuchungen zur Entstehung der Geschwülste: Philadelphia, Saunders, p 38, 1941. Collumcarcinom des Uterus, Virchows Arch J Path Anal, 23. Macfarlane C. Personal Communications, Sept 2, 1944.

Final Comments Two of the three conclusions noted by Dr Footer regarding screening still ring true. First, preinvasive disease can be diagnosed while it is virtually 100% curable. Second, detection of cancer and its precursors should be part of every gynecological or well-woman examination. In addition, education of patients and Health Plan members—a strategy emphasized in the Gynecologic Cancer Steven A. Vasilev, MD, MBA, FACOG, FACS was edu- Detection Clinic’s operations—remains a cornerstone of prevention. Pa- cated at the University of Southern California through tients should be advised of the availability and benefits of screening tests medical school, residency, and gynecologic oncology and programs as well as their limitations. Future inquiries should focus fellowship. Before joining SCPMG in 1998, he served on combinations of new technology and improved access to basic screen- as Chair of the Department of Gynecologic Oncology ing services that offer the best value for our patients and for society. ❖ at the City of Hope Comprehensive Cancer Center in References Duarte, California. Currently, he is Director of the 1. Macgregor J, Campbell M, Mann EM, Swanson KY. Screening for cervical intraepithelial Tertiary Gynecologic Oncology Referral Center in Los neoplasia in north east Scotland shows fall in incidence and mortality from invasive Angeles and is active as Clinical Professor at the Uni- cancer with concomitant rise in preinvasive disease. BMJ 1994 May 28;308(6941):1407-11. 2. Fahey MT, Irwig L, Macaskill P. Meta-analysis of Pap test accuracy. Am J Epidemiol versity of Southern California. Having recently 1995 Apr 1;141(7):680-9. authored/edited a textbook entitled Perioperative and Supportive Care in Gynecologic Oncology: Evidence- Suggested further reading Based Management, he has a strong interest in 1. McMeekin DS, McGonigle KF, Vasilev SA. Cervical cancer prevention: toward cost-effective screening. Medscape Women’s Health Online 1997;2(12). Available at: http:// evidence-based medicine and outcomes management. WomensHealth.medscape.com/M...wh3023.vasilev/wh3023.vasilev.html [Accessed June 29, 2000] E-mail: [email protected]

46 The Permanente Journal /Summer 2000 / Volume 4 No. 3 By Eric Blau, MD, FACP

soul of the healer Part I In the Shadow of Obesity

Introduction Vincent J. Felitti, MD I remember that in the first decade of my career, if I had a 300-pound patient on my exam table, I would desperately have been searching my mind to find something other than the obvious to discuss. The possi- bility of considering why a person was obese was inconceivable; it was totally out of the question. The edge of an abyss was not something I was about to approach in a naive and inquiring manner. Why would I risk leaving the security of conventional medical knowledge to learn by observation and inquiry of what was before me? And yet, years later I was to wonder why do people get fat? Where in nature is obesity? Why are so many obese adults born prematurely at low weights? What does it mean that a recently seen 850-pound, 29-year- old old woman was one of the first long-term survivors of severe prematurity—just under two pounds at birth? Should we even think about this? Is this medicine? It certainly has nothing to do with what we learned in medical school and residency. Isn’t it better to read about intermediary neurotransmitters and obesity, especially if one doesn’t think about the implication of “intermediary” or “transmitter”? On the following pages are four photographs taken by Eric Blau, MD, an internist with SCPMG and an accomplished professional photographer. His efforts in medical photojournalism have already been re- viewed in a recent book column of The Permanente Journal. These photographs, intermediary transmitters in their own way, will someday appear as part of a book he is now working on that provides the patients’ views of their obesity, but only to those physicians who dare ask.

A note from physician and photographer, Eric Blau, MD As a society, we spend millions of dollars annually in a mostly futile attempt to lose weight. In a culture already obsessed by health and youth, we tend to discriminate against the overweight among us, finding them lazy, out of control, and lacking willpower. As physicians, we reinforce these cultural models by pointing out to our overweight patients the health risks of obesity. Clearly, the ideal of beauty is not that of the overweight: fashionable clothing is created for the thin. It is always a revelation when information becomes available to make me rethink basic paradigms of medicine. My training and most of the current literature on obesity led me to believe that morbidly obese people had abnormalities that probably were genetically acquired. I thought it was only a matter of time before these would be characterized and medications developed to alleviate the suffering of millions of Americans. When I first learned of the Adverse Childhood Experiences (ACE) study and the relation between abuse and morbid obesity, I was shocked and skeptical that it was true. But after interviewing dozens of morbidly obese individuals, I am a believer. Over and over again, I would hear people state that they overeat well past the point of satisfaction—usually in response to some psychological trauma. It appears all too frequently that marked weight gain began with trauma, and becomes an habituated reaction to new life stresses. Obesity is a complex disorder and not all overweight persons have been traumatized, but unless one is aware that at least a large percentage of the grossly overweight have had severe emotional trauma, it is unlikely that successful therapies will be devised. Rather than argue the case myself, I would prefer to let some overweight persons tell their own stories. These are excerpts from interviews that focused on how being overweight has affected their lives, and how their lives have affected being overweight.

ERIC BLAU, MD, FACP, is an internist practicing in SCPMG’s Department of Preventive Medicine in San Diego.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 47 soul of the healer

“With my friend, Paul, the manner of this passing was not a sudden thing. Paul and I were in Air Force Pararescue in Vietnam. We grew up together in Oakland, went to the same schools, enlisted together, and ended in Pararescue together. Our job was to rescue downed pilots, patch them together, and get them medevaced to a facility that could do something for them. We had a rotating schedule of rescues. On that particular day, I was at the top of the list for missions, but I had an impacted wisdom tooth, so I spent the day with the base dentist having it removed. My best friend, Paul, ended up going on a mission that I should have drawn. He never came back from it. It took almost two weeks for us to find him. I went in after him several times: I volunteered for every outbound mission in his direction. We found him spread-eagled between two trees and skinned alive. There was only one thing that was recognizable about him, and they made sure that it was—that was his face. They left that intact. They didn’t touch it a bit. The rest of him looked like something you’d find in a slaughterhouse. I got weird for a while. I spent a lot of time dwelling on the fact that my friend died over there. I became a risk-taker. I increased my smoking to 8 packs of cigarettes per day—and it hasn’t changed, it’s just gone in a different direction. I have morbid obesity, advanced cardiovascular disease, diabetes, and limited respira- tory function. Do you see a pattern here? Everybody looks at the downside of obesity, of alcoholism, or drug abuse. But there is an upside, too. There has to be, or people wouldn’t do it.” “JP,” 400+ pounds

48 The Permanente Journal / Summer 2000 / Volume 4 No. 3 soul of the healer

The Permanente Journal / Summer 2000 / Volume 4 No. 3 49 soul of the healer

“When I was young, about four I think, I was molested by a teenage boy. After that, my mother would often call me in the house from playing, pull down my clothes, and check me out; it was humiliating. Later, when I was growing up, I was labeled mentally retarded, and men used to think they could do things to me and no one would believe me. When I am stressed, I eat. Food is my friend; it’s there for me. Especially because my family isn’t. I don’t eat because I’m hungry— I’m never hungry. I eat because it’s there. If it’s cake, I’ll eat it ’til it’s gone—even if I’m feeling full. I feel good when I’m eating it. But after awhile, I realize that I can’t eat enough to stop the pain.” Ella Herman, 300+ pounds

50 The Permanente Journal / Summer 2000 / Volume 4 No. 3 soul of the healer

The Permanente Journal / Summer 2000 / Volume 4 No. 3 51 soul of the healer

“I was rather slender until I was seven years old. Beginning about that time I was sexually abused by my father. It continued until I was fourteen. I never told anybody. He kept telling me it was our secret and that I shouldn’t tell anybody. In junior high school I realized how taboo this was and how I could actually get pregnant. I was terrified! It was then that I put a stop to it. I had a very low opinion of myself. I think children who are abused somehow think it is their fault. I felt guilty and that I was not terribly worthwhile. I weighed two hundred pounds then. I’ve recognized that I always eat when I’m lonesome, unhappy, or hurt. And I spent a lot of time hurt by other people who didn’t realize that I was hurt. I’d seem like this jolly person, and then I’d go home and cry half the night—and eat. I’m a binge eater. I can sit down with a box of cookies and eat the whole box—I think because I’m alone. And I eat even when I’m full. I’ve eaten a package of cookies even when it’s made me sick to my stomach. But I’d continue to eat them because they tasted good—I guess.” Helen McClure, 258 pounds

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The Permanente Journal / Summer 2000 / Volume 4 No. 3 53 soul of the healer

“No matter what you do to your face, your body is still there. I’m a hairdresser. I can make my hair look fabulous. I do great makeup. I look good without makeup: I’m an attractive female. I’m intelligent, I’m energetic, but it doesn’t matter because below the neck I am who I am. And that’s hard because even though you as an individual may not be superficial, society truly is. And I don’t know if it’s just that our society has become more superficial in other ways, too. Maybe we’re a culture of teenagers. Food doesn’t give you a hard time. Food doesn’t create arguments. It doesn’t talk. My favorite food when I’m unhappy is pasta with my Mom’s homemade sauce.” Karen McWhorter, 220 pounds

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The Permanente Journal / Summer 2000 / Volume 4 No. 3 55 By Kate Scannell, MD

Women in Medicine—A Living History

The following is a testimonial given to honor Dr Ellen Killebrew (pictured below) on Ellen not only endured those times; through her persistence and the occasion of her retirement. her perennial mentoring and support of other women physicians soul of the healer We gather here tonight to celebrate and to honor Dr Ellen who followed her, she also helped to reshape the landscape for Killebrew during this major transition in her life. Ellen’s leaving other women entering medicine. also marks a major transition in each of our lives. The impressive In 1955, Ellen entered Bucknell University in Pennsylvania to number of women doctors assembled here attests to her impact pursue a business major and to become an executive secretary, on us. How often does any occasion draw so many of us from our one of the few acceptable academic majors available to women busy professional and personal lives? then. However, during her sophomore year, Ellen decided to en- ter premedical training. Her decision was a radical act at the time. Historical Context In fact, the university mandated that Ellen obtain written permis- Within a broader historical context, Ellen also embodies some- sion from her father as a strict prerequisite for her enrolling in thing compelling for all of us. When we look around this room, premedical courses. How many of us here tonight can imagine we see an intergenerational group of women doctors who span being told that our fathers had the right to determine what we the period of the last half-century of American medical history. could study and what we could become? Some of the women sitting at these tables have recently com- pleted their medical residencies. In 1968, when Ellen finished Women in Medical Training hers at Colorado General Hospital, no other women sat at the An instructive passage in Hedda Garza’s book, Women in Medi- commencement table. In 1983, when I completed my own resi- cine, gives us a picture of this time in history: “By 1955, a new low dency in Chicago, my residency group included a total of six point had been reached. Many medical schools that had welcomed other women; at our commencement ceremony, we were “treated” women during the war no longer had a single female student. to a female striptease dancer as the main entertainment. As we Now that women were no longer needed, polls were published to embark on a new millennium, it is fitting that we honor Ellen justify the sudden change. In 1949 and 1957, hospital chiefs of Killebrew, both for her stellar individual accomplishments and staff and male physicians gave familiar answers to the question- for her obstinate insistence on being a physician. Each time Ellen naires asking them their opinions of female doctors. Many of them challenged the barriers excluding women from medicine, she commented that women doctors were “emotionally unstable,” “talk made things easier for the next group of women who came up too much,” and “get pregnant”! One dean actually declared that he against these barriers. preferred a third-rate man to a first-rate woman doctor.”1 Career Facts and Barriers Ellen’s Academic Experience The “official and usual” facts of Ellen’s career are When I asked Ellen about her experiences in premed, she re- these: Tonight we celebrate an outstanding clini- layed that she frequently had to endure dreary, misogynist attitudes. cian and teacher, a gifted cardiologist, a Clinical Among the most painful memories she recalled was being ac- Professor of Medicine at the University of Califor- cused of cheating on her biochemistry exam because no woman nia at San Francisco, a long-standing officer of the was expected to excel as she had. Male students raided her dorm American Heart Association, a published author of room looking for evidence to support their accusations—which medical works, and a respected colleague who were, of course, false. has worked 28 years for Kaiser Permanente. In 1960, just one year after Ellen completed her premedical However, as always, the facts are never training, Jefferson Medical College in Pennsylvania finally opened simple, and they are inherently thin. What its doors to women, becoming the last medical school in the expands the facts of Ellen’s career into United States forced to do so. Still, at her medical school inter- an experience that has affected each views, Ellen was asked why she wanted to “take a man’s place.” of us is the particular way in which She was queried as to whether or not she had thought about she negotiated her career through the having a family and, consequently, of dropping out of medical difficult history of women in Ameri- school. In 1962, while Ellen attended New Jersey College of Medi- can medicine. Most of Ellen’s medical cine, historian Frederick Rudolph congratulated male colleges career was lived through periods of like Yale and Harvard for “preserving the liberal inheritance of time when professional barriers to Western Civilization in the United States by protecting it from women were blatant and prejudice debilitating, feminizing, corrupting influences which shaped its was inarguably overt. Remarkably, career where coeducation prevailed.”1

Dr Ellen Killebrew. Photo by Nadine Hubbel Nadine by Photo Killebrew. Dr Ellen

KATE SCANNELL, MD, is a physician-writer who practices internal medicine, rheumatology, and geriatrics at Kaiser Permanente in Oakland, California. She is the Editor of Ethics Rounds and the author of a new book, Death of the Good Doctor. E-mail: [email protected]

56 The Permanente Journal / Summer 2000 / Volume 4 No. 3 soul of the healer

Despite this formidable climate, Ellen graduated from medical Perhaps as remarkable as her struggle is the style in which Ellen school in 1965, when, still, only 4.6% of all women with an MD practiced medicine. She bore no malice for the hardships that she degree had become full-time medical school faculty members.2 endured, and she never begrudged the success of other women When she completed her internal medicine residency at Colorado who did not have to suffer these hardships. On the contrary, Ellen General and Denver General Hospital three years later, three fourths always took time to mentor any woman who approached her with of the three million health care workers in this country were women, professional or personal issues. She was a rare exception to Janet whereas nearly all administrators and physicians were men. Only Bickel’s proclamation in “Women in medical education,” published 7% of physicians were women, a negligible difference from the in the New England Journal of Medicine in 1988: “There are few 6% figure in 1900.1 In 1970—only after The Women’s Equity Ac- departments in any school in which a student can readily find a tion League filed a class action suit on behalf of all women against woman physician in a senior position who is happy with both her every medical college in the country—the United States Congress professional life and her personal life and available to give the finally held its first hearing on the incontestable gender inequality student pointers and support.”8 in medical school admissions. And in 1970, while these difficulties prevailed, Ellen Killebrew finished her cardiology Fellowship at New Millennium Statistics the Pacific Medical Center in San Francisco. We enter the new millennium with some new “facts.” In the 1998-9 academic year, women comprised 44% of medical school Kaiser Permanente entrants and 15% of cardiology fellows.9 One prediction estimates In that same year, Ellen’s first venture into the job market brought that, by 2010, women will comprise 30% of practicing physicians.10 her to the doors of Kaiser San Francisco, but she was told that they Still, in 1995, a national cohort study showed that after 11 years, were not hiring “women cardiologists.” The physician members of only 5% of women had achieved full professorship status, com- two private practices told her the same thing. Ellen persevered pared with 23% of men with similar initial rank, type of tenure and ultimately broke through several additional barriers at Rich- track, and Board certification.11 Also, women comprise only 7% of mond and Oakland Kaiser to obtain employment. In true pioneering all full professorships in internal medicine.12 fashion, Ellen’s successful fight to secure employment immedi- Although the numbers of women in medicine and in leadership ately preceded passage of the Equal Opportunity Act in 1971, positions continue to lag behind men, other forms of gender dis- legislation that forced open the doors of professional education crimination also continue within the experiential realm of being a for all women in this country. physician. In her book, Walking out on the Boys, Dr Francis K. While Ellen was on her way to becoming one of the most re- Conley of Stanford University wrote about these modern-day vari- spected physicians at Oakland Kaiser, formidable odds continued eties of sexual inequality in medicine: “I have learned that to mark the general medical landscape for women. In a study universities, in general, no longer function as agents of societal published in 1974, two thirds of practicing male physicians did change ... [that their] liberal environment is a masquerade.”13 In not accept women as peers.3 That same year, another study re- 1994, a report in the New England Journal of Medicine documented vealed that 80% of New York City medical patients stated their a harassment rate of 73% among women responding to a survey preference for a male physician, although half had never been of sexual harassment in medical training.14 treated by a woman.4 In 1982, JAMA published an article, “Atti- tudes toward women physicians in medical academia,” which To Ellen: in Conclusion reported that almost 50% of male medical students and physicians Within the sociopolitical context of women in medicine, Ellen agreed with the statement: “Women physicians who spend long has been a genuine heroine. She braved formidable barriers in her hours at work are neglecting their responsibilities to home and path to becoming a physician, and in so doing helped to pave an family.”5 In a survey published one year later in the American easier entry for other women who followed her. When we look to Journal of Psychiatry, 30% of male physicians felt “there was a Ellen and recognize her brilliance and her rightful place in medi- significant risk to the optimal functioning of a department that cine, we are pained to think about the abuse and the misogyny hired a woman of child-bearing age.”6 she was made to endure. Many women in this room remember arriving at Kaiser Oakland Each of us has arrived here in a long procession of women, in the late 1980s and feeling immediate reassurance from Ellen’s which widens in rank by the years. And near the leading edge welcoming presence. Senior women physicians were scarce in the of the procession is Ellen Killebrew—pioneering, pulling many ’80s. By 1981, but for a single post that had been held at the Women’s of us along. We honor Ellen tonight for her courageous and Medical College of Pennsylvania in 1955, no woman had yet to hold generous leadership, her inspired mentoring, her indisputable a chief administrative position (for example, full deanship).1 As late clinical skills, her unself-conscious wisdom, and her personal as 1985, only 5% of medical school professors were women,7 and in and professional integrity. We thank her for being one of the 1988, only 15% of active physicians were women.1 rare women in a senior position who was happy with her ca-

The Permanente Journal / Summer 2000 / Volume 4 No. 3 57 reer and life and who offered her own happiness as a beacon 28;247(20):2803-7. for many of us who were looking for some light in our own 6. Franco K, Evans CL, Best AP, Zrull JP, Pizza GA. Conflicts associated with physicians’ pregnancies. Am J Psychiatry 1983 Jul;140(70):902-4. soul of the healer careers. We thank her for helping us to create and integrate a 7. Graves PL, Thomas CB. Correlates of midlife career achievement among professional identity. women physicians. JAMA 1985 Aug 9;254(6):781-7. Finally, on a personal note, besides thanking Ellen for all of 8. Bickel J. Women in medical education: a status report. N Engl J Med 1988 Dec these things, I also want her to know how much her vivacity and 15;319(24):1579-84. wit delighted me. And, simply, how much I will miss her. ❖ 9. Barzansky B, Jonas HS, Etzel SI. Educational programs in US medical schools, 1998-1999. JAMA 1999 Sep 1;282(9):842-3. References 10. Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women 1. Garza H. Women in medicine. New York: Franklin Watts; 1994. [Cites Walsh physicians: results from the Women Physicians’ Health Study. Society of General MR. Doctors wanted: no women need apply. New Haven (CT): Yale University Internal Medicine Career Satisfaction Group. Arch Intern Med 1999 Jul Press, 1977. p. 245-6.] 12;159(13):1417-26. 2. Eisenberg C. Medicine is no longer a man’s profession. N Engl J Med 11. Tesch BJ, Wood HM, Helwig AL, Nattinger AB. Promotion of women 1989;1321:1542-4. physicians in academic medicine: glass ceiling or sticky floor? JAMA 1995 Apr 3. Standley S, Soule B. Women in professions: historic antecedents and current 5;273(13):1022-5. lifestyles. In: Hardy RE, Cull JC, editors. Career guidance for young women. 12. AAMC Project Committee on Increasing Women’s Leadership Roles in Springfield (IL): Thomas; 1974. p 3-16. Academic Medicine 1996. Increasing women’s leadership in academic medicine. 4. Marieskind HI. Women in the health system: patients, providers, and Acad Med 1996 Jul;71(7):799-811. programs. St. Louis (MO): Mosby; 1980. 13. Conley FK. Walking out on the boys. New York: Farrar, Straus and Giroux; 1998. 5. Scadron A, Witte MH, Axelrod M, Greenberg EA, Arem C, Meitz JE. Attitudes 14. Komaromy M, Bindman AB, Haber RJ, Sande M. Sexual harassment in toward women physicians in medical academia. JAMA 1982 May medical training. N Engl J Med 1993 Feb 4;328(5):322-6.

Our Struggle Today Our struggle today is not to have a female Einstein get appointed as an assistant professor. It is for a woman schlemiel to get as quickly promoted as a male schlemiel. Bella Abzug, 1920-1998, congresswoman and founding feminist

58 The Permanente Journal / Summer 2000 / Volume 4 No. 3 soul of the healer

“Life on Mars” by Mohamed Osman, MD Imaginary figures on Mars, a planet prone to excitement and mystery yet to be discovered.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 59 By Jill M. Steinbruegge, MD

Commentary: Women’s Health—It’s More Than Ob-Gyn

It’s more than ob-gyn. When that simple— In fact, as Dr Rhoda Nussbaum’s reveal- pend on much more than women’s health health systems but radical—message finally began to ing research has shown (see following outcomes; it will also mean providing prod- permeate the medical mainstream, women’s article), we could even look at the subject ucts and services that are responsive to health began to emerge from the feminist of women’s health as including women’s women’s needs across the entire spectrum margins as a discipline to be taken seriously dominant social role in providing health of life care, from pediatrics to elder care. by all health care practitioners, regardless care. Dr Nussbaum’s data show that in more Part of that challenge is to improve the of gender. In my own case, the message than 90% of households, women play the gender balance among our Permanente began to crystallize soon after the 1970 primary (or at least equal) role in selecting workforce and leadership.4 The Permanente publication of the first edition of Our Bod- a health plan for the family; and in most Medical Groups generally do rather well in ies, Ourselves (originally titled Women and families, women coordinate the health care attracting women physicians, though we Their Bodies), the seminal (and much reis- of all family members, including husbands. have been less successful in promoting them sued) manifesto and handbook on women’s This means, among other things, that to leadership positions. Although a Novem- health by the Boston Women’s Health Col- health care providers have multiple reasons ber 1999 survey5 showed that 35% of all KP lective.1 Until that time, most of the medical to focus on women’s health: first, because staff physicians were women, women con- establishment regarded women’s health as quality health care means recognizing that stituted only 20.4% of “management” limited to women’s reproductive functions, women are different from men in ways other physicians (Chiefs of Service, Physicians in and, as such, the subject held limited clini- than reproductive functions; second, be- Charge) and 11.4% of “executive” physicians cal interest to me as a young physician. cause women exert enormous influence (Assistant and Associate Medical Directors). Not that I hadn’t encountered plenty of over the selection of health plans and pro- To date, only one of the nine Permanente anomalies in the standard view that viders; and third, because women exercise Medical Groups has had a woman Execu- women’s health was synonymous with that power at least in part on the basis of tive Medical Director (Louise Liang, MD, of men’s health, plus reproduction. As a psy- how well a health care organization meets Group Health Permanente). chiatrist, I had struggled with mounting their own needs as women. Given the unique advantages of our inte- evidence that certain mental health disor- We know that most of American health grated structure and our ethics-driven ders, such as depression and anxiety, had care still has a way to go to align medical practice principles, KP has a special respon- a higher incidence in women than in men. practice with today’s more enlightened prin- sibility to provide leadership in women’s I was gathering a growing body of anec- ciples of women’s health. One recent study, health. It’s in our members’ interest; and it dotal experience on conditions like for instance, documented the persistence is in our own interest. ❖ postpartum depression and perimenopausal of gender bias in physicians’ diagnosis of References depression, but clinical literature on the coronary artery disease. Women initially 1. Boston Women’s Health Book Collective, Jane subject did not exist. Consequently, discus- seen for chest pain are significantly less Pincus, Introduction. Our bodies, ourselves for the sion of the relation between women’s likely to be referred for cardiac catheteriza- new century: a book by and for women. 1973 ed. New York: Simon & Schuster. reproductive physiology and rates of men- tion than men; and black women are less 2. Schulman KA, Berlin JA, Harless W, Kerner JF, tal health disorders remained outside the likely to be referred than white women.2 Sistrunk S, Gersh BJ, et al. The effect of race and scientific mainstream. Similarly, female physicians order more Pap sex on physicians’ recommendations for cardiac catheterization. N Engl J Med 1999 Feb 25;340(8):618- Thanks to an entire generation of tireless, smear and mammography screenings than 26. [Published erratum appears in N Engl J Med 1999 determined pioneers in women’s health— male physicians do.3 The fact that these find- Apr 8;340(14):1130]. some of them within our own Permanente ings are not surprising only reinforces the 3. Lurie N, Margolis KL, McGovern PG, Mink BJ, Slater JS. Why do patients of female physicians have ranks—you no longer have to be a feminist relevance of such studies; we expect to find higher rates of breast and cervical cancer screen- to understand that it’s more than ob-gyn. more anomalies. ings? J Gen Intern Med 1997 Jan;12(1):34-43. The domain of women’s health today is At Kaiser Permanente (KP), we know we 4. Isenhart M. Women physicians in medical leadership. Med Group Manage J 1994 Mar- widely understood to include the broad- can achieve better health outcomes for Apr;41(2):20-1, 39-40. ranging interface between women’s unique women than most of our competitors— 5. Physician workforce based on consolidated nine physiology and virtually all other areas of thanks to both our integrated delivery system regions dating from August 1999-November, 1999. Aligning the physician workforce Programwide by health—both physical and mental—and is and our growing technical ability to realize gender. In: Executive/Physician Management vitally relevant to the great majority of health the promises of evidence-based medicine. Profiles. Kaiser Permanente National Diversity care providers. But improving member satisfaction will de- Department. Oakland, California; Dec 1999.

JILL M. STEINBRUEGGE, MD, is Associate Executive Director, Physician Development for The Permanente Federation in Oakland, CA. E-mail: [email protected]

60 The Permanente Journal / Summer 2000 / Volume 4 No. 3 By Rhoda Nussbaum, MD

Commentary: health systems Kaiser Permanente—Recognizing the Importance of Women

Women’s health stepped into the threatening issues such as domes- References spotlight during the last decade of tic violence and sexual abuse, 1. NIH Office of Research on Women’s the 20th century, impacting the leg- formerly considered nonmedical Health. http://www4.od.nih.gov/orwh/ [Accessed June 21, 2000]. islative, scientific, and political problems. 2. Centers for Disease Control and arenas. We applaud the efforts to Kaiser Permanente (KP) has cer- Prevention, Office of Women’s Health. change drive-by deliveries and mas- tainly put women’s health on the http://nhic-nt.health.org/Scripts/Entry.cfm [Accessed May 23, 2000]. tectomies; the energy that has put map. We would be remiss if we 3. Department of Health and Human breast cancer on the national underestimated the importance of Services. Office on Women’s Health. agenda; the increased spending on women as the primary health care http://www.4women.gov/owh/index.htm [Accessed May 24, 2000]. women’s health research and ac- consumer and the economic 4. Food and Drug Administration, Office cess; and the formation of Women’s power they wield as the key deci- of Women’s Health. http://www.fda.gov/ Health Offices at the National In- sion-makers in health care womens/default.htm [Accessed May 24, 7 2000]. stitutes of Health, Centers for purchases for their families. 5. Wentz AC. Women’s health issues. Adv Disease Control and Prevention, the For these reasons, we have de- Intern Med 1995;40:1-30. Department of Health and Human veloped task forces in several 6. Affonso DD, Lovett S, Paul S, Shepak S, Nussbaum R, Newman L, et al. Services, and the Food and Drug regions to change how we deliver Dysphoric distress in childbearing women. Administration.1-4 care to women. We have con- J Perinatol 1992 Dec;12(4):325-32. But now women’s health is truly ducted market research to 7. Rodin J, Ickovics JR. Women’s health. Review and research agenda as we coming into its own, focusing on determine what women want and approach the 21st century. Am Psychol all aspects of female health as a value in health care.8-10 We have 1990 Sep;45(9):1018-34. woman moves through each stage committed ourselves to improving 8. Thompson M, Nussbaum R. An HMO survey on mass customization of of life—adolescence, reproductive health outcomes for women and healthcare delivery for women. Women’s years, midlife, and older adult- easing their burden as the chief Health Issues 2000 Jan-Feb;10(1):10-9. hood. The health care industry is health care coordinator and 9. Thompson M, Nussbaum R. Asking 7 women to see nurses or unfamiliar taking women’s health seriously by caregiver for their families. physicians as part of primary care developing stategies to tackle im- KP’s integrated health care redesign. Am J Manag Care 2000 munologic diseases such as HIV; model targeting population- Feb;6(2):187-99. 11 10. Schmittdiel J, Selby JV, Grumbach K, osteoporosis; neurologic condi- based medicine, emphasizing Quesenberry CP Jr. Women’s provider tions, and psychologic problems, prevention, and relying on state- preferences for basic gynecology care in all prevalent among women5,6; car- of-the-art information technology a large health maintenance organization. J Women’s Health Gend Based Med 1999 diovascular disease, thought to be and robust research creates the Jul-Aug;8(6):825-33. the province of men and now framework for setting the stan- 11. Juhn P, Solomon N, Pettay H. Care known to manifest itself and re- dard in women’s health and the management: the next level of innovation for Kaiser Permanente. Permanente J spond to treatment differently in delivery of health care to women 1998 Spring;2(2):38-43; http://pkc.kp.org. women; and pervasive, often life- and their families. ❖

RHODA NUSSBAUM, MD, has dedicated her career to the health of women, from improving the overall experience of care for women members as a staff Ob/Gyn in the Kaiser Permanente San Francisco Medical Center for the past 18 years, to supporting women as providers of care. She was appointed Assistant Physician-in-Chief of KPSF in 1989. E-mail: [email protected]

The Permanente Journal / Summer 2000 / Volume 4 No. 3 61 By Rhoda Nussbaum, MD

Studies of Women’s Health Care: Selected Results

Introduction substantially less satisfaction with their care than health systems Not one to sit back as women’s health issues— women in competing HMOs.3 Therefore, to retain “drive-by” deliveries and mastectomies—hit the front and attract members, KPNC’s clear mandate was to To determine what page, Kaiser Permanente Northern California (KPNC) develop strategies for meeting women’s health care its primary customers want in 1996 formed its Women’s Health Task Force, a needs, preferences, and expectations. KPNC faced and value in health group of 20 physicians and staff selected for their the additional challenge of providing health care that care, KPNC expertise in women’s health. would become the industry benchmark for improv- conducted a The Task Force accepted the challenge of develop- ing the health and total health care experience of Women’s Health ing both a rationale and a direction for changing women and their families. Study, funded by KPNC’s system of delivering health care to its women To determine what its primary customers want and the Innovations members: The group recommended to the Board of value in health care, KPNC conducted a Women’s Program, from July Directors of TPMG that KP focus on becoming the Health Study, funded by the Innovations Program, to November 1999. premier provider of women’s health care in North- from July to November 1999. Operating from 1990 ern California. To ensure that this goal would become until 1999, the Innovations Program supported reality, KP in 1997 appointed a women’s health leader projects which promote innovative thinking and prac- and created Women’s Health-KP (Table 1).1 tice in three areas: clinical care, use of support services Women’s Health-KP addresses a spectrum of and automated systems, and the health plan’s rela- women’s health care needs which arise throughout tionships with its members and their employers. Of life. Issues targeted by Women’s Health-KP include the more than 380 projects that have received grants the leading causes of death among women as well from the Innovations Program, 75% have been as the societal influences and policies affecting adopted by the health plan. women’s health. The ultimate goal of Women’s The Women’s Health Study had three primary ob- Health-KP is to improve the quality of health care jectives: 1) to determine what would increase women services delivered to KP’s primary customers: women. members’ satisfaction, cause them to remain health plan members, and create more positive public opin- KPNC’s Reasons and Goals for Studying ion about the health plan; 2) to determine how Women’s Health redesign of delivery systems for adult primary care, KPNC’s interest in women’s health was based on obstetrics/gynecology services, pediatrics services, sound reasoning. National2 and KPNC3 consumer and other services would be accepted by women; research indicated that women constitute the primary and 3) to develop an action plan for meeting the customer base for health care. Further research by demands of KP members.1 the Task Force showed that most health care pur- chasing decisions are made by women, who drive Study Methods medical utilization: by coordinating care for them- The study used multifaceted research methodology, selves and for their entire families, women consume which included a telephone survey of 1500 randomly two thirds of all medical care.2 Even more telling selected women members and 500 women who were was the fact that KPNC’s women members expressed members of competing health plans in Northern Cali- fornia; ten focus groups representing a variety of service Table 1. Women’s Health – KP Study Facilitators areas, ages, sexual orientations, and ethnic groups; experiential interviews that tracked 75 women through Cynthia Carey-Grant, senior consultant, Women’s Health project manager medical visits; and two roundtable discussion groups Amy Conway, MPH, senior health educator, Regional Health Education with community advocates and employers. Given the Dorothy Durkac, administrative assistant, Women's Health Jennifer Eichman, MPH, consultant, Operations Support Services large number of questions we needed to ask in the Theo Ferguson, project coordinator, Information Technology telephone survey, three versions of this survey were Julie Ferris, MSW, MPH, project manager, Department of Quality presented to random thirds of this study population. and Utilization The rigorous research design produced not only quan- Lorinda Hartwell, MPH, PhD, project manager, Regional Health Education titative results but also qualitative ones as women Mark Ishimatsu, senior consultant, National Market Research Department provided their thoughts and words in detail, confirm- Rhoda Nussbaum, MD, Women’s Health leader, TPMG principal investigator ing and providing an understanding of the quantitative Jan Rapport, senior consultant, Operations Support Services Mark Thompson, PhD, lead external consultant results. The results allowed findings to be reproduced across multiple measures and methods.

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The study examined characteristics of more-satis- Access to Care fied and less-satisfied subsets of the KPNC Problems accessing urgent and routine care have population in connection with the roles and respon- an effect on members’ satisfaction with the health sibilities of women in Northern California and plan (Figure 1). More members (23%) have diffi- highlights four areas of value that should be tar- culty accessing routine care than acute care (9%), geted by KPNC: 1) when, where, and from whom and 6% indicated problems accessing both types of women want access to care; 2) the importance of care. Access has a strong bearing on member loy- coordination of care; 3) how flexible women are in alty: Members who had no problem accessing either accepting alternatives to appointments with their urgent or routine care were twice as likely to stay own primary care physician; and 4) the importance with KPNC than were members who had difficulty of perceiving Kaiser Permanente, its physicians, and accessing care. its staff as friendly and supportive. In addition to these major themes, the study collected data on Had access problems No access problems women’s preferences for the gender of their physi- 100% cian, women’s interest in new services, and health 91% care for midlife women. 90% 79% 80% Results 73% 70% General findings of the KP Women’s Health Study 60% corroborated what other consumer research has 60% found—ie, that women are key purchasers of 50% health care—but also showed that this key role 40% 40% 35% of women is even more important in Northern 30% California than previous national research indi- of respondents Percentage cated: Of the 2000 women surveyed, 92% said 20%

they had primary or equal input in choosing health 10% care coverage. This result is comparable with the national statistic, 75%. 0% Very likely to stay with KP See KP as friendly, supportive Related a negative KP Results also confirmed that attracting new mem- place experience in past year bers is both a challenge and an opportunity for KPNC: A reputation of providing excellent medical services Figure 1: Results of telephone questionnaire survey administered to 500 women health and health improvement programs for women was plan members show that women who perceive problems of access to urgent and an important criterion in selection of a health plan routine care are less satisfied, are much less loyal, are more likely to speak negatively about the health plan to friends and family, and are less likely to perceive the health for 46% of nonmembers surveyed. When asked who plan as “friendly and supportive.” comes to mind as providing superior women’s health care, 78 health plans were mentioned; however, no health plan was mentioned twice, and KPNC was Improved Satisfaction Positive word of mouth not mentioned once! This outcome indicates that Would not tell friend, A Lot More relative, or coworker Satisfied Northern California has no recognized leader in No difference women’s health care. 9%

To relate all the results of and implications of 34% 34% the KP Women’s Health Study would take a book. Instead, we present some findings that are unex- pected or that provide information that KPNC may find useful for meeting the needs of its members, 32% 91% attracting new members, and raising the level of member satisfaction. These results are grouped Somewhat More Would tell friend, relative, into the four key areas found to be most impor- Satisfied or coworker tant to members: access to care; coordination of Figure 2. Results of telephone questionnaire survey administered to 500 women health care; choice and flexibility; and friendly, support- plan members show that the perception of well-coordinated health care leads to ive clinicians. members’ satisfaction and positive comments to others about the health plan.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 63 Adopting strategies for improving access to routine health systems appointments has the potential to improve members’ Very important Somewhat important Not important satisfaction, increase their loyalty, and lead to more Half indicated that 11% positive word of mouth (reputation). Options for they would switch from their current scheduling appointments beyond normal work hours primary care were applauded by members as well as nonmem- practitioner to a bers, especially women aged <55 years: 80% of the doctor who offers members under age 55 years would be “somewhat 16% evening or very likely” to make Saturday or evening appoint- appointments and ments, 63% would be “very likely” to schedule weekend evening appointments, and 55% would be “very appointments. likely” to choose Saturday appointments. Half indi- cated that they would switch from their current primary care practitioner to a doctor who offers evening appointments and weekend appointments. 73%

Coordination of Care N=1500 Coordination of care was the second greatest differentiator between satisfied and dissatisfied Figure 3. In response to a telephone survey, most KP women: 66% of members would have “somewhat” members emphasized the importance of seeing the same or “a lot” more satisfaction if they felt KPNC was able doctor at every visit. to help them coordinate care (Figure 2). Coordina- it easier for women members to assume their role as tion of care has two aspects: 1) ensuring that a woman the coordinator of health care for themselves and for member’s care does not “fall through the cracks,” their families. Indeed, when asked to evaluate the and 2) helping women fulfill their roles as care coor- desirability of new services, women ranked most dinators for the rest of the family. Although 20% of highly those services that could improve coordina- members surveyed felt that their care “falls through tion of care: family visits, multiple screenings during the cracks,” the good news is that most of the mem- regular office visits, and same-day appointments for bers believed KPNC is doing a good job of mammograms. One fourth of women interviewed coordinating their care: 78% said their doctors are during a visit indicated that they could have avoided good at keeping track of medications and treatments. a future visit if they could have obtained another test As many as 84% of the members surveyed praised or received additional care during the index visit. KPNC’s “Preventive Health Prompts”—reminders about appointments and preventive measures such Members’ Freedom of Choice and Their Flexibility in as mammography, immunization, and cholesterol Selecting Type of Practitioner screening that are printed on the registration slips— Most women (as many as 73%) indicated a strong and said they found the information helpful for preference for seeing the same doctor during each coordinating care. visit, but women also expressed flexibility in whom The study findings put the importance of coordi- they see if their regular clinician is not available (Fig- nating health care into perspective: 69% of married ure 3). This response was seen especially with regard women indicated that they coordinate their spouse’s to low-acuity urgent care: As many as 72% of women health care, and 59% of the women surveyed said were willing to see another doctor for flu or a sore they had accompanied a family member on a health throat, whereas only 35% agreed to see another doc- care visit in the past year. In addition, 21% of the tor for routine care. Most women (72%) also would women surveyed said they regularly take care of a see a registered nurse for low-acuity urgent prob- family member or friend who has an ongoing health lems, and 64% would visit a nurse practitioner (NP) problem or who is disabled in some way. The women for a routine checkup. most likely to be a caregiver are aged >55 years, are The importance of choice was again seen in women’s married, and have an annual income under $40,000. preferences for gynecologic care. For instance, 39% of Creating services that enhance coordination of care women preferred to see their obstetrician/gynecolo- provides “one-stop shopping,” saves time, and makes gist for a Pap smear, whereas 26% preferred to receive

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their Pap smear from their general medical doctor. KPNC’s competitive position and negatively influences Another 35% expressed no preference. satisfaction, word of mouth, and member retention. KPNC asked women their opinions of the newly introduced health care team model, a grouping of Other Areas of Importance to physicians, NPs, health educators, behavioral health Health Plan Members specialists, and physical therapists that enables mem- Physician Gender Preference bers to see another doctor when their own is An unexpected result was that more than half (57%) unavailable or to receive care directly from another of the women expressed no preference for gender team member if their complaints could be better ad- of their physician. Even when it came to receiving dressed by that health care professional. Pap smears, only 44% said they preferred a female Although 81% of the women surveyed perceived physician. However, overall satisfaction was nega- the team approach to be more an asset than a barrier tively affected among members who had a strong to seeing their regular doctor, about a third of the preference for a woman physician but who were women said they would prefer to see their own phy- unable to see one.4,5 sician every time they need care, regardless of the The challenge for KPNC is to match women who reason for the visit. The study further explored the strongly prefer a female physician with a female phy- multidisciplinary approach and found that 37% of sician, allowing women with no preference to be the women wanted to see their physician for the matched with a male physician. same amount of time at every visit, 26% were willing to see other team providers and have only brief in- Menopause Information and Services teraction with their regular doctor, and 37% said they Menopause education is inadequate at KPNC: 78% would not have to see their doctor at all if their needs of women surveyed said they had not received coun- were met by other providers. Women who objected seling about menopause. As many as 94% said they to multidisciplinary, team-based care generally were had not been given a brochure or seen an educa- less satisfied with their KPNC experience. tional video on menopause, and 98% said they had Clearly, a “one-size-fits-all” approach to delivering not attended a class at KPNC on the subject, yet health care will not satisfy women. half of the women aged between 45 years and 60 years said they are informed about menopause. A Friendly, Supportive Clinicians and Staff clear possibility is that women who are informed Of the women surveyed, 32% indicated that a pro- about menopause are not receiving the information vider or staff member had said something rude or from KPNC. insensitive (Figure 4). Women who experienced rude- ness were much more likely to say negative things about KPNC; 49% of these related only negative com- Is your KP facility a Had an MD, RN, MA…staff said ments about KPNC to friends, family, or coworkers. friendly and supportive something rude, insensitive, or The good news, however, is that 82% said they be- place? made you feel uncomfortable in past two years? lieved their KPNC facility is friendly and supportive No (Figure 4). The bad news is that compared with mem- 4% bers of other health plans, twice as many women Sort of Yes KPNC members said they had experienced rudeness, 14% Yes insensitivity, or discomfort. 32% Experiencing KPNC as “friendly and supportive” 68% was the top differentiator between members who 82% were satisfied and those who were not. Of those No who said they found KPNC unfriendly, only 6% felt highly satisfied, whereas 38% expressed low-to-mod- N=1500 N=1000 erate satisfaction. Of those who experienced rudeness, Source: Member 26% were highly satisfied, whereas 45% said they Telephone Survey had low-to-moderate satisfaction with KPNC. (Q13,25) The impact of rudeness and insensitive behavior Figure 4. Telephone survey results showed that most members see KP as a friendly, by clinicians and staff is so strong that it undercuts supportive place to obtain health care.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 65 A new HEDIS 2000 measure6—one which evaluates Women are also the major decision-makers: They health systems health plans’ efforts to counsel women about meno- select a health plan to purchase and determine pause—should increase motivation to develop other whether to stay with that plan.1,2,7 Although mul- strategies to better inform members about menopause. tiple national sources state that 75% of women serve As many as 72% of as the primary purchaser of health care, the KP nonmembers New Services Women’s Health Study1 shows an even greater in- indicated that they Complementary and alternative medicine services fluence of women on how families spend their would be more held high interest for 70% of the women surveyed. health care dollars.8 likely to join KPNC Interest did not vary by members’ geographic service Women’s decisions about their health care are in- if complementary area, age or ethnic group, socioeconomic class, health fluenced by many factors. Women rely on word of health services status, or whether members were satisfied or unsatis- mouth from friends, coworkers, and family to deter- were offered. fied. Complementary and alternative medicine services mine which health plan is right for them and their held substantially more appeal for members who work families.1 In addition, what women value in health full-time. As many as 72% of nonmembers indicated care is affected by the extent of their participation in that they would be more likely to join KPNC if comple- the work force.7,9 And because women are not all mentary health services were offered. alike, KP should use its substantial capability in in- formation technology to identify members’ individual Nonmembers: The Importance of preferences and to address their specific needs—and “Word of Mouth” thus realize an advantage over our competitors. Word of mouth about KPNC had a strong effect on Women use health care services more than men nonmembers’ opinions of the organization: 74% of do: Two thirds of all inpatient, outpatient, and phar- those who had a positive impression had heard only maceutical services are used by women.6,10 This fact positive comments about KP. The percentage of non- is true today and will remain true for the foreseeable members who have a positive opinion drops to 50% future, in part due to use of obstetric and gyneco- if they have heard both positive and negative com- logic care and because of women’s longer life ments about the organization. Of nonmembers who expectancy—generally, a span of seven years.2 These had heard nothing about KP, 48% had a positive im- additional years are often characterized by chronic pression; but among nonmembers who had heard illness and high utilization of health care services. only negative comments about KP, only 15% had a Health care utilization by women is also affected positive opinion. by other issues. Compared with men, women are About one in five nonmembers surveyed were more susceptible to immunologic, neurologic, psy- interested in possibly joining KPNC. Increasing chiatric, and many other disorders and are more often positive and decreasing negative comments and subjects of violence and poverty.7 Although cardio- anecdotes about KP among women could increase vascular disease is as likely to occur in women as in our market penetration. men, rates of morbidity and mortality from cardio- Because positive word of mouth about KP strongly vascular disease are higher in women.11 influences nonmembers’ opinion and their interest in KP conducted the Women’s Health Study because joining the health plan, it is imperative for KPNC to of two important commitments incumbent on the improve nonmembers’ impressions of the health plan. health care industry: 1) knowing what women value in health care delivery and 2) meeting those needs. Comment The results of the study are applicable and useful for Women are the major point of contact between all KP Regions and are being shared with all charged KPNC and the populations it serves. Women coordi- with focusing on women’s health across KP. In North- nate care for themselves and for their partners, ern California, each Physician-in-Chief has appointed children, disabled friends, dependent family, and— a Women’s Health Liaison, who reports the study increasingly—for their aging parents. Women call the findings to audiences at each KPNC facility and works health plan, use the parking garages, and interact to implement changes in care delivery to meet and with the office staff, doctors, and health care profes- exceed the expectation of KP’s women members. sionals more often than any other definable group.7 Several women’s health demonstration projects— How well KPNC performs will be judged in large funded by the Innovations Program as a follow-up part by this subset of the population. to the Women’s Health Study—are underway in North-

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ern California. Such projects include the KP Fremont study and put it into a form that will allow the reader to get the Project, “Multilingual women’s health project,” con- most out of it. Mari’s skill as a writer is matched by her commit- ducted by Maria Servin; the KP South Sacramento ment to improving the health of women. Project, “Coordinated Preventive Health Visit,” con- References ducted by Jan Langston and Kathleen O’Brien; and 1. Women’s Health Study: findings and implications. Oakland the KP Richmond Project, “Care Coordination for (CA): Kaiser Permanente Medical Care Program, February 1999. Women and Families,” conducted by Brigid McCaw. 2. Braus P. Marketing health care to women: meeting new These demonstration projects will evaluate new mod- demands for products and services. Ithaca (NY): American Demographic Books, 1997. els of care delivery to meet the demands of women 3. 3Q98 STAR Member/Non-member for Northern CA Report. who have multiple roles and needs. Each project will Oakland (CA): Kaiser Permanente Program Offices, Market be evaluated and—if successful—will be incorporated Research Department. nd. into the facilities’ operating budgets at the conclu- 4. Thompson M, Nussbaum R. An HMO survey on mass customization of healthcare delivery for women. Women’s sion of the one-year project’s funding. The models Health Issues 2000 Jan-Feb;10(1):10-9. will be shared for adaptation and implementation 5. Thompson M, Nussbaum R. Asking women to see nurses or across KPNC and in other KP Regions. unfamiliar physicians as part of primary care redesign. Am J In addition to focusing KP’s care delivery systems Manag Care 2000 Feb:6(2):187-99. 6. HEDIS 2000: Informed health care choice: Background on the needs of women, Women’s Health-KP is com- information about the Management of Menopause Survey. mitted to improving health care outcomes for women. 7. Wentz CA. Women’s Health Issues. Adv Intern Med 1995;40:1-30. By using KP’s robust research capability to better 8. Rowland D, Davis K. Caring for women in older age. In: understand some of the differences between gen- Friedman E, editor. An unfinished revolution: women and ders, we will contribute to improving the health of healthcare in America. New York: United Hospital Fund; 1994. p 87-101. women nationwide. 9. US Department of Labor. Womens Bureau. Facts on Working KP finds itself at the beginning of an exciting new era Women: Earnings Differences Between Women and Men. http:// in American medicine. In this new era, gender differ- www.dol.gov/dol/wb/public/wb_pubs/wagegap2.htm. ences in biology, health, and illness—as well as gender 10. US Department of Health and Human Services, Public Health Service, National Institutes of Health, Office of the differences among racial and cultural subgroups—will Director. Agenda for research on women’s health for the 21st be recognized and incorporated into the health care Century: A report of the Task Force on the NIH Women’s Health delivery system to improve the health of all. ❖ Research Agenda for the 21st Century, Vol 1 Executive Summary. Bethesda (MD): NIH Publication No. 99-4385, 1999. Acknowledgment: This article would not have been possible with- 11. Towards a women’s health research agenda: findings of the out the professional assistance of Mari Edlin, a freelance writer Scientific Advisory Meeting. Washington (DC): Society for the specializing in health care and a regular contributor to a variety Advancement of Women’s Health Research; 1991. of national publications. She took the mountain of data from the

Premonition If something reveals itself to you—if you have a premonition of sickness—you ought to pay attention …. These are not things you can control or manipulate. We all have wacky dreams. But when something pictorial comes to you, that’s not through normal channels. Larry Dossey, MD, author of Reinventing Medicine

The Permanente Journal / Summer 2000 / Volume 4 No. 3 67 By Philip J. Tuso, MD, FACP Proposed Care Management for Women with Estrogen Deficiency: Identification, Risk Stratification, and Treatment

Introduction 65,000 women per year, heart disease kills about health systems For years, we have understood the importance 233,000 women per year, and breast cancer kills about of managing the care of women with estrogen de- 43,000 women per year.5 Some authors1,6 have sug- ficiency: Women’s risk for death from hip fracture gested that the decrease in risk of heart disease and ischemic heart disease increase significantly outweighs the risk of breast cancer. after menopause.1 Population care management Despite the known benefits of HRT, however, many ... we have the programs have been developed to improve qual- women choose to not take estrogen replacement. In potential to ity of life and to reduce utilization of expensive one study,7 current use of HRT was reported by 58.7% identify and resources for patients who have preventable dis- of women who had hysterectomy and by 19.6% of manage the care of eases.2 Newly developed information technology women who did not have hysterectomy. Most women all women who systems within Kaiser Permanente (KP) make it pos- either do not fill prescriptions for HRT or discon- have estrogen 8 deficiency ... sible to identify and stratify risks for chronic tinue treatment within one year after starting HRT. illnesses such as congestive heart failure, diabetes mellitus, and asthma. Using this technology, we Recent and Proposed Ways to Improve have the potential to identify and manage the care Identification and Management of of all women who have estrogen deficiency: Se- Estrogen Deficiency lection algorithms can be integrated into current In general, women are not well informed about data systems to educate and improve the overall the risks and benefits of HRT. The Health Plan Em- care of menopausal women who are at risk for ployer Data and Information Set (HEDIS), which is complications of estrogen deficiency (eg, coronary maintained by the National Committee for Quality artery disease, and osteoporosis). Assurance (NCQA), now uses a set of standardized This article describes a proposed model of care performance measures to assure purchasers and con- that has been developed to help manage the care of sumers of health care that their managed care estrogen-deficient menopausal women. organizations are informing women who may have estrogen deficiency about the risks and benefits of Management of Estrogen Deficiency: HRT as well as alternatives to this therapy. Specifi- The Problem cally, HEDIS will be sending to members of managed In general, estrogen deficiency among women is care organizations a questionnaire which focuses poorly managed: Fewer than 20% of US women over on exposure to counseling, breadth of counseling, age 50 years are adequately treated for estrogen de- and personalization of counseling. In addition, the ficiency. This statistic suggests that we have substantial American Association of Clinical Endocrinologists room for improvement. Moreover, as our adult popu- (AACE) has outlined educational guidelines10 to help lation ages, the number of women who become clinicians manage their patients’ menopausal symp- estrogen-deficient will increase. There is a growing toms (Table 1). concern that many of these women will not be treated As a managed care organization, we must be held for estrogen deficiency. accountable for our management of the care of Management of estrogen deficiency is a subject of women with estrogen deficiency. By using tracking interest to many clinicians who care for women who systems to screen women for estrogen deficiency, have had hysterectomy or who become menopausal. by educating women about estrogen deficiency, and Clinicians are aware that hormone replacement by improving compliance with prescribed treatment therapy (HRT) in women decreases symptoms of regimens, treatment programs could decrease the menopause and decreases their risk for death associ- incidence of osteoporotic fracture and coronary ar- ated with hip fracture and heart disease; indeed, tery disease in women with estrogen deficiency. mortality among women who use postmenopausal Successful preventive therapy for these women could hormones is lower than among nonusers. However, then have a dramatic impact on health care expendi- the survival benefit of HRT use diminishes with longer tures over the next two decades. A care management duration because prolonged HRT use is associated program is therefore needed and should include with a slightly increased risk of breast cancer.3.4 In population identification, risk stratification, and mod- the United States, hip fracture kills approximately els of care for estrogen-deficient menopausal women.

PHILIP J. TUSO, MD, FACP, is the Assistant Chief, Internal Medicine, for the Lancaster Medical Offices. He has been a Permanente Medical Group physician for six years. He has authored over 20 research articles, and has won numerous awards. E-mail: [email protected]

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Proposed Population-Based Care mography, Pap smear) or who attend the counseling Management Model sessions or classes can be asked to complete a simple Women should start receiving counseling in their self-examination tool (Table 2). Responses to the mid- to late forties, when most women are questionnaire can be used to identify members as perimenopausal or menopausal. These Health Plan being at low, medium, or high risk for complications members could receive counseling by a case man- associated with untreated estrogen deficiency. Feed- ager with or without attending classes that review back to primary care providers on percentage of the risks and benefits of managing estrogen deficiency impaneled women aged >45 years who are receiv- as well as alternative methods of managing this con- ing HRT may increase the percentage of women who dition. Members seen in primary care clinics for are appropriately counseled on the risks and ben- routine examination or for cancer screening (mam- efits of HRT as well as on alternatives to this method

Table 1. AACE Educational guidelines for hormone replacement therapy10: risks, benefits, and alternatives

Benefits of hormone replacement therapy • Prevention of cardiovascular disease • Prevention of osteoporosis • prevention of menopause symptoms (“hot flushes,” mood alteration, depression, sleep disturbance, vaginal dryness)

Risks of hormone replacement therapy • Thromboembolism (blood clots) • Cholelithiasis (gallstones) • Endometrial cancer (women with a uterus who receive estrogen but not progestin replacement) • Abnormal vaginal bleeding • Possible increase risk of breast cancer

Alternative therapies to hormone replacement therapy • Prevention of menopausal symptoms: Flaxseed and phytoestrogens (soy products and herbal preparationsa) Vaginal lubricants • Prevention of coronary artery disease: Smoking cessation Lipid management Blood pressure management Glucose control Responses to the • Prevention of osteoporosis: questionnaire can Smoking cessation Exercise be used to identify Vitamin D and calcium supplementation members as being Selective estrogen receptor modulators (raloxifene) at low, medium, or Biphosphonates (alendronate) high risk for Calcitronin complications associated with a Reasons why Health Plan members should consult a physician before taking herbal supplements and untreated estrogen phytoestrogens for management of estrogen deficiency: deficiency. • not all herbs are safe • not all herbs are standardized • herbal preparations may be contaminated • herbal preparations may interact with prescription medication • effectiveness of herbal preparations may not be evidence-based

The Permanente Journal / Summer 2000 / Volume 4 No. 3 69 of managing estrogen deficiency. Models of care Women who decide to take HRT should have easy health systems (Table 3) could help guide members, staff, care man- access to clinics or practitioners who can provide agers, and clinicians in developing the best education on the most appropriate treatment plan management plan for each Health Plan member. and who can arrange for follow-up consultation to answer any questions and, if necessary, to adjust Table 2. Proposed self-examination tool for women therapy. For women who have not had hysterec- tomy, HRT should include estrogen and progestin Question A: Menopausal symptoms agents because unopposed estrogen therapy in Do you have a history of: women with a uterus has been associated with en- • depression? dometrial cancer. Women who have had • urinary incontinence? • vaginal dryness? hysterectomy need only estrogen replacement. Mul- 10 • hot flushes? tiple HRT regimens have been developed. For • difficulty sleeping? women with a uterus, these regimens commonly • painful intercourse? prescribe 0.625 mg equine estrogen taken orally every day with daily or cycled medroxyprogesterone Question B: Risk factors for osteoporosis at a dosage of 5 mg to 10 mg per day. Do you have a history of: Hormone replacement therapy is contraindicated • fracture after age 50 years? in women who have a history of breast or uterine • parents or siblings who had fracture after age 50 years? cancer, thromboembolism, undiagnosed genital • taking medications such as prednisone or corticosteroid drugs? • total hysterectomy? bleeding, gallbladder disease, or undiagnosed head- 10,11 • tobacco use? ache with or without hypertension. For women in whom HRT is not well tolerated or for whom HRT Question C: Risk factors for coronary artery disease is contraindicated or not selected, alternative therapy Do you have a history of: for preventing osteoporosis includes vitamin D and • diabetes mellitus? calcium supplementation, selective estrogen recep- • high blood pressure? tor modulators (raloxifene), biphosphonates • high cholesterol level (LCL-C > 160 mg/dL [4.14 mmol/L]) (alendronate), phytoestrogens, and calcitonin.10 In • heart attack? addition to having protective effects on bone, • angiogram with abnormal findings? raloxifene may also lower LDL cholesterol levels. • parents or siblings with history of heart attack or stroke? • tobacco use? Alendronate has been shown to have no effect on reduction of symptoms associated with menopause Question D: Risk factors for breast cancer but has been approved for both prevention and treat- Do you have ment of osteoporosis. Alendronate has not been • personal history of breast cancer? shown to reduce cardiac mortality associated with • personal history of breast biopsy done to rule out diagnosis of breast estrogen deficiency.12 cancer? The effects of HRT, alendronate, and raloxifene on • mother or sisters with history of treatment for breast cancer? bone disease, coronary artery disease, menopausal • family history of bilateral breast cancer? symptoms, breast cancer, and thromboembolism are Risk groups: summarized in Table 4. As stated above, HRT, alendronate, and raloxifene all help to prevent os- • More than two symptoms of menopause (Question A) • teoporosis. The cardioprotective effects of HRT have More than two risk factors for coronary artery disease (Question B) 13 • More than two risk factors for osteoporosis (Question C) been well documented. Of all 3 treatments—HRT, • History of breast cancer or high risk for breast cancer (Question D) alendronate, and raloxifene—HRT is best for man- • Postmenopausal woman who does not receive hormone replacement aging menopausal symptoms. Raloxifene and HRT therapy may cause thromboembolic disease. Menopausal symptoms are easily managed with HRT Women with no regular primary care physician but are difficult to treat without estrogen replacement. Risk for complications by number of risk factors: Flaxseed, soy products, and certain herb products • High risk for complications: 4-6 risk factors contain phytoestrogen, which may inhibit release of • Medium risk for complications: 1-3 risk factors leutinizing hormone and subsequently help women • Low risk for complications: 0 risk factors with hot flushes and mood irregularity.14 Vaginal dry-

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Table 3. Proposed models of care for women with estrogen deficiency

Low risk for complications: • Yearly flu vaccine and routine immunizations per KP Regional guidelines • Smoking cessation • Mammogram, Pap smear, LDL cholesterol level tested per guidelines • Vitamin D (400 IU/day) and calcium (1000-1500 mg/day) supplementation • Routine contact with primary care provider at least once per year • Osteoporosis preventive therapy per KP Regional guidelines • Basic menopause education

Medium risk for complications (all low-risk-group actions) • Assure all members assigned to a primary care practitioner • Consider referral to endocrinology clinic for women with risk factors for osteoporosis • Consider referral to cardiology clinic and/or cholesterol clinic for women with risk factors for coronary artery disease • Review medication/vitamin compliance (eg, calcium supplementation, Vitamin D, hormone replacement therapy, alendronate) • Written treatment plan and refer for group menopause class • Telephone follow-up to assure self-care skills assimilated

High risk for complications (all low- and medium-risk-group actions): • Referral to specialist if indicated (endocrinology, cardiology, psychiatry, or cholesterol clinic, or any combination) • Review treatment plan for management of coronary artery disease and osteoporosis

ness can be managed with phytoestrogen creams or obstetrics-gynecology departments and use a care with nonprescription, water-based lubricants.15 Use of management strategy that includes long-term conti- herbal remedies is not without risk (Table 1), and nuity of care as well as special expertise in managing members should review their use of herbal supple- multiple risk factors. ments with their health care practitioners.16 All Health Plan members should be screened for The Problem of Noncompliance diabetes mellitus, hypertension, and hyperlipidemia, Two important reasons exist for noncompliance and appropriate treatment should be initiated accord- with HRT: 1) side effects resulting from initiation of ing to KP Regional guidelines. Women at risk for HRT and 2) belief that an increased risk of breast coronary artery disease should be screened carefully to ensure that optimum LDL levels have been Table 4. Effects of using hormone replacement therapy (HRT), achieved. After receiving dietary counseling, Health alendronate, and raloxifene for medical management of Plan members at very high risk for coronary artery estrogen deficiency disease may be considered candidates for “statin” therapy.17 All members who smoke should be ad- HRT Alendronate Raloxifene vised to stop. Education classes and individual Bone density + + + counseling should emphasize the importance of ex- ercise as well as vitamin D and calcium Coronary artery + no effect + supplementation.18 Care of women in the high-risk disease group should be managed aggressively by these members’ primary care practitioner or referred to a Menopausal symptoms + no effect - specialist, as appropriate. Some medical centers may Breast cancer + no effect + consider developing clinics to manage the care of female members who are at risk for complications Thromboembolism + no effect + associated with estrogen deficiency. Teams may con- sist of representatives from the adult medicine and + = positive effect; - = negative effect

The Permanente Journal / Summer 2000 / Volume 4 No. 3 71 cancer is associated with estrogen replacement. An Women should know that multiple studies published health systems estimated 20%-30% of women who initiate HRT dis- over the past 20 years fail to show that estrogen use continue it within one year after starting treatment.8 increases women’s risk for breast cancer.10 To ensure Well-organized Many women are concerned about associated prob- that all members receive counseling and comply with education lems, ie, abnormal uterine bleeding and the prescribed treatment regimens—and to assess the programs and inconvenience of taking hormones for the rest of their program’s overall success—measurable outcomes access to lives. Well-organized education programs and access such as those proposed (Table 5) should be moni- counselors should to counselors should be made available to women tored continuously. be made available who have questions about HRT before they consider to women who stopping treatment. Conclusion have questions about HRT before Many women avoid HRT because of the fear that Information technology is revolutionizing the way they consider by taking estrogen replacement they will increase we care for patients. Specifically, we now have the stopping their risk of developing breast cancer. In 1997, the tools to identify and stratify risks for many chronic treatment. results of a collaborative reanalysis of the effects of illnesses and to manage the care of large numbers of HRT on women were reported from 51 epidemio- Health Plan members with these chronic illnesses. logic studies of 52,705 women with breast cancer Over the next few years, we will therefore shift many and 108,411 women without breast cancer.19 The re- of our resources form disease treatment to disease sults demonstrated that an increased risk of breast prevention. In this context, population-based care cancer in estrogen users might not be conclusive. management for women represents the next phase

Table 5. Overview of proposed population-based care management for women with estrogen deficiency

1. Screen and educate all women at risk for estrogen deficiency on the risk and benefits of hormone replacement therapy as well as alternatives to this therapy.

2. Design questionnaire (eg, Tables 1 and 2) as an outreach tool to educate women and staff members about risk of complications associated with estrogen deficiency. Women can use tool for self- examination to determine risk for complications. Develop models of care (eg, Table 3) to help members and staff determine the care modality appropriate for each member. Develop care management programs to allow women aged >45 years to self-refer to educational programs (ie, lectures, tapes), to case managers, or to specialists.

3. After completing self-evaluation questionnaires during outreach programs, at routine clinic visits, or at hospital admission, identify members at risk for complications of estrogen deficiency. Multiple points of contact at which this population can be identified: • at entry programs for new members and at educational programs • at visit for mammogram or Pap smear • at orthopedic clinic evaluation for fracture • at cholesterol clinic evaluation for hyperlipidemia • at gynecology clinic follow-up after hysterectomy • at surgical clinic visit for treatment of breast lump or malignancy • at Kaiser Permanente Web site • in educational letters mailed to female members on their 45th birthday

4. Develop database to record questionnaire response (ie, to determine percentage of women at high, medium, or low risk for complications of estrogen deficiency

5. Develop database of measurable outcomes to monitor percentage of women aged >45 years who • meet LDL cholesterol goals for age per KP Regional guidelines (see laboratory database) • comply with prescribed hormone replacement regimen (see pharmacy database) • had fracture during the past year (see hospital/clinic diagnostic code) • had myocardial infarction during the past year (hospital/diagnostic code)

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of care management: after individual Health Plan are women receiving the full impact of hormone replacement therapy preventive health benefits? Women’s Health Issues 1992 members are stratified according to their health risks, Summer;2(2):75-80; discussion 80-2. long-term medical complications in these members 9. HEDIS 2000, Vol. 3: Specifications for Survey Measures. can be prevented through routine medical evalua- HEDIS Protocol for Administering CAHPS® 2.0H Survey. tions given by health care practitioners, yearly Management of Menopause Survey. Washington, DC: NCQA Publications; 1999. p. 41-54. Item No. 10236-100-00. reminder letters, and recommended participation in 10. American Association of Clinical Endocrinologists. AACE health education programs or seminars. Population- medical guidelines for clinical practice for management of based care management of women with estrogen menopause. Endocrine Pract 1999 Nov-Dec;5(6);355-66. deficiency can be modeled after highly successful 11. Pérez Gutthann S, Garcia Rodriguez LA, Castellsague J, Duque Oliart A. Hormone replacement therapy and risk of care management programs currently used by KP for venous thromboembolism: population-based case-control study. management of asthma, congestive heart failure, and Br Med J 1997 Mar 15;314(7083):796-800. diabetes mellitus. 12. Liberman UA, Weiss SR, Broll J, Minne HW, Quann H, Bell Considering these emerging needs and capabili- NH, et al. Effects of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. ties, a goal of our health maintenance organization The Alendronate Phase III Osteoporosis Treatment Study should be to inform all women of the risks and Group. N Engl J Med 1995 Nov 30;333(22):1437-43. benefits of hormone replacement therapy as well 13. Stampfer MJ, Colditz GA, Willett WC, Manson JE, Rosner B, as its alternatives. ❖ Speizer FE et al. Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the nurses’ References health study. N Engl J Med 1991 Sep 12;325(11):756-62. 1. Wood H, Wang-Dheng R, Nattinger AB. Postmenopausal 14. Lieberman S. A review of the effectiveness of Cimicifuga hormone replacement: are two hormones better than one? J racemosa (black cohosh) for the symptoms of menopause. J Gen Int Med 1993 Aug;8(8):451-8; 1993. Women’s Health 1998 Jun;7(5):525-9. 2. Bodenheimer T. Disease management—promises and pitfalls. 15. Nyirjesy P, Weitz MV, Grody MH, Lorber B. Over-the-counter N Engl J Med 1999 Apr 15;340:1202-5. and alternative medicines in the treatment of chronic vaginal 3. Grady D, Rubin SM, Petitti DB, Fox CS, Black D, Ettinger B, symptoms. Obstet Gynecol 1997 Jul;90(1):50-3. et al. Hormone therapy to prevent disease and prolong life in 16. Tuso PJ. The herbal medicine pharmacy: what Kaiser postmenopausal women. Ann Intern Med 1992 Dec Permanente providers need to know. Permanente J 1999 15;117(12):1016-37. Winter;3(1):33-7. 4. Grodstein F, Stampfer MJ, Colditz GA, Willett WC, Manson JE, 17. Darling GM, Johns JA, McCloud PI, Davis SR. Estrogen and Joffe M, et al. Postmenopausal hormone therapy and mortality. progestin compared with simvastatin for hypercholesterolemia N Engl J Med 1997 Jun 19;336(25):1769-75. in postmenopausal women. N Engl J Med 1997 Aug 5. Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm 28;337(9):595-601. AA. Race and sex differences in mortality following fracture of 18. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of the hip. Am J Public Health 1992 Aug;82(8):1147-50. calcium and vitamin D supplementation on bone density in men 6. Col NF, Eckman MH, Karas RH, Pauker SG, Goldberg RJ, Ross and women 65 years of age or older. N Engl J Med 1997 Sep EM, et al. Patient-specific decisions about hormone replacement 4;337(10):670-6. therapy in postmenopausal women. JAMA 1997 Apr 19. Breast cancer and hormone replacement therapy: 9;277(14):1140-7. collaborative reanalysis of data from 51 epidemiological studies 7. Keating NL, Cleary PD, Rossi AS, Zaslavsky AM, Ayanian JZ. of 52,705 women with breast cancer and 108,411 women Use of hormone replacement therapy by postmenopausal without breast cancer. Collaborative Group on the Hormonal women in the United States. Ann Intern Med 1999 Apr Factors in Breast Cancer [published erratum appears in Lancet 6;130(7):545-53. 1997 Nov 15;350(9089):1484]. Lancet 1997 Oct 11;350(9084):1047-59. 8. Ravnikar VA. Compliance with hormone replacement therapy:

Journey It is good to have an end to journey toward; but it is the journey that matters, in the end. Ursula K. LeGuin, award-winning science fiction and fantasy author

The Permanente Journal / Summer 2000 / Volume 4 No. 3 73 By Deidre S. Lind The Heart of a True Partnership: Dr Oliver Goldsmith Receives “Winning Spirit Award for Partnership”

Time and time again, we have learned the impor- WIN ABC, their first stop was to the office of Dr external affairs tance of partnership in the practice of medicine. Oliver Goldsmith, Medical Director and Chairman Nowhere is its value more evident than in the rela- of the Board for the Southern California Perman- tionship between Kaiser Permanente (KP) and the ente Medical Group (SCPMG). After carefully Women’s Information Network Against Breast Can- considering the WIN ABC proposal and perceiving cer (WIN ABC), an inspiring program which originated its importance and potential value to patients and ... the patient and her physician at Kaiser Permanente. their families, Dr Goldsmith granted seed funding began working WIN ABC is a national nonprofit organization dedi- for the program and designated a pilot site at the together to create cated to enhancing the levels of care, education, and KP Fontana Medical Center. a program ... support available for breast cancer patients and their families.1 What started out as a partnership between National Impact and Recognition a patient and her surgeon has grown into a collabo- The partnership has not stopped there, however. ration between an entire health care system and an In 1998, Kaiser Permanente again teamed up with advocacy group. Together, KP and WIN ABC have WIN ABC—this time led by Dr Balasz (Ernie) Bodai, had a tremendous impact on the lives of thousands a surgeon at the KP Sacramento Medical Center. To- of patients diagnosed with breast cancer as well as gether, they lobbied to pass an innovative piece of on their families. legislation, the Stamp Out Breast Cancer Act, which resulted in the creation and nationwide distribution A Patient and Her Physician: of the first semipostal fundraising postage stamp Teaming Up to Win whose proceeds support biomedical breast cancer This unique partnership started eight years ago, research. To date, with the support of such dignitar- when Dr Brad Edgerton, a Permanente plastic sur- ies as First Lady Hillary Rodham Clinton, the stamp geon at the KP West Los Angeles Medical Center, has garnered almost $11 million for breast cancer noticed some unique and impressive qualities in one research and raised public awareness about this of his patients. The patient, Betsy Mullen, had been deadly disease.3 diagnosed with breast cancer at age 33 and was The Breast Buddy Breast Care Program2 of WIN working closely with Dr Edgerton to learn as much ABC has significantly grown, and last year it was as possible about the disease. Ms Mullen took the nationally recognized as a Standard of Excellence initiative to seek out as many outside resources as by the American Association of Health Plans, a na- she could find, but she came to realize that the stan- tional trade association that represents more than dard of care as it then existed did not meet her need 1000 health maintenance organizations such as KP.4 for emotional support. Today, WIN ABC volunteers provide peer support To address this situation, the patient and her physi- and resources to hundreds of newly diagnosed cian began working together to create a program breast cancer patients through the Breast Buddy that would provide information resources, emotional Breast Care Program now expanded to serve indi- support, and a new standard of breast cancer care gent women at county hospitals. The program is not only for Ms Mullen but also for other breast can- now considered to be an excellent model of an cer patients. What resulted was the Breast Buddy effective partnership between a patient and her Breast Care Program,2 a WIN ABC program designed medical practitioner. to pair breast cancer survivors with newly diagnosed The latest recognition for this partnership has patients to provide psychological peer support and come from WIN ABC itself. On March 28, 2000, to make resources available as needed. WIN ABC presented to Dr Oliver Goldsmith the program’s first annual Winning Spirit Award for Major Support From Kaiser Permanente and the Partnership. The award honored Dr Goldsmith’s Southern California Permanente Medical Group strong, personal support for the relationship be- Ms Mullen and Dr Edgerton first set out to find tween Kaiser Permanente and WIN ABC. Dr funding for their unique program. Working under Goldsmith’s early belief in Dr Edgerton’s and Betsy the auspices of their newly formed nonprofit entity, Mullen’s vision for breast cancer care resulted in a

DEIDRE S. LIND is the Associate Director of Government and Community Relations for the California Division Public Affairs Department. She manages partnerships with consumer groups and strategies which enhance Kaiser Permanente’s external profile. E-mail: [email protected]

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powerful alliance benefiting thousands of breast References cancer patients and their families. 1. Women’s Information Network Against Breast Cancer. http:// On March 28, Partnership often involves give-and-take: We must rec- www.winabc.org [accessed June 12, 2000]. 2000, WIN ABC 2. Women’s Information Network Against Breast Cancer. Breast presented to Dr ognize that each partner is equally important to the end Buddy Breast Care Program. http://www.winabc.org/programs/ result. To best serve our patients, in addition, we must html [accessed June 12, 2000]. Oliver Goldsmith realize that individual needs are diverse and unique. We 3. Lane J. Surgeon puts his stamp on breast cancer. Permanente the program’s first J 1998 Summer;2(3):58-9. may not be able to fully meet each need by working annual Winning 4. American Association of Health Plans. http://www.aahp.org Spirit Award for alone, but by partnering with innovative organizations [accessed June 12, 2000]. Partnership. like WIN ABC, we can provide a coordinated and com- prehensive health care experience for our patients. ❖

Where Life Never Ends Neverending dream where life never ends – where people live in perfect harmony where color is not wrong where we can walk and sing without laughter of putdowns where someone greets you with words of joy where loneliness and inequality become a speck of dirt in the winds of the past – But reality must come first. Jeff White Bear Claws, Red Cloud Class of 1990, Footsteps of Wisdom

The Permanente Journal / Summer 2000 / Volume 4 No. 3 75 By M. Jean Gilbert, PhD We Have Come a Long Way: Women’s Health at the Turn of the Millennium

Twenty-six years have passed since the publica- study have provided researchers with survey re- external affairs tion of Our Bodies, Ourselves by the Boston Women’s sponses as well as biologic samples ranging from Health Book Collective.1 That bestselling book toenails to vials of blood.7 The Study of Women’s marked the beginning of a major change in women’s Health Across the Nation (SWAN) is examining health attitudes about taking active responsibility for their issues of women at midlife and is comparing the During the 1980s, health and about insisting on relationships with their health status of African American, Latino, Asian the groundwork physicians based on mutual health care decision- American and white women.8 The Women’s Health was laid for making. Women also began to lobby for research Initiative (WHI) is a massive study focusing on the substantial that would better define their health care needs: major causes of death, disability, and frailty in post- advances in Women were becoming increasingly unwilling to menopausal women. This multiyear study, conducted research on women’s health. accept as pertinent to them findings from observa- in >40 centers across the country, is the largest pre- tional studies or clinical trials that included only vention-oriented clinical trial in US history.9 Effects men. Lacking scientific data to indicate otherwise, of progesterone/estrogen regimens in postmeno- the medical establishment appeared to assume that, pausal women are being studied in the PEPI Trial.10 excepting issues of reproductive health, women’s The National Breast Cancer Prevention Trial is study- health needs were essentially the same as men’s. ing the effectiveness of tamoxifen and raloxifene in Since then, enormous changes have come about in preventing breast cancer among high-risk women.10 our knowledge about women’s health needs and The National Longitudinal Study on Adolescent how to approach them.2 Health, based on a survey of 90,000 adolescents across During the 1980s, the groundwork was laid for the country, will give us new information on risk substantial advances in research on women’s health. factors and health issues among girls.4,10 In 1986 the National Institutes of Health (NIH) es- tablished a policy that required researchers to Women and Men Differ Far More Than include women and minorities in NIH-funded re- Previously Thought search. Also in the mid-1980s, the Society for the As the vast amount of new information is being Advancement of Women’s Health Research was cre- analyzed, what are we learning? One of the major ated to help design and encourage research focused outcomes is that we now have evidence for a gen- on women’s issues. By 1991, when the US Depart- der-based biology that shows gender differences at ment of Health and Human Services created the the system, organ, tissue, cellular, and subcellular lev- Office of Women’s Health, a groundswell of sup- els as well as in epidemiology and drug response.10 port had arisen for clinical research on women’s Important examples of such differences are appar- health.3,4 In 1993, the Federal Drug Administration ent in the areas of drug response, addiction, chronic issued new guidelines that lifted the ban on includ- disease state, susceptibility to infection, and vulner- ing women of childbearing age in many clinical trials ability to mental and social problems. conducted to develop new drug products.5,6 Drug Response Research on Women’s Health Women tend to wake up from anesthesia more has Increased Massively quickly than men (mean time, 7 minutes for women In the early part of the 1990s, studies on women’s and 11 minutes for men). Some pain opiates (kappa- health mushroomed, and although it is still too early opiates) are far more effective for relieving pain in to have definitive answers regarding many impor- women than in men.3 tant issues, information from several large Even common drugs (eg, antihistamines and anti- prospective, observational studies is changing the biotics) can cause substantially different side effects way that the medical establishment understands and reactions in men than in women. Data suggest women’s needs. During the past few years, impor- that the vascular systems of women differ from men tant data have been collected from the Nurses Study, in many ways; and in turn, this difference creates a prospective study begun in 1976 that has been difference in the vasodilatory effects of many drugs. closely monitoring several cohorts of nurses. Over For example, side effects such as flushing, edema, the years, the thousands of nurses included in the and palpitations produced by the calcium blocker

M. JEAN GILBERT, PhD, a medical anthropologist, joined Kaiser Permanente’s Organizational Research Department in 1990. Prior to that, she directed cross-cultural epidemiologic research at UCLA and has published widely in the area of alcohol use and alcoholism. She is the former Director of Cultural Competence for the California Division, Pasadena. E-mail: [email protected]

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amlodipine were found to be more pronounced in After menopause, women lose more bone mass women.5 Women’s higher levels of body fat content than men—the reason why 80% of osteoporosis pa- are also believed to alter the effects of drugs.5 tients are women. Arthritis and other rheumatoid conditions (ie, chronic inflammation and stiffness of Addiction joints, muscles, and tendons) are more common in Women who smoke cigarettes are 7% to 20% more women than in men.4,10 likely to become affected with lung cancer than men who smoke the same amount of tobacco.3 Susceptibility to HIV Infection and Other After consuming the same amount of alcohol, Sexually Transmitted Diseases women have a higher blood alcohol content than During unprotected intercourse with an infected men, even when allowing for different body size. partner, women are twice as likely as men to con- Compared with men, women drinkers have a higher tract a sexually transmitted disease and are ten times incidence of liver disease, even though they gener- more likely to contract HIV.8,13 ally consume less alcohol for shorter periods of time.8,11 Differences in how men’s and women’s bod- Vulnerability to Mental and Social Problems ies process alcohol are probably responsible for the Depression is two to three times more common in greater tissue damage suffered by women.8,11 women than in men, partly because women’s brains produce less of the hormone serotonin.14 Violence is Chronic Disease State a major public health problem for women. Women In part because they live longer than men (seven are six times more likely than men to be abused by years on average), women are more likely to be af- someone they know and are ten times more likely to fected by such chronic, disabling conditions as become victims of sexual assault. Despite a move to osteoarthritis, osteoporosis, urinary incontinence, and treat domestic violence as a medical condition, the Alzheimer’s disease.3 lack of good screening protocols and lack of tested, Although women have lower rates of chronic ob- effective interventions impede progress in this area.8 structive pulmonary disease (COPD) than men, the COPD rates for women have nearly doubled since Health Status Varies Greatly 1979, and the most rapid increases have been seen Across Groups of Women among women ≥75 years.8,9 Recent data also indicate that disease incidence and Even though women have stronger immune sys- mortality rates vary considerably across racial and eth- tems to protect them from disease, women are more nic subgroups of women in the United States.10,15-17 likely to acquire autoimmune diseases such as lu- Some findings follow: pus, scleroderma, rheumatoid arthritis, and multiple • Although heart disease is the leading cause sclerosis. These diseases also present differently of death among whites, blacks and Latinas, In part because in men and women: Greater disease acuity is seen cancer is the leading cause of death among they live longer in women. These gender differences are thought Asian/Pacific Islander women. than men (seven years on average), to be mediated by differences in the mechanism • African American women have the highest 3,8 women are more of antibodies. age-adjusted rate of death from heart likely to be affected Heart attacks are the No. 1 killer of men and women, disease (164 deaths per 1000 women), by such chronic, but women tend to have heart attacks about 10-15 and Asian/Pacific Islanders have the disabling conditions years later in life, and the initial attack is more often lowest rate (56 deaths per 100,000 as osteoarthritis, fatal in women. Moreover, women are 25% more women). White women, Latinas, and osteoporosis, likely than men to have a second heart attack within Native Americans have rates between the urinary one year after their first heart attack. A heart attack other two. incontinence, and often manifests differently in women and men: • Cerebrovascular-related death among Alzheimer’s 3 Women are much less likely than men to report chest African American women occurs at a rate disease. pain and are more likely to report feelings of indi- of 40 per 100,000 women—a rate far gestion, nausea, and extreme fatigue.2-4,7,12 exceeding that of any other group. The Researchers have also learned that high levels of rate for white women ranks second (23 high-density lipoprotein (HDL) have a much greater deaths per 100,000 women). protective effect in women than in men. • Although the incidence of breast cancer

The Permanente Journal / Summer 2000 / Volume 4 No. 3 77 among white women (112 cases per Kaiser Permanente’s Focus on Women’s Health external affairs 100,000 women) is higher than among Kaiser Permanente researchers and clinicians are any women of color, the mortality rate actively pursuing research on women’s health issues The organization is from the disease among white women (27 and are developing programs that address women’s differentiating itself deaths per 100,000 women) dropped 6% most critical health needs. The organization is differ- from other health during 1989-1993, whereas mortality rates entiating itself from other health plans by both the plans by both the among black women continue to increase. rigor and quantity of the attention given to women’s rigor and quantity Asian women have the lowest breast health concerns. Literally dozens of research and of the attention cancer incidence (69 cases per 100,000 program development efforts in women’s health are given to women’s women) and mortality rate (13 deaths per ongoing within the organization.18,19 health concerns. 100,000 women). The Kaiser Permanente Northern California (KPNC) • The incidence of cervical cancer is much Division of Research is partnering with one of the 40 higher among Vietnamese women (42 centers of the WHI national study and also in the part cases per 100,000 women) than among of the study known as WHIMS—the Women’s Health Latinas (16 cases per 100,000 women), Initiative Memory Study—which examines the effect blacks (13 cases per 100,000 women), and of hormone replacement on Alzheimer’s disease pro- whites (9 cases per 100,000). gression. Through a subcontract with the University • The highest prevalence of type II of California at Davis, KPNC is also included in the diabetes is found among some groups of SWAN examination of women in midlife, a study spon- Native American women, such as the sored by the National Institute on Aging. Pima and Papago (Tohono O’odham). A study, Health Implications of Sexual Orientation Well over one third of Hawaiian women Among Women, has been undertaken to discover are diabetic. Although Latinas have a whether health behavior and health-seeking behav- higher lifetime prevalence of diabetes, ior differ among women with different sexual African American women have higher orientation. The KPNC medical center at Richmond rates of morbidity and mortality from has fielded a research and demonstration model for the disorder. reducing family violence through primary preven- • Although rates of infant and maternal tion, screening, and appropriate referral. mortality have dropped dramatically in the At Kaiser Permanente Southern California (KPSC), United States during the past four researchers in the Department of Research and Evalu- decades, the infant mortality rate among ation are participating in a study funded by the African Americans has remained 2.4 times National Institute on Aging to investigate the effects the rate among whites and Latinas, and of hormone replacement therapy (HRT) on the maternal mortality rate is four times Alzheimer’s disease.20 Researchers in the same KPSC that of women in the general population. department are also collaborating with the Pacific • Clear discrepancy in health status, Institute for Women’s Health on a demonstration and mortality, and morbidity are found across evaluation project focused on determining the feasi- subgroups of women and is of great bility and acceptability of making emergency concern to the nation. Differences in contraceptive pills available. health care access, insurance, use of Most of the research being done within Kaiser Per- preventive screening, risk factors, manente is linked to program development or behaviors, and even genetic variation are service delivery and focuses on enhancing quality all believed to contribute to this discrep- of care for women members.20,21 For example, the ancy. Major initiatives undertaken by the study on women’s acceptance of emergency con- Centers for Disease Control and Preven- traceptive pills includes development of provider tion and the Agency for Health Policy and and patient education materials, repackaging oral Research in 1999 are designed to unravel contraceptives into emergency contraceptive kits, the reasons for differences among and development of information that will enable populations and to create programs for other health care organizations to replicate the pro- narrowing the health care gaps between gram. Similarly, after Kaiser Permanente researchers defined groups of women. studied different modes of care for women who were

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at high risk for preterm labor, the study results were That women’s health issues are now being taken used to establish a preterm delivery prevention pro- very seriously in this country is evident from recently gram that is helping to set the standard of care for passed legislation that makes managed care more these high-risk patients. accountable to women patients. This legislation in- At KPNC, the Regional Health Education and cludes the Newborns’ and Mothers’ Health Protection Women’s Health Departments are researching, de- Act,23 which requires a minimum hospital stay of 48 veloping, and testing Menopause: a Kaiser hours after a normal vaginal birth and 96 hours after Permanente Guidebook for Women as part of an over- a Caesarean delivery unless mother and physician all effort to provide women members with specific agree to an earlier discharge. The proposed Patients’ kinds of services focused on the menopausal period. Bill of Rights makes choosing an obstetrician and One Kaiser Permanente service area is implement- gynecologist for primary care the law of the land. ing the “Women’s Health Prevention Visit,” a Saturday Now that numerous studies and marketing analy- morning clinic time devoted to providing multiple ses have learned that women are the primary women’s health services and counseling at a single decision-makers in choosing a family’s health plan visit. Through a project called Care Coordination for and that women assume a coordinating role in their Women and Families, another service area will inte- families’ care, attention to women’s health issues is grate behavioral health care into obstetrics and playing an important role in the financial success of gynecology services. health care organizations. As Kaiser Permanente Kaiser Permanente has developed the nation’s first builds and further improves its firm base in research evidence-based clinical practice guidelines for and in coordinated clinical programs for women, we BRCAl, the gene linked to increased risk of breast can expect higher member satisfaction and contin- or ovarian cancer. These guidelines make recom- ued member growth. ❖ mendations for genetic counseling of specific groups Acknowledgment: Tracy Rone, MA, assisted with research. of women on the basis of their personal and family References histories of cancer. 1. Pincus J, editor. Our bodies, ourselves for the new century: a As the findings from Kaiser Permanente’s research book by and for women. Boston: Boston Women’s Health Book Collective; 1998. [The early version is out of print. Several later and demonstration projects focused on women are editions have subsequently been printed, and this is the latest integrated into its service delivery patterns, the qual- one. It has a review of the publications.] ity of services to women members is enhanced and 2. Women’s health at the millennium: how far we’ve come. Harvard Women’s Health Watch. 1999 Dec;7(4):2-5. important leadership in women’s health is provided. 3. Women’s health research: the next phase. News and Features 1997 Fall. National Institutes of Health, Office of Research on Women’s Health. (http://www.nih.gov/news/nf/womenshealth) Women As Consumers and Coordinators of Accessed on July 7, 1999. 4. NIH Agenda on Women’s Health Research. Overview. Office Health Care of Women’s Health Research Home Page. 1999 July. (http:// A New York Times article22 recently pointed out that www4.od.nih.gov/orwh/overview). Accessed on July 7, 1999. 5. Executive summary: gender studies in product development. an integrated managed care program seems tailor- Federal Drug Administration. 1999 Mar 10 (http://www.fda.gov) made for women because it provides a coordinated Accessed on July 7, 1999. system of care that makes preventive services readily 6. Nunnelee JD. The inclusion of women in clinical trials of hypertensive medications. J Vasc Nurs 1995;13(2):41-9. available—and women use preventive services at 7. Wolk A, Manson JE, Stampfer MJ, Colditz GA, Hu FB, Speizer twice the rate men do. Indeed, the Women’s Health FE, et al. Long-term intake of dietary fiber and decreased risk of Study21 conducted among Kaiser Permanente’s coronary heart disease. JAMA 1999;281:1998-2004. 8. Women’s Health Issues. US Public Health Service’s Office on women members in 1998 indicated that coordina- Women’s Health. (http://www.4women.gov/owh/pub/ tion of care is one of four priority areas of concern to womhealth%issues/index) Accessed on July 7, 1999. women, along with access, choice and flexibility, and 9. Overview: Women’s Health Initiative. The National Heart, Lung and Blood Institute. (http://www.nhlbi.nih.gov/nhlbi/ friendly and supportive clinicians and staff. Not sur- whil/) Accessed on July 7, 1999. prisingly, considering that women place a much 10. LaRosa JH, Alexander LL. Women’s health research. Chicago: stronger value on the quality of interpersonal rela- Center for Research on Women and Gender, University of Illinois at Chicago; nd (http://www.hwcweb.hwc.ca/canusa/) tionships, this same study found that encountering Accessed on July 7, 1999. friendly and supportive physicians was most impor- 11. Alcohol research and women’s health. Gender differences play tant in differentiating satisfied versus unsatisfied an important role. Office of Research on Women’s Health. News and Features; 1997 Fall. (http://www.nih.gov/news/nf/womenshealth) female members. Accessed on July 7, 1999.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 79 soul of the healer

“Parental Respect” by Mohamed Osman, MD A daughter’s reluctance to keep straight eye contact with her mother signifies a formal gesture of respect in many cultures.

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12. Patlak M. Women and heart disease. Washington, DC: US 18. 1998 Annual Report/Media Guide. Oakland, California: Food and Drug Administration; November 1994. (www.fda.gov/ Division of Research, The Permanente Medical Group. bbs/topics/CON) Accessed on Oct. 22, 1999. 19. 1998 Annual Report. Research and Evaluation Department. 13. Women’s Health in the US: NIAID research on health issues Pasadena, California: Southern California Permanente Medical affecting women. (www.niaid.gov/publications/womenshealth/ Group; 1998. textonly/html) Accessed on July 7, 1999. 20. Hartwell L, Ferris J. Study confirms unique role of women in 14. Bhatia SC, Bhatia SK. Depression in women: diagnostic and health care. Part IV. The Monocle 1999 Sept-Oct;13(5):4-5. treatment considerations. Am Fam Physician 1998;60:225-34, 239-40. 21. Conway A, Hartwell L. Menopause guidebook being 15. Leigh WA. Women of color health data book. National developed: pilot testing occurring in October. The Monocle Institutes of Health. Bethesda, MD: Office of Research on 1999 Sept-Oct;13(5):5-6. Women’s Health; 1998. NIH Pub No. 98-4247. 22. Katzenstein L. Beyond the horror stories, good news about 16. The health of minority women. US Public Health Service. managed care. The New York Times. 1999 Jun 13. Office on Women’s Health. (www.4women.gov/owh/pub/ 23. HIPAA Newborns’ and Mothers’ Health Protection ACT—IRS. minority/index.html) Accessed on July 7, 1999. Notice of proposed rulemaking by cross-reference to temporary 17. Ensuring health access for Latinas. San Francisco: Latino regulations. Fed Regist 1998 Oct 27;63(207):57564. Coalition for a Healthy California; Jan 1999.

Bad Belly The most important thing I know to be able to heal is not to take a cold drink on an empty stomach on a hot day … It gives you Bad Belly … you can’t heal if you have Bad Belly. Don Eligio Panti, 95-year-old Mayan healer, from Carl A. Hammershlag, MD The Theft of the Spirit

The Permanente Journal / Summer 2000 / Volume 4 No. 3 81 By Joanne L. Hustead, JD; Donald W. Parsons, MD Women’s Health and Federal Policy

Historical Background organized and started to change public reluctance to be tested: they fear that the external affairs Until the latter part of the 20th century, attitudes and public policy. The Family and act of testing will itself alarm a wary em- the only women’s health issues recognized Medical Leave Act,1 signed into law in 1993, ployer and may lead to loss of a by policymakers were those related to recognized the expanding role of women promotion, loss of insurability, or even women’s childbearing capacity. As a re- in the workplace and the needs of women loss of a job. sult, early debates over women’s health and men to balance their dual roles as Recent advances by the Human Genome were characterized by misguided and arti- breadwinners and caregivers. The Violence Project promise increased ability to pre- ficially narrow views of the policies and Against Women Act (VAWA)2 was passed dict other genetic diseases (and perhaps, changes necessary to meet women’s real in 1994 and energized the public discus- ultimately, most chronic diseases) in the health care needs. sion around domestic violence as an future. The Coalition for Genetic Fairness,3 From the early days of Margaret Sanger important health issue. spearheaded by the National Partnership and fights over the legality of contracep- for Women & Families and comprising tion to the high-pitched battle over the right Gender-Specific Medicine dozens of advocacy organizations con- to legal abortion—and to today’s struggles As we enter a new era of booming medi- cerned with known or suspected genetic to cure diseases like breast cancer and to cal technology, many challenges remain. diseases, is actively seeking stronger fed- raise awareness about women and heart One of the most important challenges, eral protection against misuse of genetic disease—women have organized around stemming from the historical exclusion of information as part of a Patients’ Bill of health issues and have struggled to gain women from clinical research, is the need Rights or through separate legislation. Such recognition of their unique health needs to better understand the biological differ- protection would build on the Health In- as well as the broad range of women’s ences between men and women and how surance Portability and Accountability Act health concerns. various diseases and their treatments af- of 1996 (HIPAA),4 which provides that em- fect women. This clinically important area ployment-based group health plans cannot Expanding Recognition is known as “gender-specific” medicine. discriminate against present or potential of Women’s Health Needs The right to inclusion in clinical research policyholders on the basis of genetic in- Women’s greater use of health care ser- isn’t enough; researchers need to analyze formation. HIPAA also provides that genetic vices and their tendency to orchestrate scientific and clinical data by gender if we information alone cannot be treated as a health care for other members of the fam- are to gain greater insight into biological “pre-existing condition.” ily (young and old) make nearly every differences between the sexes. pressing health care issue of the day a Privacy of Medical Information women’s health issue as well. These is- Human Genome Research Meanwhile, Congress continues its sues include the need for universal health Advances in the understanding of the struggle with the question of how to guar- insurance coverage, the need for strong human genome raise especially pressing antee the privacy of all medical patient protections, and the need for a concerns. Women have been at the fore- information, including genetic informa- Medicare prescription drug benefit. As front of the genetic revolution for many tion. Proposed regulations promulgated they take on these and other 21st-century years—first because of their involvement by the Secretary of Health and Human battles, women and women’s organiza- with prenatal testing, and then with the Services at the close of 19995 respond to tions are building on the groundbreaking discovery of the BRCA1 and BRCA2 genes many privacy concerns, but specific Con- efforts of the women who came before a few years ago. These discoveries made gressional action may be needed before them. it possible to identify some women at all parties feel a sense of trust. Most ob- The last decade of the 20th century was higher risk for breast or ovarian cancer. servers believe that Congressional action a time of great policy changes. Women Greater understanding of the cause of dis- on comprehensive medical privacy legis- brought their exclusion from clinical trials ease brings the hope for insight into lation is not likely to happen this year. to the Congress and to the public and de- treatment and prevention, but it opens a However, the computer revolution and an manded—and won—inclusion. Advocates Pandora’s box of potential discrimination everchanging health care system that for women with breast cancer, ovarian can- if information passes into the wrong places private medical information into cer, osteoporosis, and other diseases that hands—employers or insurers, for ex- many hands will keep the issue in the predominantly or exclusively affect women ample. Some women have indicated a public eye.

JOANNE L. HUSTEAD, JD, is the Director of Legal and Public Policy at the National Partnership for Women & Families. She received her law degree from the University of Pennsylvania School of Law in 1982. Her primary areas of expertise are the health care delivery/insurance system, and women’s health. E-mail: [email protected] DONALD W. PARSONS, MD, is the Permanente Federation’s Associate Executive Director for Health Policy Development. E-mail: [email protected]

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The Breast and Cervical Cancer Treatment Act by prohibiting health insurance discrimination against More likely to gain Congressional approval this year victims of domestic violence in more markets.4 In is an important program to provide treatment for low- addition, California Congressman Fortney (Pete) Stark Women brought income, uninsured women diagnosed with breast or has introduced legislation to establish federal stan- their exclusion from cervical cancer. The Centers for Disease Control and dards for use of safer needles to protect the nursing clinical trials to the Prevention (CDC) established a national breast and and health care technician workforce (predominantly Congress and to the cervical cancer screening program for low-income, female) against needle-stick injuries.11 public and uninsured women in 1990,6 but this program did not demanded—and guarantee treatment for women who had positive won—inclusion. screening test results. The Breast and Cervical Cancer When Will Women’s Health Policy Meet Treatment Act7 has been introduced to fill this gap by Women’s Needs? providing for Medicaid coverage through a new state Many women’s organizations are still working option. This proposal was passed in early May by the hard to bring this diverse range of issues to the US House of Representatives with one dissenting vote attention of the public and policymakers, but and is likely to be enacted into law this year. much work remains to be done before women’s health policy evolves to meet women’s needs. The Family and Medical Leave Act With all this attention, women’s health, social, en- Women are the nation’s primary health care con- vironmental, and workplace concerns can no sumers and caregivers. Nonetheless, many women longer be ignored. ❖ still have an unmet need for time off from work to References care for themselves or a family member or to have a 1. Family and Medical Leave Act of 1993, Pub L No. 103-3, 107 child. The Family and Medical Leave Act (FMLA),1 Stat 6. (Feb. 5, 1993). 2. Violence Against Women Act (VAWA) of 1994, Pub L No. 103- which provides job protection and continuous health 322, 108 Stat 1796. (Sept 13, 1994). insurance for people who need time off from work 3. Coalition for Genetic Fairness. http:// because of childbirth or adoption, family illness, or www.nationalpartnership.org/healthcare/genetic/coalition.htm. 4. Health Insurance Portability and Accountability Act of 1996 their own serious medical condition, has been em- (HIPAA), Pub L No. 104-191, 110 Stat 1936 (Aug 21, 1996). [For braced and applauded by employers and politicians more information on HIPAA, visit the National Partnership’s alike. However, only businesses that employ 50 or Web page (http://www.nationalpartnership.org/healthcare/ hipaa/guide.htm) and read or download the HIPAA guide. more people are required to comply with this law. HIPAA also provides some protection for victims of domestic Efforts are underway to expand the scope of the FMLA violence from discrimination by employment-based group to include midsized businesses (ie, those with 25 to health plans.] 5. Department of Health and Human Services. Secretary of 49 employees), expand opportunities for taking leave Health and Human Services. Proposed rule: medical privacy. 64 from work, and expand sources of funding such Fed Reg 59918 (Nov 3, 1999). leave—for example, unemployment insurance and 6. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Cancer disability insurance. The federal government has is- Prevention and Control National Breast and Cervical Cancer sued a final regulation8 to clarify that states can use Early Detection Program. http://www.cdc.gov/cancer/nbccedp/ unemployment funds for this purpose. States are also index.html. 7. Breast and Cervical Cancer Treatment Act of 1999, [pending], addressing this issue. This year Minnesota consid- S 662, 106th Cong, 1st Sess (1999); Breast and Cervical Cancer ered financial incentives for employers, and California, Prevention and Treatment Act of 2000, HR 4386, 106th Cong, Illinois, New York, Connecticut, and New Hampshire 2nd Sess (2000). 8. 65 Fed Reg 37210 (June 13, 2000). already have authorized studies of ways to make fam- 9. For more information on the FMLA and state proposals to ily leave more affordable.9 make family and medical leave more affordable, visit the National Partnership’s Web page (http:// Women’s Safety Legislation www.nationalpartnership.org/workandfamily/workmain.htm). 10. Violence Against Women Act II (VAWA II), [pending] S 51, Other bills pending or proposals under consider- 106th Cong, 1st Sess. (1999). ation include a reauthorization of VAWA, and VAWA 11. Health Care Worker Needlestick Prevention Act, [pending] II,10 which, among other things, would build on HIPAA HR 1899, 106th Cong, 1st Sess (1999).

The Permanente Journal / Summer 2000 / Volume 4 No. 3 83 Book Reviews

book review Your Guy’s Guide to Gynecology: a Resource for Men and Women. By Bruce Bekkar, MD and Udo Wahn, MD Review by Patricia C. Gallo, PA-C Your Guy’s Guide to Gynecology is a plethora of information for today’s men who care about the women in their lives. This reference combines highly technical information and top-secret female facts in a humorous writing style that helps make learning easy for most men. The book helps uncover the mysteries surrounding female health problems and covers all the important topics men will need to understand women’s health issues. Bruce Bekkar, MD and Udo Wahn, MD wrote Your Guy’s Guide. Both are Board-certified, practicing gynecologists with SCPMG and hold teaching positions with the Department of Reproductive Medicine at the University of Califor- nia at San Diego. Between them, they represent more than 30 years of clinical experience providing health care for women. Dr Wahn has been on the staff at Kaiser Permanente in San Diego for more than 16 years; Dr Bekkar, for 12 years. These physicians have been teaching an ongoing monthly class at SCPMG, San Diego—“For Men Only”—to help men better understand women and enable men to be more supportive when PMS, menopause, and other gynecologic issues emerge. The monthly class has become very popular and helpful to our members, and now the same important information is available in a book. The authors’ premise is that men do care about women’s health problems despite what women believe. As guys, Bekkar and Wahn believe this lack of attentiveness is due to lack of information—not insensitivity or a short attention span. Your Guy’s Guide to Gynecology enables men to be comfortable with women’s issues by providing them information in an interactive, “guy-friendly” way. The authors have included helpful suggestions for men who have specific female questions. My favorite example is from Chapter 6, “Attack of the Killer Hormones.” Here “Supportive Guy” (the icon for sensible suggestions) recommends what to do if your partner has PMS. The suggestion goes something like this: Help out more around the house. Be understanding. Listen patiently. Ask her how she is feeling. Encourage her to exercise and watch her diet. And don’t forget to hide the chocolate, guys! Although marketed for men, this book isn’t just for them; many women will want to use it as a resource guide as well. Other women will want to buy it for their guy. Household partners who read this book together will be better able to manage gynecologic issues and thus make their relationship stronger. By sharing this book with their male partners, some women will no longer find themselves alone when dealing with their health problems, and their male partners will become more comfortable discussing the various issues of women’s physical and emotional health. For health care professionals, this book is humorous, easy to read, and informative. It is an important book that could help health care practitioners present information to their patients in a down-to-earth style that is easily understood. Your Guy’s Guide to Gynecology is a reference source that should be included in your personal library of medical texts. Readers—men, women, and health care professionals of all kinds—should find this book an overdue resource that helps to demystify gynecology, a subject that has been taboo for too long. 325 p. $24.95 ISBN: 0965506746. East Sandwich, MA: North Star Publications [Ant Hill Press], 2000. Patricia C. Gallo, PA-C, has been with the Department of Preventive Medicine in San Diego for 12 years. Previously, she worked in Occupational Medicine for the Consolidated Rail Corporation in Philadelphia, Pennsylvania. She attended the Physician Assistant Program at Hahnemann University. She is the mother of two children and is married to a Physician Assistant.

Lymphedema: A Breast Cancer Patient’s Guide to Prevention and Healing By Jeannie Burt & Gwen White, PT; Foreword by Judith Casley-Smith, MD Review by Diane C. Strum In July 1997, at age 49, I was diagnosed with Stage II breast cancer. I was stunned, devastated, and filled with fear about the future. As do most women diagnosed with breast cancer, I started reading books, most of which were recommended or given to me by well-meaning friends. However, the focus on statistical survival rates for women with breast cancer only served to create more fear in me, and I soon abandoned reading about breast cancer and instead placed my trust in my physicians. I considered myself fortunate that both my surgeon and my oncologist at Kaiser Permanente in San Diego informed me about all the possibilities associated with my cancer, including lymphedema. However, I was angry and fearful about this other possible consequence of the cancer, yet another assault and deformity on my body. Had this book been available and brought to my attention, I could have at least minimized my fear of lymphe- dema. The book is written by two women: one is a physical therapist at Kaiser Permanente in Portland, Oregon;

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the other, a woman with lymphedema. I found the book both informative and comforting. Throughout the book, the authors present a message of hopefulness about a woman’s ability to both prevent and control lymphedema. The book is easy to read and to understand. It is written from a firsthand perspective and includes not only a comprehensive, lay explanation of what lymphedema is and why it occurs but also contains great information on how to prevent it, treatments available, resources, support groups, and probably what for me was most important: ways to self-treat. For me, one of the great losses associated with breast cancer was the loss of control over my body. I was a person who had taken good care of myself for most of my adult life. I had good eating habits, exercised regularly, and didn’t smoke. I had engaged in this healthy lifestyle as a way of balancing a strong familial history of heart disease that struck family members at a young age. My friends and family all said that I was the last person they would have expected to develop breast cancer. Yet it seemed nothing I had done had helped prevent cancer. I felt I had lost control over my body and what was happening to me. And so, the emphasis in this book on how to prevent lymphedema—and more important, how to self-treat when lymphedema develops—was of particular interest to me; I could do something to help the condition if it developed. The authors offer hope that a person with lymphedema can at least gain some control over it, unlike my cancer. I liked and appreciated the organization of the book. The chapters were well named, so I could skip around in the book and first read chapters of most interest or that I felt were most relevant to me. I learned new things about what not to do and how to be aware of the early signs of lymphedema. The chapter on preventing lymphedema refreshed my memory about what my physicians had told me to be careful of; and those admonitions made more sense to me as I better understood the etiology of lymphedema. For example, I better understood why I should avoid cuts on the hand and arm on the lumpectomy side of my body and site of lymph node removal; why my right arm shouldn’t be used for taking my blood pressure or for administering shots; why I shouldn’t cut my cuticles; and why I should wear gloves while gardening. For me personally, as someone who works for Kaiser Permanente and who receives all my care at Kaiser Permanente from Perman- ente physicians, the book validated the treatment I had received for my cancer. In addition, I felt a renewed sense of appreciation for the care I received and for my good fortune to have been treated by caring physicians who were so thorough about all aspects and ramifications of my cancer. Conclusion: I suggest that this book be given or at least recommended to all breast cancer patients diagnosed and treated at Kaiser Permanente. It would be a very caring thing to do. 224 p. $12.95 ISBN 0-89793-2641. Alameda, CA: Hunter House, 2000. Diane C. Strum is Director of Government Relations and Community Services for Kaiser Permanente in San Diego.

To Life! Select Recipes and Nutritional Guidance for a Healthy Heart Mended Hearts Chapter 188, compilers Review by Jeanne Weissman, Viviana Lombrozo, Louise Felitti To Life! What a wonderful title for a cookbook designed to guide patients with coronary artery disease through the uncertainties of low-fat cuisine. The goal is depicted clearly on the book’s attractive, colorful cover. Inside, help abounds. The recipes are favorites gathered by Mended Hearts Chapter 188 at Kaiser Permanente in Oakland from individuals and from famous Bay Area restaurants. Famous chef Graham Kerr has contributed a section on basic cooking techniques. Each recipe contains a nutritional analysis of calories, fat, cholesterol, carbohydrates, protein, and sodium. The dishes described here are not “hospital food.” The book contains a remarkable range of recipes—reminiscent of the famous, ethnically diverse restaurants of San Francisco but all simple and designed for relatively inexperienced cooks. If you’ve never eaten cactus (nopalitos), here’s a new experience. If you think potato-leek soup is out because of the cream, here’s a nice solution. And if you like desserts, the book presents a baker’s dozen. William Castelli, MD, former Medical Director of the Framingham Heart Study, once commented that most Americans eat only ten menus. To Life is a cure for dull eating. Arthur Klatsky, MD, retired Senior Cardiologist from TPMG in Oakland, is one of the people to whom this book is dedicated. He has contributed a most interesting chapter on the role of alcohol in heart disease. And a retired cardiologist equally valued by our Health Plan members in Oakland, Rudolph Oehm, MD, authored the chapter on nutrition. Both cardiologists have obviously extended themselves beyond the usual concept of what cardiologists do.

The Permanente Journal / Summer 2000 / Volume 4 No. 3 85 book review It would be helpful if future editions of the book mentioned specific brand names. For instance, only one truly low-sodium soy sauce (65 mg/tbsp vs 1000 mg/tbsp) is available in the United States: Bonsai Soy Sauce (800-826-0688). New food items might also be listed: Land O’Lakes nonfat Half-and-Half cream substitute; Trader Joe’s Raspberry-Jalapeno Sauce, which makes an excellent fat-free, low sodium appetizer on crackers and a delicious sauce on fish; and Eden brand Kombu, a product used to reduce the gaseous effect of eating beans. Creation of a Web site might help the Mended Hearts Chapter to keep this kind of useful information current. This book can readily be recommended for providing guidance and motivation for better eating to busy people who want to keep their families healthy or who want to undo the damage created by high-fat diets. The book can be purchased directly from Mended Hearts Chapter 188, c/o the Health Education Center, Kaiser Permanente Medical Center, 280 West MacArthur Boulevard, Oakland, CA 94611-5693; or from Morton Schaffran, 700 Hancock Way, El Cerrito, CA 94530, 510/525-5773. 179 p. $15. Oakland, California: Kaiser [Permanente], 1999. Library of Congress 99-63539 About the reviewers: One reviewer is married to someone who recently had coronary artery surgery; another reviewer is a vegetarian artist; and another is a serious cook.

Medical Guides Review by Eve F. Lynch What is more important: a good bedside manner, or a good bedside manual? Both are essential parts of the overall health care picture. Everyone benefits when patients have access to medical information that can be perused at leisure or referred to in a crisis. Medical care costs can be avoided or diminished when patients don’t immediately reach for the phone at the onset of minor medical situations. Patient confidence in medical professionals increases when office visit advice is confirmed by a text. And patient education, under- standing, and compliance may well improve when information is read and reread on the patient’s own time. But which text to choose? Kaiser Permanente’s (KP’s) Healthwise Handbook: A Self-Care Guide for You and Your Family is a 300-page paperback that is easy to use and easy to keep on a bedside table. In addition to the expected sections on health problems, this book also advises health plan members how to get the most from the KP system, how to make and prepare for medical appointments, how to share in medical decisions, when to use emergency services, and how to prevent and detect specific medical problems. This book is easy to use—permitting search by symptom and advising patients when to treat themselves at home and when to call a health professional. Descriptions are concise and include only the information needed for determining what action, if any, to take in response to a given set of symptoms. Unlike the relatively brief Healthwise Handbook, The American College of Physicians’ Com- plete Home Medical Guide is a 1000-page tome, a true medical encyclopedia that covers all human medical topics. The book is packaged with a complimentary CD-ROM, “The Ultimate Human Body,” whose three-dimensional graphics allow users “to rotate the body, peel away the layers, examine the organs, circulatory system, and the skeleton, and call up data, thus ensuring a total understanding of how the body’s complex organs work.” Like all Dorling Kindersley publications, the book is a gorgeous production with slick paper and numerous color photo- graphs and illustrations. Handy flowcharts based on queries about specific symptoms help readers determine whether to contact a health care provider or to use home treatment. The book also contains a lengthy list of health organizations and their Web site addresses. Although the book is well organized and is a pleasure to read, it contains much more information than is necessary for occasional consultation by most patients. Thus, this book is most suitable for those who wish to read extensively about the human body or who tend to be hypochondriacal. The Mayo Clinic has tackled the tome-versus-handbook dilemma by publishing one volume of each type. The Mayo Clinic Family Health Book is some 1350 pages long and includes cradle-to-grave coverage of human dis- eases and disorders. In addition, the book discusses staying well, first aid and emergency care, nutrition and fitness, and modern medical care. Forms are included for helping patients to draft advance directives. The large book also contains an extensive photographic guide to common skin disorders. The shorter book, the Mayo Clinic Guide to Self-Care, includes fewer than 300 pages and is a handbook more suitable for bedside consultation. For most people, one of the shorter books mentioned here will be most suitable for everyday use. Use of the texts showed that just the weight of the two larger volumes hindered rapid research. These tomes are literally too weighty to use handily—sort of like dragging the Oxford English Dictionary into bed or bathroom for consultation during a midnight

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bout of diarrhea or fever. The big books require readers to scan a topic’s abundant index listings to find the page pertaining to first aid— not what is wanted when rushing to find a treatment for burns. Although the two longer books are fairly comparable in scope, as are the pair of handbooks, they are not identical. Nor do the bigger books necessarily contain all the information that the handbooks contain. For ex- ample, only the KP Healthwise Handbook instructs patients on the “hot wire” technique of relieving the pressure of a blood clot located under a fingernail or toenail; the other three books don’t mention this very useful topic. The Mayo Clinic Family Health Book instructs how to make a tourniquet, whereas the handbooks mention the tourni- quet as a last resort but do not direct how to make one, and the American College of Physicians’ book advises patients never to use one. Where emergency help is required, the Mayo Clinic Guide to Self-Care instructs the reader to “Dial 911,” whereas the other books merely instruct patients to “contact professional help”; the more specific directive—to dial “911”—would probably be of greater use to a panicked reader. Either of the medical encyclopedias mentioned here would make a good addition to any home reference library but might not occasion much use. On the other hand, I have countless times referred to a medical handbook similar to the two smaller texts listed here. Clearly, some form of home medical reference is important. Which one of these four is best is more a matter of personal preference. If your patients have received the KP Healthwise Handbook, they probably have all they need. Ask them to read it–- especially the sections on how to better participate in their medical care and any section currently relevant to their own health. Kemper DW, et al, compilers. Kaiser Permanente Healthwise Handbook: a self-care guide for you and your family. 12th ed. Boise, Idaho: Healthwise 1995, ©1994. 352 p. $14.95. ISBN 1877930-091 Goldmann DR, editor. American College of Physicians complete home medical guide. 1st Amer ed. New York: DK Publishing; 1999. 1104 p. $40.00. ISBN 0-7894-4412-7 Larson DE, Editor. Mayo Clinic family health book. 2nd ed. New York: W. Morrow; 1996. $42.50. ISBN 0688144780 Hagen PT, editor. Mayo Clinic guide to self-care. 2nd ed. New York: Kensington; 1999. 272 p. $19.95. ISBN 0962786578 Eve Lynch is a San Francisco attorney, recently retired into motherhood.

Women’s Cancers: How to Prevent Them, How to Treat Them, How to Beat Them. By Kerry A. McGinn, RN, NP and Pamela J. Haylock, RN Review by Eve F. Lynch Do you know when local versus systemic cancer therapies are applied, and why? Do you know the side effects of chemotherapy? Do you even know what cancer really is? Well, undoubtedly you know, but I didn’t know, and I bet I’m a lot like the majority of your patients—which is why the book Women’s Cancers: How to Prevent Them, How to Treat Them, How to Beat Them is the perfect prescription for anyone needing well-organized, understand- able information on cancer. This book is written for the layperson, who—trust me—typically has no accurate knowledge of cancer. But despite its readability, Women’s Cancers is not overly simplistic. On the contrary, topics are covered thoroughly, educating its readers to be able to conduct intelligent discussion with their caregivers. The authors even include lists of suggested questions to inspire such discussion. The book spans breast cancer, the various gynecologic cancers, and lung and colorectal cancers, the last two being as much “women’s cancers” as they are men’s. The authors discuss precancerous conditions, risk factors, prevention, screening, staging and grading of cancer, signs and symptoms, diagnosis and treatment (including traditional and alternative therapies), as well as the psychologic, physical, and emotional ramifications of enduring cancer. A great quantity of information is presented without overwhelming the reader. All technical terms are explained at first appearance in the text and can thus be easily understood without the reader having to look up words (although a glossary is included). Further, the authors refer frequently to other texts which the reader can access for even more or different information on cancer; the vast bibliography also serves as a useful resource. Women’s Cancers is written with a compassionate voice. The authors are concerned about the human being behind the cancer diagnosis. They acknowledge the fears attendant upon a suspicion of or diagnosis of cancer and give a prominent place in the book to the psychologic and emotional aspects of enduring a major illness. As an example of the authors’ understanding of the feelings that arise upon even the contemplation of cancer, the following occurred while I was reading the book: I was feeling slightly queasy just reading about a technique called wire localization biopsy, used to explore breast abnormalities. The next section is entitled “Feelings

The Permanente Journal / Summer 2000 / Volume 4 No. 3 87 book review About a Biopsy” and begins, “It is scary to have a biopsy or other diagnostic procedure.” The section goes on to realistically consider possible feelings when facing a biopsy. What a well-placed section! And how helpful that the authors discuss such things at all. Fear must be a real problem in getting patients to participate in their own care. Identifying areas in which fear may arise and preparing to deal with them is important. The large part of the book dedicated to discussing such things as fear, other people’s reactions to illness, life changes due to cancer, and the like may well end up being more important to a patient than understanding the technical aspects of diagnosis and treatment. The authors warn that “life after cancer” normally does not mean that a woman can resume her previously scheduled life, and they discuss the physical and emotional changes a person will be left to work with as well as challenges to be faced in society, such as discrimination from insurers and employers. Forewarned is forearmed, and the authors know that a woman is better off when armed with information and ideas about how to take part in her own destiny. Meant to empower women through knowledge and inspiration, the book discusses the patient’s assembling her own recovery team, made up of doctors, nurse practitioners, practitioners of complementary therapies, support groups, family, friends, and the patient herself. The book’s attitude is inspiring, demonstrating that any patient can take action instead of resigning herself to being a “cancer victim.” Women’s Cancers, a tool for self-empowerment and a guide on how to live, not just survive, is an ideal book for people with cancer and for those who care about them. 512 p. $19.95. ISBN: 0897932234 Alameda, CA: Hunter House, 1998 [2nd ed.]. Eve Lynch is a San Francisco attorney, recently retired into motherhood.

Escape from Quotation Marks The last third of the 20th century has inserted, with blatant cynicism, quotation marks around most of our cherished notions of social, political, hisotrical, and psychological existence. Indeed, the whole notion of what a human being is in the age of cloning, cyberspace, and public opinion polls has undergone a radical transformation. Andrei Codrescu, commentator on National Public Radio

88 The Permanente Journal / Summer 2000 / Volume 4 No. 3 Request Your Ed Leave Today! announcements Plan ahead for the best value. Kaiser Permanente Primary Care Conference April 9-13, 2001 Outrigger Wailea Resort Wailea, Maui, HI For a Conference Brochure For Travel and Lodging Information Contact Helen Taylor at [email protected] Contact CMX Travel at [email protected] or phone (510) 987-4374 or phone (877) 843-8500 (toll free)

Kaiser Permanente National Entire Set Specials Primary Care Conference Session A: $115.00 AUDIOTAPE ORDER FORM Session B: $115.00 April 23-28, 2000 Kauai Marriott Resort & Beach Club SESSION A: Practical Primary Care Skills SESSION B: Womens Health ❏ ❏ 00KPNC-P1A&B Keynote: The Future of Healthcare: ❏ ❏ 00KPNC-W1A&B Keynote: The Future of Healthcare: Delivering Delivering Service & the KP Promise (2 Tape Set) Service and the KP Promise (2 Tape Set) ❏ ❏ 00KPNC-P2A&B Disease Management and The Care ❏ ❏ 00KPNC-W2A&B What Women Want in Health Care (2 Tape Management Institute (2 Tape Set) Set) ❏ 00KPNC-P3 Current Concepts in the Management of Diabetes ❏ ❏ 00KPNC-W3A&B Providing Evidence-Based, Cost-Effective ❏ 00KPNC-P4 Common Pediatric Infectious Diseases: Clinical Preventive Services For Adult Women (2 Tape Set) Management of the Febrile Infant ❏ ❏ 00KPNC-W4 Abnormal Vaginal Bleeding: From Menarche to ❏ 00KPNC-P5 Managing Osteoarthritis: Making Your Patients Menopause and Yourself More Comfortable ❏ ❏ 00KPNC-W5A&B Menopause and Libido: The Psychological ❏ ❏ 00KPNC-P6A&B The Patient, the Clinician, and the Aspects of PMS and Menopause (2 Tape Set) Microbe: An Update in Infectious Diseases (2 Tape Set) ❏ ❏ 00KPNC-W6A&B Update on Osteoporosis: Diagnosis, ❏ ❏ 00KPNC-P7A&B End of Life Care: Patient Concerns and Prevention and Treatment Alternatives to Standard HRT: Low Dosage Provider Challenges (2 Tape Set) Estrogen, SERMs and Phytoestrogens (2 Tape Set) ❏ ❏ 00KPNC-P8A&B Integrative Care For Congestive Heart ❏ ❏ 00KPNC-W7A&B Gender Specific Aspects of Health Promotion Failure (2 Tape Set) (2 Tape Set) ❏ ❏ 00KPNC-P9A&B Improving Disability Management in ❏ ❏ 00KPNC-W8A&B Common Gyn Disorders Plus STDs (2 Tape Primary Care Practice (2 Tape Set) Set) ❏ ❏ 00KPNC-P10A&B Depression in Primary Care (2 Tape ❏ ❏ 00KPNC-W9A&B Gender-Specific Medicine: Cardiovascular Set) Disease and Women’s Health (2 Tape Set) ❏ ❏ 00KPNC-P11A&B New Asthma Concepts (2 Tape Set) ❏ 00KPNC-W10 Reproductive Health and Family Planning ❏ ❏ 00KPNC-P12A&B Pediatric Preventive Services (2 Tape ❏ ❏ 00KPNC-W11A&B Sociological Aspects of Women’s Health (2 Set) Tape Set) ❏ ❏ 00KPNC-W12A&B Women’s Work and Health: Interactions and Approaches (2 Tape Set) ORDERING INFORMATION PRICES AND DISCOUNTS BY PHONE: With your credit Name ______Individual audiotapes are $8.00 each card, please call Toll-Free: Company ______❏ Entire A or B Session Set Special: All 800-369-5718. audiotapes listed in A or B Session Monday thru Friday: Address ______Track, in albums for only $115.00 7:00 am to 5:00 pm PST City, State, Zip ______❏ Any 12 audiotapes for the price of 10, BY MAIL: Check tapes Telephone ______including storage album only $80.00 desired, complete form, and ❏ Any 6 audiotapes for the price of 5, mail to Mobiltape at the Payment method : Make checks payable to MOBILTAPE only $40.00 address below. COMPANY, INC. ❏ US Currency Only ❏ Cash ❏ Check ❏ Charge Card Matching syllabus for A or B Sessions, BY FAX: 24 hrs/day. Fax order Master Card - Visa - American Express (circle correct card) only $18.00 form with credit card info to: Number ______Exp. Date ______DOMESTIC SHIPPING CHARGES (661) 295-847 Amount for audiotapes/handouts $ ______BY WEB: www.mobiltape.com Audio: $2.00 per tape; $8.00 max CA orders 8.25% sales tax $______Syllabus: $5.00 Domestic Shipping $______Please allow 3 weeks for shipping International Shipping $______TOTAL OF ORDER $______Mobiltape Co. Inc., 24730 Avenue Tibbitts, Suite 170, Valencia, CA 91355 (661) 295-0504

The Permanente Journal / Summer 2000 / Volume 4 No. 3 89 Let’s Build Bridges to announcements Better Health Care

San Francisco is known for its bridges, majestic passages across the city’s stormy waterways. It is fitting that the health care

December 5–8, 2000 industry will gather here for its premier San Francisco Hilton and Towers conference on quality improvement. San Francisco, California Improving health care is, after all, a matter of building better bridges. So, join us in San Francisco. And be part of the journey to the other side!

Share ideas with over 2,500 colleagues from around the world.

Learn from experienced leaders, visionaries and quality improvement experts. Gain new skills and creative approaches to leading change within your organization.

Over 100 workshops, mini-courses and learning sessions on topics such as • Leadership and Governance • Finance and Measurement • Clinical Improvement • Service Quality and Satisfaction • Ambulatory Practice CME credits are available.

Plenary Speakers: Donald Berwick, MD, MPP President and CEO Institute for Healthcare Improvement

Paul Plsek Quality Improvement Author and Consultant

12thAnnualNationalFORUM on Quality Improvement in Health Care

Register online at www.ihi.org, or call us toll free at (888) 320-6937 for a brochure and registration form. Popular sessions fill quickly, so register early!

90 The Permanente Journal / Summer 2000 / Volume 4 No. 3 announcements

Blue Window of Hope On February 1, 2000, a new Web site, “Blue Window of Hope,” was launched by three Kaiser Permanente RNs. The Web site is designed to be a venue for exploring prayer, health, and healing, as well as death, dying, and end-of-life issues in terms of research and application. The creators of this Web site hope it will be an asset to any medical professional dealing with a chronically ill patient. You are invited to visit the site at: http://bluewindowofhope.com.

New Women’s Health Web Site Launched KP Southern California’s Women’s Health Leadership Committee (WHLCo) has launched a new Intranet Web site dedicated to women’s health issues. The Web site helps providers easily get the information they need to better manage the health of female members. The site features information about the Women’s Health Leadership Committee, women’s health programs and contacts, breast cancer, Internet links, and patient education materials. To access the women’s health Web site, go to: http://kpnet.kp.org/california/scpmg/womenshealth/.

Cardiovascular Conference The Second Annual Kaiser Permanente meeting Aortic Dissections and Carotids, Transesophageal on Cardiovascular Medicine and Surgical Therapies Echocardiography, Mitral Valve Disease:Diagnosis (COAST Conference) will be held Friday through and Time for Intervention, and New Imaging Tech- Sunday, October 27–29, 2000, at the Hyatt Regency niques: Focus on Intravascular Ultrasound and CAD. Monterey Resort and Conference Center in Monterey, The conference is sponsored by The Permanente California. Friday evening there will be a dinner Federation CME Office and you may report up to and reception at the Monterey Bay Aquarium, fol- 10 Category 1 CME Credits. The registration fee is lowed by a day and a half of presentations. $150.00 (all categories). For information and/or reg- Conference highlights include: The Internet and istration form/brochure, please contact Juliene Cardiovascular Medicine, Interventional Therapy for Malecot by phone, (415)202-3495, or by e-mail, CAD: The State of the Art, Endovascular Stenting of [email protected].

TPJ wins APEX 2000 Award of Excellence For 12 years, Communications Concepts, Inc, has sponsored the APEX awards for publication excellence. Entries are judged for graphic design, editorial content and the success in achieving overall communications effectiveness and excellence. Communications Concepts, Inc helps publish- ing, PR and marketing professionals improve publications and communications programs through publications, a Web site and PEP, the Publication Evaluation Program. TPJ received the APEX Award of Excellence in the Magazine and Journals – Printed category.

Learning Relates to Relation People learn best from those they can relate to… James M. Kouzes, Encouraging the Heart, A Leaders Guide to Rewarding and Recognizing Others

The Permanente Journal / Summer 2000 / Volume 4 No. 3 91 ? Instructions to Authors

Send all manuscripts to: • External Affairs Merry Parker, Managing Editor Nonclinical articles on external issues related to the prac- The Permanente Journal tice and perception of Permanente Medicine. These may 500 NE Multnomah St, Suite 100 include articles by customers and consumer groups, as well Portland, OR 97232 as internally generated articles on health policy, the media, (503) 813-2659 the marketplace, and our social mission. (word count range is 725-3000) Editorial Policies • Medical Legal Update

instructions for authors Manuscripts are received with the understanding that they have Articles educating clinicians about medical-legal issues, in- not been published or submitted for publication in whole or in cluding risk management, claims review, loss prevention, part elsewhere, except for a scientific abstract, unless otherwise and ethical issues. Improved clinician communication with specified. Manuscripts will be reviewed by the Editor, Associate patients, families, and the health care team is the goal. Editors, members of the Review Board, and appropriate special- (word count range is 725-1400) ists internally and externally as deemed necessary. Acceptance of • Soul of the Healer a paper for publication is based on the relevance, quality of work Poetry, stories, musings, and nonfiction articles written by described, clarity of the presentation, and especially applicability Permanente clinicians as an expression of the soul of the to daily clinical practice. If the article is accepted for publication, healer. This is a forum to appreciate each other personally editorial revision may be made to aid clarity and understanding through creativity in the humanities. without altering the meaning (see Proofreading). Authors are re- (word count range is 725-2200) minded that they assume full responsibility for final wording and • A Moment in Time form of all materials submitted for publication. The contact au- A look back at milestones in the history of the Permanente thor will be required to complete coauthor and acknowledgment Medical Groups. consent forms before publication. (word count range is 700-740) Articles, editorials, letters to the editor, and other text material • Abstracts in the Journal represent the opinion of the authors and do not Abstracts from articles published in other journals, prefer- necessarily reflect the opinion of Kaiser Permanente. entially featuring the work of Permanente physicians. Authors submitting a manuscript do so with the understanding • Announcements that if it is accepted for publication, copyright of the article, in- Significant achievements related to the practice or man- cluding the right to reproduce the article in all forms and media, agement of medicine by Permanente physicians or shall be assigned exclusively to the publisher. The publisher will Permanente Medical Groups. Also posted will be upcoming grant any reasonable request by the author for permission to courses, meetings, and conferences sponsored by the Per- reproduce any part of his/her contribution to the Journal. manente Medical Groups or Kaiser Permanente. • The Lighter Side of Permanente Medicine Types of Papers Jokes, stories, and humorous encounters tied to the practice There is no required length, although concise, readable, and of Permanente medicine, managed care, or health care in gen- practical articles within the ranges listed are preferred. Empha- eral. size information that clinicians can use in their practice, that gives them regional and national perspective, and that integrates “Per- Cover Letter manente Medicine” into the largest scope of health care delivery. In a cover letter, please give a concise statement of the authors’ view of the importance and uniqueness of the article. Also provide Notes About Specific Sections several names and addresses of non-Kaiser Permanente experts who • Clinical Contributions could provide informed, objective reviews of the work. The names Clinical articles on the practice of medicine within the of any persons considered unlikely by the authors to supply Permanente Medical Groups and their affiliates. Article nonbiased reviews may also be submitted; this request will be hon- topics may include reviews of “successful” practices, pro- ored. It is important that the cover letter also include the names, grams and policies, and analyses of new technologies. addresses, phone numbers, and fax numbers of all coauthors. (word count range is 725-5000) • Original Research Manuscript Preparation and Processing Articles on Kaiser Permanente’s research contributions A 3-1/2” disk containing the article and one complete paper through original, empirically-based research in areas of great copy of the manuscript must be submitted, along with a photo- clinical importance. This includes outcomes research, stud- graph of the author(s) labeled with name and a 2-3 sentence ies that use Kaiser Permanente databases, and rigorous author profile. (Please, no photos smaller than 2”×3” or larger evaluations of best practices and innovations in clinical care. than 5”×7”.) If more than four authors, submit the authors’ pro- (word count range is 725-5000) files only—no photographs. • Health Systems Manuscripts must be typewritten in a word-processing program Articles from a “systems” perspective, recognizing that medi- (identify program and platform used), double-spaced, with mar- cine is practiced in the larger context of health care, including gins of at least 1 inch. All parts of the manuscript must be included ambulatory care delivery, hospital strategy, program expan- in a single file on the disk, and the disk file must match the print- sion, and network development and is supported by out. Tables and illustrations are also to be included in separate information technology and the Internet. Growth in this sys- electronic files. The 3-1/2” disk must be labeled with the first author’s tem occurs through the leadership, education, and name, an abbreviated article title, the file name(s), the disk format development of clinicians. (eg, Mac), and the software used (eg, Microsoft Word 6.0, Microsoft (word count range is 725-3000) PowerPoint, Microsoft Excel).

92 The Permanente Journal / Summer 2000 / Volume 4 No. 3 ?

instructions for authors

The first page of the manuscript should contain the following must also be in numeric order (do not list references in alphabetical information: 1) title of paper; 2) authors’ names; 3) name(s) of order). The list should be double-spaced under the heading REFER- Kaiser Permanente Division and medical office in which work ENCES. Abbreviations for title of medical periodicals should conform was done; 4) name and address of author to whom communica- to those used in the latest edition of Index Medicus. tions regarding the manuscript should be directed; 5) telephone and fax number of the communicating author; 6) word count. Examples. The second page of an Article (Clinical or Nonclinical) should Journal article, one to six authors contain an Abstract (limit: 250 words). The abstract for Nonclinical 1. Beutler E. The effect of methemoglobin formation on sickle Articles should use these headings: Context, Objective, Design, cell disease. J Clin Invest 1961;40:1856-1858. Main Outcome Measure(s), Results, and Conclusion(s). Also list 2. Karpatkin S, Charmatz A. Heterogeneity of human platelets. key words and terms, in alphabetical order, under which you be- III. Glycogen metabolism in platelets of different sizes. Br J lieve the article should be indexed. Haematol 1970;19:135-143. Begin the text on a new page. Define all abbreviations except Journal article, more than six authors those that have been approved by the International System of Units 3. Golomb HM, Vardiman J, Sweet DL Jr, et al. Hairy cell leuke- for length, mass, time, electric current, temperature, luminous in- mia: Evidence for the existence of a spectrum of functional tensity, and amount of substance. Provide a footnote or box at the characteristics. Br J Haematol 1978;38:161-2. beginning of the article to define abbreviations when great num- Journal article in press bers of abbreviations are used. Do not create abbreviations for drugs, 4. O’Malley JE, Eisenberg L. The hyperkinetic syndrome. Semin procedures, or substrates. Use generic drug names. If a brand name Psychiatry (in press) is used, insert it in parentheses after the generic name. (Note: A copy of the manuscript must be included.) Complete book Institutional Review Board (IRB) Review 5. Lillie RD. Histopathologic Technique and Practical Histochem- istry (ed 3). New York, NY: McGraw Hill: 1965. Documentation of IRB approval or exemption must be appended Chapter of book to the manuscript being submitted for publication in The Perman- 6. Moore G, Minowada J. Human hemopoietic cell lines: A ente Journal. If there has been no IRB review of the project, please progress report. In: Farnes P. Hemic Cells in Vitro, vol. 4. so indicate. In this case, the article will be reviewed by Kaiser Baltimore, MD: Williams & Wilkins; 1969. 100-105. Foundation Research Institute to determine if IRB review should have been conducted. The result of this review may determine Editing Assistance whether or not the article will be considered for publication. You can obtain help with preparing your manuscript from the Preparing Illustrations and Tables Medical Editing Department, which is a resource available to many researchers throughout the Program. The department’s professional Illustrations and tables are desirable and highly encouraged be- editors can help you organize your paper, edit your text, and verify cause they expand the value of the article. Tables and illustrations references before publication in The Permanente Journal. Call must be cited in order in the text using Arabic numerals. Submit Medical Editing at 510-987-3573 for further information. one complete set as glossy prints or high-quality laser prints, and include electronic files on disk for each illustration and/or table. Proofreading Do not staple, clip, or write heavily on the back. Paste a label on Contributors are provided with galley proofs and are asked to the back of each illustration indicating its number in order of ap- proofread them for typesetting errors. Important changes in data pearance, author’s name, and the top edge of the picture. are allowed, but authors are requested to not make excessive al- Legends for illustrations should be typewritten, double-spaced, terations. Galley proofs should be returned within 48 hours. on a separate sheet, and included at the end of the manuscript. A legend must accompany each illustration. Checklist for Authors Figures, especially charts, graphs, and line drawings, are gener- ally reduced in size for publication. To maintain legibility, all ___ 3.5” disk labeled with author name, article title, file numbers, letters, and symbols should be large enough originally name(s), word count, disk format, and word-processing so that when reduced they will remain at least 2 mm high. software used Each table should be typed on a separate sheet and appropri- ___ Cover letter ately numbered. Abbreviations used in the table should be defined ___ One copy of manuscript in the legend to the table; legends should be typed on the same ___ Title page sheets as the tables. ___ Author profile (2-3 sentences) Any figure, table, or long portions of text that have been previ- × ously published must be accompanied by a letter of permission to ___ Author photo (no smaller than 2” 3”, no larger reprint, signed by the publisher, at the time of submittal. It is the than 5”×7”) responsibility of the author to obtain such permission. ___ Structured Abstract (limit: 250 words): include key words ___ References (double-spaced on a separate sheet) Legal and Ethical Considerations ___ Illustrations, properly labeled (one original set, electronic Avoid use of patients’ names, initials, and medical record num- and hard copy) bers. A patient must not be recognizable in photographs or case ___ Figure legends (double-spaced) descriptions unless written consent of the subject has been obtained. ___ Tables (provide a brief title) References ___ Permission to reproduce previously published material; References must be numbered with Arabic numerals and cited in photographic consent the text in numeric order. The reference list at the end of the article ___ IRB Documentation

The Permanente Journal / Summer 2000 / Volume 4 No. 3 93 ?

The Permanente Journal Author’s Form

Copyright Transfer The Permanente Journal (TPJ) is owned, published, and copyrighted by The Permanente Federation. In the event that TPJ publishes my work and in consideration of the editing and publication of my work, I transfer to TPJ all rights, title, and interest to all parts of the written work named below. TPJ shall own the work, including 1) copyright; 2) the right to grant permission to republish the article in whole or in part; 3) the right to produce reprints for distribution; and 4) the right to republish the work in a collection of articles in any

instructions for authors other mechanical or electronic format. In addition, I affirm that the work has not been previously published, is not subject to copyright or other rights except my own to be transferred to TPJ, and has not otherwise been submitted for publication, except under circum- stances communicated to TPJ in writing at the time the work was submitted. (All authors must sign below. Photocopy form if necessary.)

Manuscript Title ______

______

______Principal Author Signature & Date Coauthor Signature & Date Coauthor Signature & Date ______Print Name Print Name Print Name ______Address Address Address

Coauthor Agreement • I certify that the author(s) listed below is/are coauthor(s) of the above manuscript. Principal author signature: ______Print Name: ______Address: ______Phone : ______• I agree to be named as a coauthor of the above manuscript. • I have reviewed the final version of the above manuscript and approve it for publication. • To the best of my knowledge and belief, the above manuscript has not been published and is not being considered for publication except as described in an attachment hereto. • Except as described in an attachment hereto, to the best of my knowledge and belief, all intellectual contributions, technical help, financial or material support, and financial or other relationships that may constitute or lead to a conflict of interest, have been acknowledged or disclosed in the manuscript.

______Coauthor Signature & Date Coauthor Signature & Date Coauthor Signature & Date ______Print Name Print Name Print Name ______Address Address Address

Consent to Acknowledgment • I agree that I have made a substantive contribution to the above manuscript. • I have reviewed and approved the language in the manuscript acknowledging my contribution. • I consent to the acknowledgment in the manuscript and understand that readers may infer my endorsement of the data or conclusions reported in the manuscript.

______Acknowledgee Signature & Date Acknowledgee Signature & Date Acknowledgee Signature & Date ______Print Name Print Name Print Name ______Address Address Address

94 The Permanente Journal / Summer 2000 / Volume 4 No. 3 CME Evaluation Form continuing medical education

All PMG physicians and those clinicians eligible to do so may earn up to two hours of Category 1 credit for reading and analyzing the four designated CME articles, by selecting the most appropriate answer to the questions below, and by successfully completing the evaluation form. This form must be returned (fax or mail to the address listed on the back of this form) to The Permanente Journal by September 30, 2000 in order to receive credit. You will receive an acknowledgment by October 31, 2000. You must complete all sections to receive credit. The Kaiser Permanente National Continuing Medical Education Program (KPNCMEP) is accredited by the Accredita- tion Council for Continuing Medical Education to provide continuing medical education for physicians. The KPNCMEP takes responsibility for the content, quality, and scientific integrity of this CME activity. The KPNCMEP designates this educational activity for up to two hours of Category 1 CME credit for each TPJ issue applicable to the AMA Physician Recognition award and/or state award. Each physician should claim credit for only those hours that were actually spent in this educational activity. Author disclaimer forms are on file with no conflicts listed or necessary disclaimers.

Section A. Article 1. Management of Libido Problems in Menopause (page 29) The likelihood that a 58 year old woman will present with new onset pain with sexual relations and difficulty achieving orgasm is: a. very low b. low c. average e. above average d. every patient Which situation below would most likely decrease free testosterone via increasing sex hormone binding globulin in some women and thus may impact libido in those menopausal females? a. estrogen patch b. estrogen patch or birth control pill c. oral estrogen and a progestogen

Article 2. Likelihood That a Woman Will Have No Major Risk Factors At the Time of First Myocardial Infarction or Stroke (page 35) The likelihood that a woman age 45-74 years of age who presents for the first time with an ischemic stroke or an acute myocardial infarction will not have hypertension or diabetes or cigarette smoking as a risk factor is: a. ≤6% b. 7-16% c. 17-26% d. ≥27% Among women with newly diagnosed myocardial infarction, which risk factor decreases in prevalence with increasing age? a. Hypertension b. Diabetes c. High cholesterol level d. Smoking

Article 3. The Gynecological Cancer Detection Clinic—Commentary (page 39) A modern cervical cancer screening program is based on the following principles: (circle all that apply) a. Cervical cytology specimens are obtained from both the external cervical as well as the endocervical canal, using a spatula and endocervical brush b. Lugol’s solution is applied to the cervical surface, and biopsies are obtained from non-staining areas as part of initial screening c. The main target lesion for optimal screening is pre-cancer or dysplasia while it is in a highly curable state d. The sensitivity and specificity of the Pap smear are low enough that adjuvant cost-effective screening tools should be sought to optimize outcomes e. A single, isolated, apparently normal Pap smear has less meaning than repeatedly normal smears, which are associated with a much lower incidence of dysplasia or cancer

The Permanente Journal / Summer 2000 / Volume 4 No. 3 95 The following is true regarding proposed adjuvant modalities for cervical cancer screening programs: (circle all that apply) a. Adjuvant tests should be measured in terms of both the clinical and economic outcomes they produce b. A lower rate of ASCUS Pap smears is usually reported by those laboratories using computer-assisted screening c. Visual methods used to augment the Pap smear cause a lower false negative rate and may assist in triaging patients to observation and follow-up vs treatment d. To date, HPV strain testing has not led to changes in patient management, but recent studies may support a role in triage and/or screening

Article 4. Proposed Care Management for Women with Estrogen Deficiency: Identification, Risk Stratification, and Treatment (page 68) Health Plan Employer Data Information Set (HEDIS) will be sending a questionnaire to members of managed care organizations focusing on which of the following measures: continuing medical education a. Exposure, personalization, and breadth of counseling for women at risk for estrogen deficiency b. Which medications are used to prevent coronary artery disease and osteoporosis in postmenopausal women c. How much money a managed care organization spends on osteoporosis and coronary artery disease prevention d. What percentage of women between the ages of 47 and 57 get information regarding the management of estrogen deficiency from the Internet Which of the following is correct regarding the benefits of a Population Care Management Program for women with estrogen deficiency: a. Identification and risk stratification of women who are at risk for complications associated with estrogen deficiency b. Increase percent of women who are appropriately counseled on the risk, benefits and alternative of managing estrogen deficiency c. Develop a database to monitor percentage of women over 45 who have met goals for cholesterol management, who are compliant with osteoporosis prevention therapy, and who have been treated for a fracture or myocardial infarction over the past year d. None of the above e. All of the above

Section B. Referring to the CME articles and the stated objectives, please check the box next to each statement as appropriate

Article 1 Article 2 Article 3 Article 4 Strongly Strongly Strongly Strongly Strongly Strongly Strongly Strongly Agree Disagree Agree Disagree Agree Disagree Agree Disagree 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 The article covered the stated objectives I learned something new that was important I plan to use this information as appropriate I plan to seek more information on this topic I understood what the author was trying to say

Section C. What change(s) (if any) do you plan to make in your practice as a result of reading these articles?

Section D. (Please print) Name: E-mail Address: Address:

Signature: Date:

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96 The Permanente Journal / Summer 2000 / Volume 4 No. 3 The Permanente Journal

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Review Board Colorado Permanente Medical Group, PC (CPMG): Paul Barrett Jr, MD; Pat Connor, PA; Wayne DuBois, PA; Richard Erickson, MD; Spencer Erman, MD; Timothy Garling, PA; Mark Groshek, MD; Bob Lederer, MD; David Price, MD; Richard Spurlock, MD; Andrew Wiesenthal, MD Hawaii Permanente Medical Group, Inc. (HPMG): Dorothy Chu, MD; Robert Decker, MD; Randy Jensen, MSN; John Payne Jr, MD; Raymond Tam, MD Mid-Atlantic Permanente Medical Group, PC (MAPMG): Barbara Boardman, MD; Nooshin Farr, MD, FACP; Kirk Huang, MD; John Hurley, MD; Ann Komelasky, NP; Robert Kritzler, MD; Jonathan Rosenthal, MD; Christopher Spevak, MD; Surender Vaswani, MD, FACP; Bradley Winston, MD Northwest Permanente, PC, Physicians and Surgeons (NWP): Mike Barrett, MD; Jan Bellis-Squires; Ben Brown, MD; Homer Chin, MD; Colleen Chun, MD; Maurice Comeau, MD; John Gale, MD; Stephen Gancher, MD; Jim Gersbach; Vern Harpole, MD; A. Hayward, MD; Carolyn Hokanson, MD; Roderick Hooker, PA; Peter Jacky, PhD, FACMG; Kathleen Kennedy, MD; Mike Kositch, MD; John Lasater, MD; Reed Paulson, MD; Jacob Reiss, MD; Eric Schuman, PA; David Scott, MD; Michael Stine, MS, LPC; Paul Wallace, MD; Don Wissusik, MA, MS, LPC Ohio Permanente Medical Group, Inc. (OPMG): Joseph Armao, MD; Nuzhat Ashai, MD; Ronald Copeland, MD; Charles Duncan, MD; Aiyappan Menon, MD; Roland Philip, MD The Permanente Medical Group, Inc. (TPMG): David Baer, MD; Kenneth Berniker, MD; Gilbert Carroll, MD; Andrew Chan, MD; Calvin Chao, MD; Francis Chui, MD FACP; Charles Clemons, MD; Linda Copeland, MD; David Cornish, MD; Sakti Das, MD; Anne Delaney, MD; Ward Flad, MD; Robin Fross, MD; Jay Gehrig, MD; Lisa Hake, MD; Helen Hammer, MD; Pat Hardy, MD; Aquia Heath, MD; Kathleen Hering, RNC, FNP/GNP; Raymond Hilsinger Jr, MD; Robert Hosang, MD; Thomas Kidwell, MD; Susan Kutner, MD; Irene Landaw, MD; Richard Leahy, MD, JD, FCLM; John Loftus, MD; Joseph Mason, MD; Barry Jay Miller, MD; Dana Miller-Blair, MD; Jerome Minkoff, MD; Conrad Pappas, MD PhD; Barbi Phelps-Sanda, MD; Mary Piper, NP; S. Ramachandra, MD; Jack Rozance, MD; James Ruben, MD; Edgar Schoen, MD; William Sheridan, MD; Stanford Shoor, MD; Lee Shratter, MD; Shelley Spiro, NP; Gary Stein, MD; John Stienstra, DPM; KM Tan, MD; B. Rao Tripuraneni, MD; David Williams, MD Permanente Medical Group of Mid-America, PA (PMGofMA): Ellen Averett, PhD; Steven Hull, MD The Southeast Permanente Medical Group, Inc. (TSPMG): Jeffrey Hoffman, MD; Adrienne Mims, MD; Fred Reifsteck, MD Southern California Permanente Medical Group (SCPMG): Donna Beard, NP; Allen Bredt, MD; Dale Daniel, MD; James Delaney, PA; Richard Drucker, MD; Raed Fahmy, MD; F. Ronald Feinstein, DMD; Vincent Felitti, MD; Woldemariam Gebreselassie, MD; Todd Goldenberg, MD; Jimmy Hara, MD; Joel Hyatt, MD; A. Robert Kagan, MD; Michael Kanter, MD; Charles Koo, MD; Barbara Kotlik, NP; Sok Lee, MD; Jenifer Lipman, NP; George Longstreth, MD; Bryan Maltby, MD; S. Michael Marcy, MD; Gholam Pezeshkpour, MD; Ronald Rosengart, MD; Robert Schechter, MD; Jerry Schilz, MD; Patricia Schmidt, MD; Michael Schwartz, MD; Ira Jeffry Strumpf, MD; Reva Winkler, MD; Frederick Ziel, MD Kaiser Foundation Health Plan (KFHP), Program Offices: Ann Evans, MS; Patricia Lynch; Julia Shepard; Nancy Vaughan Guest Reviewers (Group Health): Tim Gilmore, MD; Deborah Hammond, MD; Frank Marre, DO, MS; Steven Shaffer, MD; Jeff Shornick, MD; Lester Sloan, PA