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Am Fam Physician. 1999;60(9):2630-2637

Increased Education Is Needed About Use of Herbal Products

(51st Annual Scientific Assembly of the American Academy of Family Physicians) The majority of family physicians are unprepared to advise their patients about herbal products and supplements, and are unaware of the prevalence of their use even though more than one half of their patients may be current users of such products. This is the conclusion of a survey of 16 primary care clinicians at a family practice clinic and 185 of their adult patients who were seen during a one-month period. The patients in the study were between 18 and 86 years of age. Seventy-seven percent had an annual income of less than $20,000, and 62 percent had a high school–level education or less. Sixty percent of these patients were current users of herbs or supplements. The most common herbs used were garlic, ginseng, echinacea and gingko, and the most common supplements used were vitamins A, B6, C, E and zinc. Consistent with other studies, herb and supplement use was more likely in those with higher incomes and educational levels, but over one half of the less-educated, low-income population were users. Fifty-three percent of those that used herbs/supplements had not told their clinicians about their use of these products, and 41 percent of users listed friends and family as their primary source of information about herbs and supplements. Although 87 percent of the clinicians who were surveyed had been asked about herbs and supplements by their patients, only 31 percent of the clinicians reported having received any instruction on these products. Less than 50 percent of the clinicians were able to correctly identify the relevant side effects for three (St. John's wort, ginseng, chromium) of the top five herbs most frequently asked about. The investigator believes that family physicians should educate themselves about herbs and supplements and their side effects, and should communicate with their patients about their use of herbs and supplements to screen for potential drug interactions.—margaret planta, m.d., San Joaquin Family Practice Residency Program, Stockton, Calif.

On-site Mental Health Professional Unnecessary in Depression Treatment

(American Academy of Family Physicians) An office-based intervention with a primary care physician and office nurse team can improve the care of patients with major depression without reliance on an on-site mental health professional, according to a study of 24 family physicians and 12 family practices in the Ambulatory Sentinel Practice Network (ASPN), the Wisconsin Research Network (WReN) and the Minnesota Academy of Family Physicians Research Network (MAF-PRN). The study used a randomized block design to match the 12 family practices based on rurality and baseline depression care. One practice in each pair was randomized to “usual care” and the other to intervention care. The intervention consisted of brief training for the primary care physicians on the depression guidelines from the Agency for Health Care Policy and Research, and training for the office nurses on how to work with depressed patients, how to identify and work through 23 specific barriers to care, and how to monitor patient progress and response to treatment over an eight-week period. Of the 11,006 patients over 17 years of age who were screened for major depression, 479 met the diagnostic criteria and were randomized to receive intervention or usual care. Outcome data were obtained at six months for 90.6 percent of the sample and were measured on the proportion of patients completing three months of antidepressant medication and/or eight or more mental health counseling visits, the change in scores on the 100-point depression symptom scale and patient satisfaction after six months. Compared with patients who received usual care, patients in the intervention group showed improved satisfaction with care, and were more likely to receive a three-month course of antidepressant medication and to have eight or more mental health visits. The intervention patients demonstrated significant symptom improvement at six months with a 5-point improvement in depressive symptoms attributable to the intervention. Those beginning a new treatment episode reported an 18-point improvement attributable to the intervention. In the treatment of depression, the researchers concluded that on-site intervention from a primary care physician and office nurse team can be as successful as intervention from an on-site mental health professional.—paul a. nutting, m.d., St. Anthony Family Medicine Residency Program, Denver, Colorado.

Physician Preventive Care Can Be Enhanced by Outside Facilitator

(American Academy of Family Physicians) According to results of a randomized controlled trial, community-based primary care practices can greatly improve prevention systems and prevention practices if they choose their own priorities and use an outside health education facilitator. In the study, 44 community-based primary care practices had outside health educators assess their preventive services with a baseline interview and survey. Each practice then reviewed the survey results with the health educator and set goals to improve the prevention systems, tools and records in their practices. The goals were chosen from a list of 19 items known to improve performance of prevention systems. The health educators visited the practices randomized to the intervention group three more times at intervals of four to six weeks, while the practices randomized to the comparison group received no additional visits. Assessments were performed at the conclusion of the study to measure improved prevention activities. The outcome variable was the mean rate of prevention goal achievement at the end of the study. On average, the intervention group achieved 50 percent of the goals attempted, and the control group achieved 31 percent of the goals attempted. The difference between the two groups was statistically significant. The investigator noted that the practices achieved greater success in making significant changes when a health educator provided three visits for education and guidance on the chosen goals.—leonard m. finn, m.d., University of Massachusetts Medical School Family Practice Residency Program, Needham, Mass.

Prevention Program Helps Women at Risk of Cardiovascular Disease

(American Academy of Family Physicians) Results from an intervention program targeted to women in Sweden at risk for cardiovascular disease showed improvements eight years later in weight, blood pressure and modifiable risk factors. In 1985–86, a three-month lifestyle intervention program was conducted in Strömstad, Sweden (a population with unusually high rates of cardiovascular disease) in women 45 to 64 years of age with cardiovascular disease risk factors modifiable by lifestyle changes. Of the 383 eligible women, 114 participated in the intervention program and 269 were in the control group. All 383 women were offered a follow-up examination eight years after the intervention program. At follow-up, women who had participated in the intervention showed significant reduction in mean systolic blood pressure, had higher intake of dietary fibers, more positive attitudes and better knowledge of healthy diets, compared with those in the control group. The women in the intervention group also showed no increase in mean body weight or serum triglyceride concentrations. This group of women also had significant, favorable changes in body weight and systolic blood pressure when compared with another Swedish female population not exposed to an intervention program. The investigator believes that considering the high rate of stroke in women within this community, the apparent reduction in systolic blood pressure in the intervention group is very promising.—cecilia björkelund, Department of Primary Health Care, Vasa Hospital, Göteborg, Sweden.

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