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W Barlow

Publications and source records attributed to W Barlow.

At least 19 recordsLinked to original sources
PubMed2001

Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain.

BACKGROUND: Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain. METHODS: We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects. RESULTS: Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P =.01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P =.002; dysfunction scale: 6.29 vs 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care. CONCLUSIONS: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.

Acupuncture Therapy↗
PubMed1999

Natural history of interstitial cystitis in 274 patients receiving sulfated polysaccharide therapy.

OBJECTIVES: To assess the natural history of interstitial cystitis in the presence of sulfated polysaccharide treatment. METHODS: This was a longitudinal study of 274 patients. Questionnaires were administered at first visit to obtain information on demographic characteristics, medical history, other risk factors, and type and severity of symptoms. Follow-up questionnaires were administered at subsequent visits to measure symptom progress. Patient status over time was measured for three symptoms: pain, urgency, and nocturia. Changes in symptom and severity were assessed at 6, 12, and 24 months on treatment. Comparisons of symptom change from baseline to 6 and 12 months were assessed for different characteristics among patients with the most severe symptoms. RESULTS: After 1 year of treatment, a decrease of two or more points in symptom score was observed for 33.5% of all patients for pain and 35.4% for urgency. Among patients with the most severe symptoms, a decrease of two or more points was observed in more than 54% for pain and urgency; 55.7% experienced remission to the moderate and mild level (49.2% and 6.5%, respectively). There was no appreciable decrease in nocturia at any severity level. With the exception of feeling heavy and experiencing dull pain at baseline, patients who did not report a specific type of pain improved more than those who did. CONCLUSIONS: The results of this study suggest that treatment with sulfated polysaccharides can help alleviate the symptoms of patients suffering from the most severe stages of interstitial cystitis.

Adult↗
PubMed1999

Survival and treatment for colorectal cancer Medicare patients in two group/staff health maintenance organizations and the fee-for-service setting.

The current study compares treatment use and long-term survival in colorectal cancer patients between Medicare beneficiaries enrolled in two large prepaid group/staff health maintenance organizations (HMOs) and the fee-for-service (FFS) setting. The study is based on 15,352 colorectal cancer cases diagnosed between 1985 and 1992 and followed through 1995. Survival differences between the HMO and FFS cases were assessed using Cox regression. Treatment differences were evaluated using logistic regression. HMO cases had a lower overall mortality than did FFS cases but not a significantly lower colorectal cancer-specific mortality. Use of surgical resection was similar between HMO and FFS cases. However, rectal cancer cases in the HMOs were more likely to receive postsurgical radiation therapy than FFS cases. Superior overall survival in the HMOs may be the result of increased colorectal cancer screening, greater use of adjuvant therapies, and selection of healthier individuals.

Aged↗
PubMed1999

Prostate cancer treatment and ten-year survival among group/staff HMO and fee-for-service Medicare patients.

OBJECTIVE: To compare treatment patterns and the ten-year survival of prostate cancer patients in two large, nonprofit, group/staff HMOs to those of patients receiving care in the fee-for-service health setting. DATA SOURCES/STUDY DESIGN: A cohort of men age 65 and over diagnosed with prostate cancer between 1985 and the end of 1992 and followed through 1994. Subjects (n = 21,741) were ascertained by two population-based tumor registries covering the greater San Francisco-Oakland and Seattle-Puget Sound areas. Linkage of registry data with Medicare claims data and with HMO inpatient utilization data allowed the determination of health plan enrollment and the measurement of comorbid conditions. Multivariate regression models were used to examine HMO versus FFS treatment and survival differences adjusting for sociodemographic and clinical characteristics. PRINCIPAL FINDINGS: Among cases with non-metastatic prostate cancer, HMO patients were more likely than FFS patients to receive aggressive therapy (either prostatectomy or radiation) in San Francisco-Oakland (odds ratio [OR] = 1.69, 95% CI = 1.46-1.96) but not in Seattle (OR = 1.15, 0.93-1.43). Among men receiving aggressive therapy, HMO cases were three to five times more likely to receive radiation therapy than prostatectomy. Overall mortality was equivalent over ten years (HMO versus FFS mortality risk ratio [RR] = 1.01, 0.94-1.08), but prostate cancer mortality was higher for HMO cases than for FFS cases (RR = 1.25, 1.13-1.39). CONCLUSION: Despite marked treatment differences for clinically localized prostate cancer, overall ten-year survival for patients enrolled in two nonprofit group/staff HMOs was equivalent to survival among patients receiving care in the FFS setting, even after adjustment for sociodemographic and clinical characteristics. Similar overall but better prostate cancer-specific survival among FFS patients is most plausibly explained by differences between the HMO and FFS patients in both tumor characteristics and unmeasured patient selection factors.

Aged↗
PubMed1998

A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain.

BACKGROUND AND METHODS: There are few data on the relative effectiveness and costs of treatments for low back pain. We randomly assigned 321 adults with low back pain that persisted for seven days after a primary care visit to the McKenzie method of physical therapy, chiropractic manipulation, or a minimal intervention (provision of an educational booklet). Patients with sciatica were excluded. Physical therapy or chiropractic manipulation was provided for one month (the number of visits was determined by the practitioner but was limited to a maximum of nine); patients were followed for a total of two years. The bothersomeness of symptoms was measured on an 11-point scale, and the level of dysfunction was measured on the 24-point Roland Disability Scale. RESULTS: After adjustment for base-line differences, the chiropractic group had less severe symptoms than the booklet group at four weeks (P=0.02), and there was a trend toward less severe symptoms in the physical therapy group (P=0.06). However, these differences were small and not significant after transformations of the data to adjust for their non-normal distribution. Differences in the extent of dysfunction among the groups were small and approached significance only at one year, with greater dysfunction in the booklet group than in the other two groups (P=0.05). For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were $437 for the physical-therapy group, $429 for the chiropractic group, and $153 for the booklet group. CONCLUSIONS: For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.

Adult↗
PubMed1998

Medication use for low back pain in primary care.

STUDY DESIGN: A longitudinal observational study of primary care patients with low back pain. OBJECTIVES: 1) To describe medications prescribed for back pain, 2) to identify patient characteristics associated with type of drug therapy, 3) to determine if the prescription of certain drugs is associated with better outcomes, and 4) to compare physician prescribing behavior with national guidelines. SUMMARY OF BACKGROUND DATA: Few previous studies have focused on medication prescribing patterns for back pain in primary care. METHODS: Two-hundred nineteen patients aged 20-69 years who were making a first visit for an episode of back pain were studied. After the visit, patients completed questionnaires regarding sociodemographic characteristics, health status, back pain experience, and use of medications. Symptom severity and dysfunction were assessed by telephone 1 week after the visit. RESULTS: Sixty-nine percent of patients were prescribed nonsteroidal anti-inflammatory drugs, 35% muscle relaxants, 12% narcotics, and 4% acetaminophen. Twenty percent received no medications. Patients were more likely to receive medications if they had a desire for medication, pain below the knee, less than 3 weeks of pain before visit, more severe symptoms, or greater dysfunction. Patients with more severe symptoms were more likely to receive narcotics or muscle relaxants. Patients with greater dysfunction were also more likely to receive narcotics. Type of drug therapy predicted symptom severity but not dysfunction after 1 week. Controlling for other factors, those receiving medications had less severe symptoms after 1 week than patients who received no medication. Patients receiving both muscle relaxants and nonsteroidal anti-inflammatory drugs had the best outcomes. Medication use for back pain in this health maintenance organization was generally concordant with national guidelines. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs, often augmented by muscle relaxants, are a standard medical treatment for back pain in primary care. In this observational study, patients prescribed medications, particularly muscle relaxants, reported less severe symptoms after 1 week than those receiving no medications. However, randomized trials are needed to determine which medication or combinations of medications are most effective.

Adult↗
PubMed1997

Breast cancer survival and treatment in health maintenance organization and fee-for-service settings.

BACKGROUND: Enrollment in health maintenance organizations (HMOs) has increased rapidly during the past 10 years, reflecting a growing emphasis on health care cost containment. To determine whether there is a difference in the treatment and outcome for female patients with breast cancer enrolled in HMOs versus a fee-for-service setting, we compared the 10-year survival and initial treatment of patients with breast cancer enrolled in both types of plans. METHODS: With the use of tumor registries covering the greater San Francisco-Oakland and Seattle-Puget Sound areas, respectively, we obtained information on the treatment and outcome for 13,358 female patients with breast cancer, aged 65 years and older, diagnosed between 1985 and 1992. We linked registry information with Medicare data and data from the two large HMOs included in the study. We compared the survival and treatment differences between HMO and fee-for-service care after adjusting for tumor stage, comorbidity, and sociodemographic characteristics. RESULTS: In San Francisco-Oakland, the 10-year adjusted risk ratio for breast cancer deaths among HMO patients compared with fee-for-service patients was 0.71 (95% confidence interval [CI] = 0.59-0.87) and was comparable for all deaths. In Seattle-Puget Sound, the risk ratio for breast cancer deaths was 1.01 (95% CI = 0.77-1.33) but somewhat lower for all deaths. Women enrolled in HMOs were more likely to receive breast-conserving surgery than women in fee-for-service (odds ratio = 1.55 in San Francisco-Oakland; 3.39 in Seattle). HMO enrollees undergoing breast-conserving surgery were also more likely to receive adjuvant radiotherapy (San Francisco-Oakland odds ratio = 2.49; Seattle odds ratio = 4.62). CONCLUSIONS: Long-term survival outcomes in the two prepaid group practice HMOs in this study were at least equal to, and possibly better than, outcomes in the fee-for-service system. In addition, the use of recommended therapy for early stage breast cancer was more frequent in the two HMOs.

Aged↗
PubMed1997

Use of exogenous hormones and risk of temporomandibular disorder pain.

Temporomandibular disorders (TMD) are common pain conditions that have their highest prevalence among women of reproductive age. The higher prevalence of TMD pain among women, pattern of onset after puberty and lowered prevalence rates in the post-menopausal years suggest that female reproductive hormones may play an etiologic role in TMD. Two epidemiologic studies were designed to assess whether use of exogenous hormones is associated with increased risk of TMD pain. Both used data from automated pharmacy records of women enrolled in a large health maintenance organization to identify prescriptions filled for post-menopausal hormone replacement therapies (Study 1) or for oral contraceptives (OCs) (Study 2). Study 1 employed an age-matched case-control design to compare post-menopausal hormone use among 1291 women over age 40 referred for TMD treatment and 5164 controls not referred. After controlling for health services use, the odds of being a TMD case were approximately 30% higher among those receiving estrogen compared to those not exposed (P = 0.002); a clear dose-response relationship was evident. The relationship of progestin use to TMD was not statistically significant. Study 2 used a similar design to examine the relationship of OC use to referral for TMD care, drawing on data from 1473 cases and 5892 controls aged 15-35. Use of OCs was also associated with referral for TMD care, with an increased risk of TMD of approximately 20% for OC users, after controlling for health services use (P < 0.05). These results suggest that female reproductive hormones may play an etiologic role in orofacial pain. This relationship warrants further investigation through epidemiologic, clinical and basic research.

Adult↗
PubMed1996

Predicting poor outcomes for back pain seen in primary care using patients' own criteria.

STUDY DESIGN: A prospective cohort study of patients seen in primary care for low back pain. OBJECTIVES: A new measure of back pain outcomes is used to describe the status of back problems at various intervals after visits to primary care physicians and to identify subsets of patients with worse prognoses. SUMMARY OF BACKGROUND DATA: Most previous studies of the prognosis of back pain in primary care have failed to provide clinically useful information. METHODS: Baseline data were collected from 219 patients making an initial visit for an episode of low back pain to a primary care clinic. A measure of how patients reported they would feel if they had their current back symptoms for the rest of their lives ("Symptom Satisfaction") was used to distinguish good from poor outcomes. Patient outcomes were assessed 1, 3, 7, and 52 weeks after the index visit. RESULTS: Only 67% of patients reported good outcomes after 7 weeks, and only 71% were satisfied with their condition 1 year later. After controlling for the effects of other variables measured during the initial physician visit, only younger age, depression, and pain below the knee were significant predictors of poor outcome at 7 weeks, and only pain below the knee and depression were significant predictors at 1 year. CONCLUSIONS: The proportion of primary care patients with back pain who have poor outcomes appears to be higher than generally recognized. Ways of improving how primary care responds to patients with persisting pain should be investigated.

Adult↗
PubMed1996

Pitfalls of patient education. Limited success of a program for back pain in primary care.

STUDY DESIGN: Low back pain patients seen in primary care were allocated randomly to one of two educational interventions or to usual care. OBJECTIVE: To evaluate educational interventions designed to improve the outcomes of primary care for low back pain. SUMMARY OF BACKGROUND DATA: Patients with back pain are frequently dissatisfied with their medical care and identify lack of information as the most insufficient aspect. METHODS: In a large Health Maintenance Organization clinic, 293 subjects were allocated randomly to receive usual care, an educational booklet, or a 15-minute session with a clinic nurse, including the booklet and a follow-up telephone call. Outcome measures included satisfaction with care, perceived knowledge, participation in exercise, functional status, symptom relief, and health care use. Outcomes were assessed 1, 3, 7, and 52 weeks after the intervention. RESULTS: The nurse intervention resulted in higher patient satisfaction than usual care (P < 0.001) and higher perceived knowledge (P < 0.001). Self-reported exercise participation was also higher in the nurse intervention group after a 1-week follow-up period (97% vs. 65% in the other groups; P < 0.0001). There were no significant differences among the three groups in worry, symptoms, functional status, or health care use at any follow-up interval. Differences in self-reported exercise and perceived knowledge were no longer significant after 7 weeks. CONCLUSIONS: These findings challenge the value of purely educational approaches in reducing functional impact or health care use related to back pain and also challenge the value of fitness exercise in the most acute phase of back pain.

Adult↗
PubMed1996

Predictors of chronic benzodiazepine use in a health maintenance organization sample.

While expert recommendations caution against long-term benzodiazepine use in the elderly, survey data suggest increasing benzodiazepine use with age. Computerized pharmacy records of staff-model HMO were used to examine benzodiazepine prescribing. Six-month prevalence of benzodiazepine use (2.8%) and prevalence of continued use (0.7%) were lower than earlier reports. Prevalence was higher in women and increased steadily with age. Among 7012 patients beginning benzodiazepine treatment, duration of use increased with patient age, prescription by a psychiatrist (vs. primary care or medical/surgical specialist), use of higher-potency drugs (lorazepam, and alprazolem, clonazepam) and larger number of pills in the initial prescription. Individual physicians varied significantly in drug choice, initial prescription size, and likelihood of chronic use. Among 200 patients treated in primary care, the physician-recorded indication for prescription was anxiety or depression in 27%, insomnia in 20%, and pain symptoms in 38%. These findings indicate a gap between benzodiazepine efficacy research and current clinical practice.

Adolescent↗
PubMed1996

A prospective study of contact lens complications in a managed care setting.

BACKGROUND: Understanding the rate of contact lensrelated complications and the factors that affect their occurrence can facilitate better prescribing decisions. METHODS: In a managed care setting, 1496 patient visits were evaluated using a common protocol by 11 optometrists to determine the prevalence of all contact lens-related complications. RESULTS: Over one-half (61%) of the visits were normal, with the remainder showing some type of complication. The more prevalent complications included superficial punctate staining (17.3%) and neovascularization (11.4%). Total complications were less prevalent with rigid gas permeable (RGP) and disposable lens types. Planned replacement soft lenses, used on a daily wear schedule, had the lowest prevalence of more serious complications when compared to conventional soft and disposable lenses. Patients on an extended wear schedule greater than 3 days were more likely to experience complications. The use of nonapproved care systems showed more complications, with serious complications reduced when a one-step care system was used. CONCLUSION: Choice of lens type, wearing schedule, and care system does affect the prevalence of complications, which underlines the importance of the recommendations of the prescriber.

Adolescent↗
PubMed1996

Measurement of interrater agreement with adjustment for covariates.

The kappa coefficient measures chance-corrected agreement between two observers in the dichotomous classification of subjects. The marginal probability of classification by each rater may depend on one or more confounding variables, however. Failure to account for these confounders may lead to inflated estimates of agreement. A multinomial model is used that assumes both raters have the same marginal probability of classification, but this probability may depend on one or more covariates. The model may be fit using software for conditional logistic regression. Additionally, likelihood-based confidence intervals for the parameter representing agreement may be computed. A simple example is discussed to illustrate model-fitting and application of the technique.

Adult↗
PubMed1995

Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care.

PURPOSE: This study was conducted to evaluate the effect of stage at diagnosis, age, and level of comorbidity (presence of other illness) on the costs of treating three types of cancer among members of a health maintenance organization. METHODS: Among 388,000 members enrolled anytime during 1990 and 1991 in Group Health Cooperative (GHC) of Puget Sound (Washington State), we estimated the total and net direct costs of medical care for colon, prostate, and breast cancers, including both incident (290, 554, and 645 patients, respectively) and prevalent (1046, 1295, and 2299 patients, respectively) cases. We summarized costs for initial, continuing, and terminal phases of care. Net costs were the difference between the costs of the care of each case subject and the average costs of the care for all enrollees without the cancer of interest who were of the same sex and in the same 5-year age group. Differences in estimated total and net costs by stage at diagnosis, age, and comorbidity were separately evaluated using multivariate regression modeling. All P values were two-sided. Comorbidity was based on a score calculated from 1988 pharmacy data. RESULTS: Total costs of initial care increased with stage at diagnosis for colon (P = .0013) and breast (P < .0001) cancer cases, but not for prostate cancer cases. Total initial costs decreased with age for prostate (P = .0225) and breast (P = .0002) cancers but did not change with degree of comorbidity for any of the three cancers. Total continuing medical care costs increased with stage at diagnosis for colon (P < .0001) and breast (P < .0001) cancer cases but not for prostate cancer cases. Total terminal care costs were similar by stage for all three cancers. Net initial costs differed with stage for all three cancers (P < .05). Net continuing care costs increased with stage (P < .0001) and decreased with age (P < .001) for colon and breast cancers but not for prostate cancer. Net continuing care costs decreased with comorbidity for all three cancers (P = .004, P = .011, and P < .0001 for colon, prostate, and breast cancers, respectively). Among regional stage cancers, continuing care costs decreased with age for colon (P < .0017) and breast (P = .033) cancers but not for prostate cancers. CONCLUSIONS: The results show that total costs vary by stage at diagnosis and age, but the patterns of variation differ for each cancer. Costs of cancer are not simply additive to costs of other conditions. IMPLICATIONS: More needs to be done to explore the reasons and implications of age-related cost differences. Cost-effectiveness analyses of cancer control interventions that shift cancer stage distributions may need to consider both the age and comorbidity of the target populations.

Adult↗
PubMed1995

Health care costs of primary care patients with recognized depression.

BACKGROUND: While an extensive literature documents the influence of depression on general medical services utilization, estimates of the economic burden of depression have focused on the direct costs of depression treatment. Higher use of general medical services may contribute significantly to the true cost of depressive illness. METHODS: Computerized record systems of a large staff-model health maintenance organization (HMO) were used to identify consecutive primary care patients with visit diagnoses of depression (n = 6257) and a comparison sample of primary care patients with no depression diagnosis (n = 6257). The HMO accounting records were used to compare components of health care costs. RESULTS: Patients diagnosed as depressed had higher annual health care costs ($4246 vs $2371, P < .001) and higher costs for every category of care (eg, primary care, medical specialty, medical inpatient, pharmacy, laboratory). Similar cost differences were observed for each of the subgroups examined (patients treated with antidepressants, those not treated with antidepressants, and those diagnosed at routine physical examination visits). Pharmacy records indicated greater chronic medical illness in the diagnosed depression group, but large cost differences remained after adjustment ($3971 vs $2644). Twofold cost differences persisted for at least 12 months after initiation of treatment. CONCLUSIONS: Diagnosis of depression is associated with a generalized increase in use of health services that is only partially explained by comorbid medical conditions. In the primary care sector, this greater medical utilization exceeds direct treatment costs for depression. The persistence of utilization differences suggests that recognition and initiation of treatment alone are not adequate to reduce utilization differences.

Adult↗
PubMed1995

Health care costs associated with depressive and anxiety disorders in primary care.

OBJECTIVE: The authors examined the overall health care costs associated with depression and anxiety among primary care patients. METHOD: Of 2,110 consecutive primary care patients in a health maintenance organization, 1,962 were screened with the 12-item General Health Questionnaire. A stratified random sample of 615 patients were selected for further diagnostic assessment; 373 of these patients completed the Composite International Diagnostic Interview at baseline and 328 were reassessed 12 months later. Computerized cost records were used to calculate total health care costs for the 6-month period surrounding the baseline assessment and a similar period surrounding the follow-up assessment. Cost accounting data were available for 327 patients at baseline and for 206 patients at both assessments. RESULTS: Primary care patients with DSM-III-R anxiety or depressive disorders at baseline had markedly higher baseline costs ($2,390) than patients with subthreshold disorders ($1,098) and those with no anxiety or depressive disorder ($1,397). Large cost differences persisted after adjustment for medical morbidity. Cost differences reflected higher utilization of general medical services rather than higher mental health treatment costs. Although most patients with baseline anxiety or depressive disorders showed significant improvement, longitudinal analyses did not show any clear relationship between change in psychiatric diagnosis and change in health care cost. CONCLUSIONS: Among primary care patients, anxiety and depressive disorders are associated with markedly higher health care costs even after adjustment for medical comorbidity. In this small sample, improvement in depression over 1 year was not clearly associated with decreases in cost.

Adolescent↗