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PubMed2006

Examining the relationship between bone mineral density and fracture risk reduction during pharmacologic treatment of osteoporosis.

Osteoporosis is a skeletal disorder characterized by compromised bone strength that predisposes the patient to an increased risk for fracture. Elements of bone strength include bone mineralization, architecture, turnover, size, and bone mineral density (BMD). Measurement of BMD is the most readily available, noninvasive method for assessing osteoporotic fracture risk and is used by the World Health Organization for diagnostic purposes. Because low BMD is predictive of increased fracture risk, it was believed that changes in BMD during pharmacologic therapy for osteoporosis would strongly predict observed fracture risk reductions. We examined the relationship between changes in BMD and reduction in fracture risk during pharmacologic therapy in postmenopausal women with osteoporosis. The correlation between BMD increases and fracture risk reduction during treatment is not consistent; larger increases in BMD do not necessarily correlate with greater reductions in fracture risk. Multiple factors, in addition to BMD, appear to contribute to the increased bone strength and decreased fracture risk achieved with approved drug therapies for osteoporosis. Until the exact relationship of these factors is fully understood, clinicians should continue to evaluate drug efficacy for osteoporosis based on the fracture risk reductions from well-designed clinical trials.

Aged↗

PubMed2006

High-risk individuals' willingness to pay for diabetes risk-reduction programs.

OBJECTIVE: The purpose of this study was to estimate how much at-risk individuals are willing to pay for type 2 diabetes primary prevention programs. RESEARCH DESIGN AND METHODS: An Internet-based, choice-format conjoint survey was presented to individuals at elevated risk for type 2 diabetes. Hypothetical diabetes risk-reduction programs included seven features: diet, exercise, counseling, medication, weight loss goal, risk reduction, and program costs. The sample included 582 individuals aged > or =45 years, two-thirds of whom were obese. Conditional logit models were used to calculate participants' willingness to pay for risk reduction programs. Each respondent's self-assessed risk of developing diabetes was compared with an objective measure based on a diabetes screening tool. RESULTS: Many respondents underestimated their personal risk of developing diabetes. Those with a low perceived risk were less likely to indicate that they would participate in a diabetes prevention program. Individuals had the strongest preference for programs with large weight loss goals, fewer restrictions on diet, and larger reductions in the risk of diabetes. Respondents were willing to pay approximately $1,500 over 3 years to participate in a lifestyle intervention program similar to the Diabetes Prevention Program. Individuals with a high perceived risk were willing to pay more than individuals with lower perceived risk. CONCLUSIONS: Many individuals will be willing to participate in interventions to delay or prevent diabetes if the interventions are subsidized, but most will be unwilling to pay the full program cost. Our results also offer insights for designing risk-reduction programs that appeal to potential participants.

Attitude to Health↗

PubMed2001

Evaluating the effectiveness of risk-reduction strategies for consumer chemical products.

Communication about risks offers a voluntary approach to reducing exposure to pollutants. Its adequacy depends on its impact on behavior. Estimating those impacts first requires characterizing current activities and their associated risk levels, and then predicting the effectiveness of risk-reduction strategies. Characterizing the risks from chemical consumer products requires knowledge of both the physical and the behavioral processes that influence exposures. This article presents an integrated approach that combines consumer interviews, users' beliefs and behaviors, and quantitative exposure modeling. This model was demonstrated in the context of consumer exposure to a methylene chloride-based paint stripper, showing how it could be used to evaluate current levels of risk and predict the effectiveness of proposed voluntary risk-reduction strategies.

Environmental Exposure↗

PubMed1995

Cancer risk reduction in Mexican American women: the role of acculturation, education, and health risk factors.

This article describes a two-factor schema for the development of culturally appropriate cancer risk reduction interventions for Mexican American women. Regarding this approach, risk factors for two major cancer areas are reviewed: cigarette smoking and obesity/diet. We first describe a schema that facilitates the planning of strategies associated with preferred health interventions and preventive approaches for cancer risk reduction with Mexican American and other Latino/Hispanic persons. This schema examines Acculturation and Education as key factors that should be considered in developing health education messages and interventions that are culturally and educationally appropriate to the identified subpopulations of Hispanics in terms of language and informational content of the message and in terms of psychological factors related to health behavior change. Empirical data from a community sample is presented for the purpose of illustrating the validity of this schema. Then we review studies that examine the effect of acculturation on the distribution of the risk factors, based on studies in the current literature. Here we note the target group of women with the highest risk, based on the available information on Acculturation and other sociodemographic factors. Additionally, an illustration is presented where information and the concepts offered by the two-factor schema facilitate the analysis of (a) health education message needs and (b) needed behavior change, thus pointing to (c) more appropriate health promotion strategies for targeted Hispanic/Latino individuals or groups. The information described in this article aims to help program planners, researchers, and health educators in the design of more effective programs of health intervention for Mexican American and other Hispanic/Latino women.

Acculturation↗

PubMedDate not supplied

Beliefs, perceptions, and practices related to osteoporosis risk reduction among women with multiple sclerosis.

Women with multiple sclerosis (MS) are at increased risk for osteoporosis and fracture; in turn, osteoporosis has the potential to exacerbate the physical limitations imposed by MS. This qualitative study explored the understanding of osteoporosis risk and risk reduction, strategies being used to reduce risk, and related beliefs among 27 women with MS. Participants were recruited at a regional MS Society meeting. The women completed personal data forms, and responded to open-ended questions during taped interviews, which were transcribed and subjected to comparative content analysis. Five themes emerged from the data: knowledge about osteoporosis, sense of vulnerability, interactions with healthcare providers, preventive actions, and sense of control. All of the women had some knowledge about osteoporosis risk reduction, and most of the women were actively attempting to reduce their risk. However, few of the women had full knowledge, or were doing all that they might do, to minimize their risk. Few of their healthcare providers had discussed the issue or responded to their concerns, even when women had histories of multiple fractures. The women did comprehened their increased risk and most attempted to manage it, although input was lacking from healthcare providers about osteoporosis risk reduction.

Adult↗

PubMed2004

Is bone mineral density predictive of fracture risk reduction?

Bone mineral density (BMD) measurement is a widely available noninvasive means of identifying individuals with osteoporosis and, possibly, those at high risk for fracture. This nonsystematic review examines the relationship between BMD increase and fracture risk reduction in clinical trials evaluating osteoporosis therapy. The trials examined here are predominantly in postmenopausal women. BMD increase correlates poorly with fracture risk reduction in clinical trials of osteoporosis therapy conducted in postmenopausal women. Although BMD may increase with therapy, the increase is not measurable until later, and the overall increase is too small to account for the timing and magnitude of fracture risk reduction. BMD is only one of many contributors to bone strength and fracture risk reduction. Bone strength is derived from bone quantity, which consists of density and size, and bone quality, which, in turn, consists of structure (micro- and macroarchitecture), material properties, and turnover. Data are beginning to accrue suggesting that changes in bone turnover markers may be an accurate predictor of fracture risk reduction. Future research will elucidate the link between changes in bone turnover markers and bone architecture as a measure of osteoporosis treatment efficacy. Until then, physicians will continue to rely on fracture risk reduction data from well-designed clinical trials when judging the efficacy of different treatments for osteoporosis.

Biomarkers↗

PubMed1991

The next problem: maintenance of AIDS risk reduction among intravenous drug users.

Intravenous drug users have surprised many policymakers and researchers by exhibiting large-scale AIDS risk reduction. Relapse from desired behavior change has been a traditional problem in treatment for drug misuse/dependence. Failure to maintain AIDS risk reduction was examined in a study of 399 intravenous drug users from New York City. Over 80% of the subjects reported initiating risk reduction, but 36% of those also reported that they did not fully maintain the risk reduction. Factors associated with initiating risk reduction were not necessarily associated with maintenance, indicating that different types of change processes may be occurring. At the policy level, one needs to think of long-term efforts to reduce the spread of HIV among drug users; "quick fix" programs are not likely to be effective.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

Prevention-oriented primary care: a collaborative model for office-based cardiovascular risk reduction.

All physicians are in a unique position to influence their patients risk of coronary artery disease (CAD). The physician must first assess the degree of CAD risk, and then, collaborating with the patient, develop a CAD risk reduction strategy that is tailored to the patient's needs and likely to succeed. Prevention-oriented primary care (POPC) is a host/environment office-based model that can be used in primary care practices to accomplish this goal. This article describes a patient-physician interactive model that can be used as an office-based approach to CAD risk reduction. This model can guide the physician and patient through a collaborative approach to healthcare aimed at preventing CAD. It is based on the recognition that a clear systematic interchange between physician and patient that is evidence based and patient centered is the key to successful risk factor modification. The efficacy of this evidence-based model is currently being studied. It uses a computer software product our team developed called the ERIS/St. Joseph health risk appraisal. This article describes eight important elements of this CAD risk reduction model: 1) physician-patient interviewing/communication styles; 2) defined physician and patient roles; 3) a computerized, prevention-oriented patient history and health-risk appraisal; 4) the patient's list of his or her health priorities; 5) the physician's list of medical priorities for CAD risk reduction; 6) a shared patient-physician priority list; 7) specific intervention plans, with target goals, and critical pathways/strategies for reaching the goals; and 8) planned follow-up care with measurable and targeted outcome goals.

Coronary Disease↗

PubMed1998

Better glycaemic control and risk reduction of diabetic complications in Type 2 diabetes: comparison with the DCCT.

OBJECTIVE: To construct dose response curves relating the development of diabetic complications (retinopathy and microalbuminuria) to mean glycaemic exposure in a cohort of Type 2 patients followed over a period of several years. This allows a comparison with similar data on Type 1 subjects reported by the Diabetes Control and Complications Trial (DCCT) and provides a rational basis for deciding what levels of glycaemic control should be aimed for in advising individual patients and in setting guidelines for conducting health services. RESEARCH DESIGN AND METHODS: This was an analysis of data prospectively collected in our computerized data base for Type 2 patients who attended and were followed up at the Complications Assessment Service of our Diabetes Center. The initial development of retinopathy and microalbuminuria was analyzed with respect to the mean HbA1c during the follow up period. Statistical procedures identical to those employed in the DCCT were used to construct the dose response curve. RESULTS: A smooth relationship between the development of retinopathy with increasing hyperglycaemia was found. For every 10% decrease in HbA1c, there was a 24%) (confidence interval (CI): 16-32) reduction in relative risk, about 2/3 of that reported for insulin-dependent diabetes mellitus (IDDM) patients. The relationship between microalbuminuria and HbAc was more linear and less steep with a relative risk reduction of 9% (CI: -2-19%) for any 10% fall in HbA1c, about 1/3 of that reported for IDDM subjects. No threshold of HbA1c can be found for the relative risk of developing complications. However, more cases of complications are prevented by the same degree of improvement in glycaemic control at higher levels of HbA1c. CONCLUSIONS: The development of diabetic retinopathy in Type 2 subjects is also related to the magnitude of hyperglycaemia although the degree of dependence is less than that in Type 1. Glycaemic control has less influence on microalbuminuria in Type 2. In terms of relative risk, no threshold of 'safe HbA1c' can be found but in absolute terms more cases of diabetic complications can be prevented by improving the glycaemic control of the very hyperglycaemic patients.

Albuminuria↗

PubMed1991

Organizing as a new approach to AIDS risk reduction for intravenous drug users.

This paper looks at an innovative approach to AIDS risk reduction among intravenous drug users who are not in treatment. The new method utilizes an organizing model that involves the mobilization of drug users to promote risk reduction. This strategy targets the group as well as the individual for change. Standard outreach techniques have had some success in achieving HIV risk reduction, particularly for behavior that reduces risk through altering drug use behavior, but still leaves many users at risk. Intravenous drug users in the Netherlands and gays in the United States have organized around HIV-related issues with some success. Preliminary evidence from New York City suggests that organizing drug users may be an effective approach for achieving significant HIV risk reduction for individual users as well as those they associate with.

Acquired Immunodeficiency Syndrome↗

PubMed1997

The challenge of risk reduction therapy for cardiovascular disease.

Patients with cardiovascular disease can derive significant benefit from the implementation of risk reduction therapies. Until recently, management of patients with coronary heart disease has centered on the use of angioplasty, bypass surgery and medical therapy for severe fixed obstructions. Several large randomized clinical trials now demonstrate the importance of medical risk reduction therapies in these patients. A consensus panel of the American Heart Association recommends that health care providers use a group of risk reduction therapies, which can significantly extend overall survival, improve quality of life, decrease the need for interventional procedures such as angioplasty and bypass grafting, and reduce the incidence of subsequent myocardial infarction. Since a minority of patients with cardiovascular disease now benefit from these strategies, changes in our health care delivery systems are recommended. Risk reduction case management by nursing staff can assist physicians and improve implementation of and patient adherence to these therapies. Programs are being discussed to develop support by third-party insurers for risk reduction therapies. Application of these therapies should be a routine part of care for patients with cardiovascular disease.

American Heart Association↗

PubMed2006

Perceptions of Canadian vascular surgeons toward pharmacological risk reduction in patients with peripheral arterial disease.

Patients with peripheral arterial disease (PAD) are at a markedly higher risk of cardiovascular morbidity and mortality, with evidence indicating that risk-reduction pharmacotherapy can serve to attenuate cardiovascular events in these patients. Given the central role of vascular surgeons in the treatment of patients with PAD, we sought to determine their perceptions and knowledge of risk-reduction pharmacotherapy in patients with PAD. We conducted a cross-sectional survey of 79 Canadian vascular surgeons who attended the 2004 annual meeting of the Canadian Society for Vascular Surgery, the largest and most representative meeting of its kind in Canada. The recommended targets of low-density lipoprotein cholesterol, blood glucose, and blood pressure were known to 53.8%, 40.4%, and 57.7% of vascular surgeons, respectively. The majority of vascular surgeons (65.4%) reported screening for risk factors in <50% of cases. Although 90.4% of vascular surgeons would recommend antiplatelet therapy for PAD, only 5.8% would recommend angiotensin converting enzyme (ACE) inhibitors and 19.2% would recommend lipid-lowering therapy with statins. Eighty-four percent of Canadian vascular surgeons indicated that their self-assessment of risk reduction in PAD was average to below average, yet 90.4% of them believed that risk-reduction therapy should be recommended or initiated by vascular surgeons. Canadian vascular surgeons' perceptions toward risk reduction in PAD identify knowledge and action gaps, despite the recognition that recommending and instituting therapy is important to patient care. Given the heightened risk of cardiovascular disease in patients with PAD, these data have important implications.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed2006

Cardiovascular risk reduction.

A case on cardiovascular risk reduction is presented. Multiple cardiovascular risks (dyslipidemia, hypertension, and diabetes) are addressed. Management of the metabolic syndrome and appropriate testing for the newer cardiovascular marker, C-reactive protein, are also discussed. The case emphasizes the importance of patient education about chronic disease states, which are often asymptomatic.

Aged↗

PubMed2001

Scope and scale insensitivities in a contingent valuation study of risk reductions.

A contingent valuation study asking willingness to pay (WTP) for reducing the overall death risk as well as the risk for fatal and non-fatal injuries in road traffic accidents was performed in Sweden 1998. Different sub-samples were used to test for scale (different risk reductions) and scope (different outcomes) effects, existence of which implies that a respondent is capable of differentiating a WTP-answer accordingly. The results indicated that respondents needed some reference point for their valuation. For instance, dependent samples showed, contrary to independent ones, a significant difference between WTP of dying from any cause and in a traffic accident for the same relative but different absolute risk reduction. Regarding non-fatal traffic accidents, tests were performed comparing valuation of risk reductions for injuries with different outcomes but identical baseline risks and relative risk reductions. Similar to the case above, dependent samples differentiated their WTP and were willing to pay significantly more for a severe injury than for a slight one, which was not the case for independent samples.

Accidents, Traffic↗

PubMed2001

Relation between intensity of physical activity and breast cancer risk reduction.

PURPOSE: To examine the influence of frequency, duration, and intensity of physical activity on risk of breast cancer and to compare breast cancer risks associated with self-reported versus assigned intensity levels of activity. METHODS: A population-based case-control study of 1233 incident breast cancer cases and 1241 controls was conducted in Alberta between 1995 and 1997. The frequency, duration and intensity of occupational, household, and recreational activities were measured throughout lifetime using the Lifetime Total Physical Activity Questionnaire and cognitive interviewing methods. Unconditional logistic regression analyses were used to estimate odds ratios and a full assessment of confounding and effect modification was undertaken. Odds ratios for self-reported and compendium-based assigned levels of activity were compared for lifetime total activity and by type of activity. RESULTS: Breast cancer risk reductions were comparable when self-reported and assigned intensity values were used, although the results and trends were more evident with the assigned intensity data. Moderate-intensity occupational and household activities decreased breast cancer risk, whereas recreational activity, at any intensity level, did not contribute to a breast cancer risk reduction. CONCLUSION: This study found that moderate-intensity activities were the major contributors to the decrease in breast cancer risk found in this study and that risk reductions were more evident when the frequency and duration of activity alone were modeled. Of the three types of activity considered, the greatest risk reductions observed were for occupational and household activities.

Activities of Daily Living↗

PubMed2002

Self-efficacy estimates for drug use practices predict risk reduction among injection drug users.

We used baseline outcome efficacy (OE) estimates for human immunodeficiency virus (HIV) risk reduction to predict subsequent risk reduction 6 months hence among 792 injection drug users in a prospective study. Declines in drug use, frequency of injection, and needle sharing were found among those with high OE scores after adjustment for baseline behavior and antecedent factors. No OE effect was found in multivariate analysis for shooting gallery attendance, a risk that substantially declined in this cohort. OE for needle disinfection was associated with reduced drug risk behaviors, but not for improved needle hygiene practices over time. The self-efficacy model is useful in understanding psychological factors in risk reduction among injection drug users.

Adult↗

PubMed1999

American Society of Clinical Oncology technology assessment on breast cancer risk reduction strategies: tamoxifen and raloxifene.

OBJECTIVE: To conduct an evidence-based technology assessment to determine whether tamoxifen and raloxifene as breast cancer risk-reduction strategies are appropriate for broad-based conventional use in clinical practice. POTENTIAL INTERVENTION: Tamoxifen and raloxifene. OUTCOME: Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefits. EVIDENCE: A comprehensive, formal literature review was conducted for tamoxifen and raloxifene on the following topics: breast cancer risk reduction; tamoxifen side effects and toxicity, including endometrial cancer risk; tamoxifen influences on nonmalignant diseases, including coronary heart disease and osteoporosis; and decision making by women at risk for breast cancer. Testimony was collected from invited experts and interested parties. VALUES: More weight was given to publications that described randomized trials. BENEFITS/HARMS/COSTS: The American Society of Clinical Oncology (ASCO) Working Group acknowledges that a woman's decision regarding breast cancer risk-reduction strategies will depend on the importance and weight attributed to the information provided regarding both cancer and non-cancer-related risks. CONCLUSIONS: For women with a defined 5-year projected risk of breast cancer of >/= 1.66%, tamoxifen (at 20 mg/d for up to 5 years) may be offered to reduce their risk. It is premature to recommend raloxifene use to lower the risk of developing breast cancer outside of a clinical trial setting. On the basis of available information, use of raloxifene should currently be reserved for its approved indication to prevent bone loss in postmenopausal women. Conclusions are based on single-agent use of the drugs. At the present time, the effect of using tamoxifen or raloxifene with other medications (such as hormone replacement therapy), or using tamoxifen and raloxifene in combination or sequentially, has not been studied adequately. The continuing use of placebo-controlled trials in other risk-reduction trials highlights the current unanswered issues concerning the use of such interventions, especially when the influence on net health benefit remains to be determined. Breast cancer risk reduction is a rapidly evolving area. This technology assessment represents an ongoing process with existing plans to monitor and review data and to update recommendations in a timely matter. (See VALIDATION: The conclusions of the Working Group were evaluated by the ASCO Health Services Research Committee and by the ASCO Board of Directors. SPONSOR: American Society of Clinical Oncology.

Anticarcinogenic Agents↗

PubMed2003

A randomized comparison of patients' understanding of number needed to treat and other common risk reduction formats.

BACKGROUND: Commentators have suggested that patients may understand quantitative information about treatment benefits better when they are presented as numbers needed to treat (NNT) rather than as absolute or relative risk reductions. OBJECTIVE: To determine whether NNT helps patients interpret treatment benefits better than absolute risk reduction (ARR), relative risk reduction (RRR), or a combination of all three of these risk reduction presentations (COMBO). DESIGN: Randomized cross-sectional survey. SETTING: University internal medicine clinic. PATIENTS: Three hundred fifty-seven men and women, ages 50 to 80, who presented for health care. INTERVENTIONS: Subjects were given written information about the baseline risk of a hypothetical "disease Y" and were asked (1) to compare the benefits of two drug treatments for disease Y, stating which provided more benefit; and (2) to calculate the effect of one of those drug treatments on a given baseline risk of disease. Risk information was presented to each subject in one of four randomly allocated risk formats: NNT, ARR, RRR, or COMBO. MAIN RESULTS: When asked to state which of two treatments provided more benefit, subjects who received the RRR format responded correctly most often (60% correct vs 43% for COMBO, 42% for ARR, and 30% for NNT, P =.001). Most subjects were unable to calculate the effect of drug treatment on the given baseline risk of disease, although subjects receiving the RRR and ARR formats responded correctly more often (21% and 17% compared to 7% for COMBO and 6% for NNT, P =.004). CONCLUSION: Patients are best able to interpret the benefits of treatment when they are presented in an RRR format with a given baseline risk of disease. ARR also is easily interpreted. NNT is often misinterpreted by patients and should not be used alone to communicate risk to patients.

Aged↗