Mary Ann Moon

A young adult’s acute response to alcohol predicts whether he or she will escalate to problem drinking within 2 years, but not in the way in which most experts would expect, according to a report in the April issue of the Archives of General Psychiatry.

Young adults who experience greater positive effects from drinking – for example, reporting that they like and want more of alcohol’s stimulant effects – and lesser negative effects such as sedation are more likely to drink heavily and to progress to problem drinking. In contrast, those who do not experience high levels of positive effects but have greater negative effects – for example, attaining only a mild "buzz" and then rapidly feeling sluggish – are less likely to drink heavily and progress to problem drinking.

"Although the finding that heavier drinkers enjoy the effects of alcohol more than lighter drinkers seems intuitive, there has been limited evidence thus far to support this notion. Indeed, the prevailing model, the low-level response theory, posits that persons who experience a lower level of response to alcohol will engage in heavier drinking over time because they do not feel the internal cues of intoxication" or the warning signs to stop drinking, said Andrea C. King, Ph.D., of the department of psychiatry and behavioral neuroscience at the University of Chicago and her associates.

The investigators studied drinking in 190 healthy volunteers aged 21-35 years, including 85 women and 105 men. In all, 104 of these subjects were classified as heavy drinkers, consuming 10-40 standard alcoholic drinks per week and engaging in regular binge drinking (consuming five or more drinks at one time, and doing so between one and five times per week). The remaining 86 subjects were classified as light drinkers, consuming one to five standard alcoholic drinks per week and engaging in binge drinking five or fewer times per year.

In the first phase of the study, the subjects were assigned in random order to three individual, 5-hour laboratory sessions in which they drank a placebo beverage, a low-alcohol beverage, or a high-alcohol beverage; they were then assessed at 30, 60, 120, and 180 minutes. In the second phase of the study, the subjects were followed every 3 months for 2 years to assess changes in their everyday patterns of alcohol use.

The heavy drinkers showed a markedly different acute response to alcohol than did the light drinkers.

Heavy drinkers reported feeling greater positive and rewarding effects, particularly at the high dose of alcohol. They enjoyed the stimulant effects of drinking to a greater degree, and said that they "wanted more." They did not experience much sedation. In contrast, light drinkers did not experience the positive or rewarding effects of alcohol as much, did not enjoy the stimulant effects as much, and did not "want more." They reported higher sedation and feeling tired and sluggish after drinking, particularly after drinking the high-dose beverage. Light drinkers also showed increases in salivary cortisol levels (a marker of stress) when "coming down" from the high-dose beverage, whereas heavy drinkers did not.

"Collectively, these responses may serve as a protective factor underlying [light] drinkers’ ability to ‘put the brakes on’ and limit their drinking," Dr. King and her colleagues said (Arch. Gen. Psych. 2011;68:389-99).

During the 2-year follow-up, few light drinkers increased their alcohol consumption. In contrast, heavy drinkers were likely to maintain or increase their alcohol intake, particularly to raise their frequency of binge drinking. These subjects increased their likelihood of meeting DSM-IV criteria for alcohol abuse and dependence, the researchers said.

"Taken together, [our] results indicate that the low-level response theory should be revised to include heightened sensitivity to rewarding and stimulating alcohol effects as equally important predictors as lack of sedative responses in the development and maintenance of problematic drinking among at-risk persons," they added.

"We plan to continue to follow up these participants to examine their drinking patterns over a longer time."

One important limitation of the study is the legal requirement that participants be at least aged 21 years to be given alcohol. Therefore, "it is unclear whether the findings can be generalized to younger drinkers," Dr. King and her colleagues wrote.

This study was supported by the National Institute on Alcohol Abuse and Alcoholism, the comprehensive cancer center at the University of Chicago, and the National Center for Research Resources. No conflicts of interest were reported.

A young adult’s acute response to alcohol predicts whether he or she will escalate to problem drinking within 2 years, but not in the way in which most experts would expect, according to a report in the April issue of the Archives of General Psychiatry.

Young adults who experience greater positive effects from drinking – for example, reporting that they like and want more of alcohol’s stimulant effects – and lesser negative effects such as sedation are more likely to drink heavily and to progress to problem drinking. In contrast, those who do not experience high levels of positive effects but have greater negative effects – for example, attaining only a mild "buzz" and then rapidly feeling sluggish – are less likely to drink heavily and progress to problem drinking.

"Although the finding that heavier drinkers enjoy the effects of alcohol more than lighter drinkers seems intuitive, there has been limited evidence thus far to support this notion. Indeed, the prevailing model, the low-level response theory, posits that persons who experience a lower level of response to alcohol will engage in heavier drinking over time because they do not feel the internal cues of intoxication" or the warning signs to stop drinking, said Andrea C. King, Ph.D., of the department of psychiatry and behavioral neuroscience at the University of Chicago and her associates.

The investigators studied drinking in 190 healthy volunteers aged 21-35 years, including 85 women and 105 men. In all, 104 of these subjects were classified as heavy drinkers, consuming 10-40 standard alcoholic drinks per week and engaging in regular binge drinking (consuming five or more drinks at one time, and doing so between one and five times per week). The remaining 86 subjects were classified as light drinkers, consuming one to five standard alcoholic drinks per week and engaging in binge drinking five or fewer times per year.

In the first phase of the study, the subjects were assigned in random order to three individual, 5-hour laboratory sessions in which they drank a placebo beverage, a low-alcohol beverage, or a high-alcohol beverage; they were then assessed at 30, 60, 120, and 180 minutes. In the second phase of the study, the subjects were followed every 3 months for 2 years to assess changes in their everyday patterns of alcohol use.

The heavy drinkers showed a markedly different acute response to alcohol than did the light drinkers.

Heavy drinkers reported feeling greater positive and rewarding effects, particularly at the high dose of alcohol. They enjoyed the stimulant effects of drinking to a greater degree, and said that they "wanted more." They did not experience much sedation. In contrast, light drinkers did not experience the positive or rewarding effects of alcohol as much, did not enjoy the stimulant effects as much, and did not "want more." They reported higher sedation and feeling tired and sluggish after drinking, particularly after drinking the high-dose beverage. Light drinkers also showed increases in salivary cortisol levels (a marker of stress) when "coming down" from the high-dose beverage, whereas heavy drinkers did not.

"Collectively, these responses may serve as a protective factor underlying [light] drinkers’ ability to ‘put the brakes on’ and limit their drinking," Dr. King and her colleagues said (Arch. Gen. Psych. 2011;68:389-99).

During the 2-year follow-up, few light drinkers increased their alcohol consumption. In contrast, heavy drinkers were likely to maintain or increase their alcohol intake, particularly to raise their frequency of binge drinking. These subjects increased their likelihood of meeting DSM-IV criteria for alcohol abuse and dependence, the researchers said.

"Taken together, [our] results indicate that the low-level response theory should be revised to include heightened sensitivity to rewarding and stimulating alcohol effects as equally important predictors as lack of sedative responses in the development and maintenance of problematic drinking among at-risk persons," they added.

"We plan to continue to follow up these participants to examine their drinking patterns over a longer time."

One important limitation of the study is the legal requirement that participants be at least aged 21 years to be given alcohol. Therefore, "it is unclear whether the findings can be generalized to younger drinkers," Dr. King and her colleagues wrote.

This study was supported by the National Institute on Alcohol Abuse and Alcoholism, the comprehensive cancer center at the University of Chicago, and the National Center for Research Resources. No conflicts of interest were reported.

A young adult’s acute response to alcohol predicts whether he or she will escalate to problem drinking within 2 years, but not in the way in which most experts would expect, according to a report in the April issue of the Archives of General Psychiatry.

Young adults who experience greater positive effects from drinking – for example, reporting that they like and want more of alcohol’s stimulant effects – and lesser negative effects such as sedation are more likely to drink heavily and to progress to problem drinking. In contrast, those who do not experience high levels of positive effects but have greater negative effects – for example, attaining only a mild "buzz" and then rapidly feeling sluggish – are less likely to drink heavily and progress to problem drinking.

"Although the finding that heavier drinkers enjoy the effects of alcohol more than lighter drinkers seems intuitive, there has been limited evidence thus far to support this notion. Indeed, the prevailing model, the low-level response theory, posits that persons who experience a lower level of response to alcohol will engage in heavier drinking over time because they do not feel the internal cues of intoxication" or the warning signs to stop drinking, said Andrea C. King, Ph.D., of the department of psychiatry and behavioral neuroscience at the University of Chicago and her associates.

The investigators studied drinking in 190 healthy volunteers aged 21-35 years, including 85 women and 105 men. In all, 104 of these subjects were classified as heavy drinkers, consuming 10-40 standard alcoholic drinks per week and engaging in regular binge drinking (consuming five or more drinks at one time, and doing so between one and five times per week). The remaining 86 subjects were classified as light drinkers, consuming one to five standard alcoholic drinks per week and engaging in binge drinking five or fewer times per year.

In the first phase of the study, the subjects were assigned in random order to three individual, 5-hour laboratory sessions in which they drank a placebo beverage, a low-alcohol beverage, or a high-alcohol beverage; they were then assessed at 30, 60, 120, and 180 minutes. In the second phase of the study, the subjects were followed every 3 months for 2 years to assess changes in their everyday patterns of alcohol use.

The heavy drinkers showed a markedly different acute response to alcohol than did the light drinkers.

Heavy drinkers reported feeling greater positive and rewarding effects, particularly at the high dose of alcohol. They enjoyed the stimulant effects of drinking to a greater degree, and said that they "wanted more." They did not experience much sedation. In contrast, light drinkers did not experience the positive or rewarding effects of alcohol as much, did not enjoy the stimulant effects as much, and did not "want more." They reported higher sedation and feeling tired and sluggish after drinking, particularly after drinking the high-dose beverage. Light drinkers also showed increases in salivary cortisol levels (a marker of stress) when "coming down" from the high-dose beverage, whereas heavy drinkers did not.

"Collectively, these responses may serve as a protective factor underlying [light] drinkers’ ability to ‘put the brakes on’ and limit their drinking," Dr. King and her colleagues said (Arch. Gen. Psych. 2011;68:389-99).

During the 2-year follow-up, few light drinkers increased their alcohol consumption. In contrast, heavy drinkers were likely to maintain or increase their alcohol intake, particularly to raise their frequency of binge drinking. These subjects increased their likelihood of meeting DSM-IV criteria for alcohol abuse and dependence, the researchers said.

"Taken together, [our] results indicate that the low-level response theory should be revised to include heightened sensitivity to rewarding and stimulating alcohol effects as equally important predictors as lack of sedative responses in the development and maintenance of problematic drinking among at-risk persons," they added.

"We plan to continue to follow up these participants to examine their drinking patterns over a longer time."

One important limitation of the study is the legal requirement that participants be at least aged 21 years to be given alcohol. Therefore, "it is unclear whether the findings can be generalized to younger drinkers," Dr. King and her colleagues wrote.

This study was supported by the National Institute on Alcohol Abuse and Alcoholism, the comprehensive cancer center at the University of Chicago, and the National Center for Research Resources. No conflicts of interest were reported.

A young adult’s acute response to alcohol predicts whether he or she will escalate to problem drinking within 2 years, but not in the way in which most experts would expect, according to a report in the April issue of the Archives of General Psychiatry.

Young adults who experience greater positive effects from drinking – for example, reporting that they like and want more of alcohol’s stimulant effects – and lesser negative effects such as sedation are more likely to drink heavily and to progress to problem drinking. In contrast, those who do not experience high levels of positive effects but have greater negative effects – for example, attaining only a mild "buzz" and then rapidly feeling sluggish – are less likely to drink heavily and progress to problem drinking.

"Although the finding that heavier drinkers enjoy the effects of alcohol more than lighter drinkers seems intuitive, there has been limited evidence thus far to support this notion. Indeed, the prevailing model, the low-level response theory, posits that persons who experience a lower level of response to alcohol will engage in heavier drinking over time because they do not feel the internal cues of intoxication" or the warning signs to stop drinking, said Andrea C. King, Ph.D., of the department of psychiatry and behavioral neuroscience at the University of Chicago and her associates.

The investigators studied drinking in 190 healthy volunteers aged 21-35 years, including 85 women and 105 men. In all, 104 of these subjects were classified as heavy drinkers, consuming 10-40 standard alcoholic drinks per week and engaging in regular binge drinking (consuming five or more drinks at one time, and doing so between one and five times per week). The remaining 86 subjects were classified as light drinkers, consuming one to five standard alcoholic drinks per week and engaging in binge drinking five or fewer times per year.

In the first phase of the study, the subjects were assigned in random order to three individual, 5-hour laboratory sessions in which they drank a placebo beverage, a low-alcohol beverage, or a high-alcohol beverage; they were then assessed at 30, 60, 120, and 180 minutes. In the second phase of the study, the subjects were followed every 3 months for 2 years to assess changes in their everyday patterns of alcohol use.

The heavy drinkers showed a markedly different acute response to alcohol than did the light drinkers.

Heavy drinkers reported feeling greater positive and rewarding effects, particularly at the high dose of alcohol. They enjoyed the stimulant effects of drinking to a greater degree, and said that they "wanted more." They did not experience much sedation. In contrast, light drinkers did not experience the positive or rewarding effects of alcohol as much, did not enjoy the stimulant effects as much, and did not "want more." They reported higher sedation and feeling tired and sluggish after drinking, particularly after drinking the high-dose beverage. Light drinkers also showed increases in salivary cortisol levels (a marker of stress) when "coming down" from the high-dose beverage, whereas heavy drinkers did not.

"Collectively, these responses may serve as a protective factor underlying [light] drinkers’ ability to ‘put the brakes on’ and limit their drinking," Dr. King and her colleagues said (Arch. Gen. Psych. 2011;68:389-99).

During the 2-year follow-up, few light drinkers increased their alcohol consumption. In contrast, heavy drinkers were likely to maintain or increase their alcohol intake, particularly to raise their frequency of binge drinking. These subjects increased their likelihood of meeting DSM-IV criteria for alcohol abuse and dependence, the researchers said.

"Taken together, [our] results indicate that the low-level response theory should be revised to include heightened sensitivity to rewarding and stimulating alcohol effects as equally important predictors as lack of sedative responses in the development and maintenance of problematic drinking among at-risk persons," they added.

"We plan to continue to follow up these participants to examine their drinking patterns over a longer time."

One important limitation of the study is the legal requirement that participants be at least aged 21 years to be given alcohol. Therefore, "it is unclear whether the findings can be generalized to younger drinkers," Dr. King and her colleagues wrote.

This study was supported by the National Institute on Alcohol Abuse and Alcoholism, the comprehensive cancer center at the University of Chicago, and the National Center for Research Resources. No conflicts of interest were reported.

A young adult’s acute response to alcohol predicts whether he or she will escalate to problem drinking within 2 years, but not in the way in which most experts would expect, according to a report in the April issue of the Archives of General Psychiatry.

Young adults who experience greater positive effects from drinking – for example, reporting that they like and want more of alcohol’s stimulant effects – and lesser negative effects such as sedation are more likely to drink heavily and to progress to problem drinking. In contrast, those who do not experience high levels of positive effects but have greater negative effects – for example, attaining only a mild "buzz" and then rapidly feeling sluggish – are less likely to drink heavily and progress to problem drinking.

"Although the finding that heavier drinkers enjoy the effects of alcohol more than lighter drinkers seems intuitive, there has been limited evidence thus far to support this notion. Indeed, the prevailing model, the low-level response theory, posits that persons who experience a lower level of response to alcohol will engage in heavier drinking over time because they do not feel the internal cues of intoxication" or the warning signs to stop drinking, said Andrea C. King, Ph.D., of the department of psychiatry and behavioral neuroscience at the University of Chicago and her associates.

The investigators studied drinking in 190 healthy volunteers aged 21-35 years, including 85 women and 105 men. In all, 104 of these subjects were classified as heavy drinkers, consuming 10-40 standard alcoholic drinks per week and engaging in regular binge drinking (consuming five or more drinks at one time, and doing so between one and five times per week). The remaining 86 subjects were classified as light drinkers, consuming one to five standard alcoholic drinks per week and engaging in binge drinking five or fewer times per year.

In the first phase of the study, the subjects were assigned in random order to three individual, 5-hour laboratory sessions in which they drank a placebo beverage, a low-alcohol beverage, or a high-alcohol beverage; they were then assessed at 30, 60, 120, and 180 minutes. In the second phase of the study, the subjects were followed every 3 months for 2 years to assess changes in their everyday patterns of alcohol use.

The heavy drinkers showed a markedly different acute response to alcohol than did the light drinkers.

Heavy drinkers reported feeling greater positive and rewarding effects, particularly at the high dose of alcohol. They enjoyed the stimulant effects of drinking to a greater degree, and said that they "wanted more." They did not experience much sedation. In contrast, light drinkers did not experience the positive or rewarding effects of alcohol as much, did not enjoy the stimulant effects as much, and did not "want more." They reported higher sedation and feeling tired and sluggish after drinking, particularly after drinking the high-dose beverage. Light drinkers also showed increases in salivary cortisol levels (a marker of stress) when "coming down" from the high-dose beverage, whereas heavy drinkers did not.

"Collectively, these responses may serve as a protective factor underlying [light] drinkers’ ability to ‘put the brakes on’ and limit their drinking," Dr. King and her colleagues said (Arch. Gen. Psych. 2011;68:389-99).

During the 2-year follow-up, few light drinkers increased their alcohol consumption. In contrast, heavy drinkers were likely to maintain or increase their alcohol intake, particularly to raise their frequency of binge drinking. These subjects increased their likelihood of meeting DSM-IV criteria for alcohol abuse and dependence, the researchers said.

"Taken together, [our] results indicate that the low-level response theory should be revised to include heightened sensitivity to rewarding and stimulating alcohol effects as equally important predictors as lack of sedative responses in the development and maintenance of problematic drinking among at-risk persons," they added.

"We plan to continue to follow up these participants to examine their drinking patterns over a longer time."

One important limitation of the study is the legal requirement that participants be at least aged 21 years to be given alcohol. Therefore, "it is unclear whether the findings can be generalized to younger drinkers," Dr. King and her colleagues wrote.

This study was supported by the National Institute on Alcohol Abuse and Alcoholism, the comprehensive cancer center at the University of Chicago, and the National Center for Research Resources. No conflicts of interest were reported.

A young adult’s acute response to alcohol predicts whether he or she will escalate to problem drinking within 2 years, but not in the way in which most experts would expect, according to a report in the April issue of the Archives of General Psychiatry.

Young adults who experience greater positive effects from drinking – for example, reporting that they like and want more of alcohol’s stimulant effects – and lesser negative effects such as sedation are more likely to drink heavily and to progress to problem drinking. In contrast, those who do not experience high levels of positive effects but have greater negative effects – for example, attaining only a mild "buzz" and then rapidly feeling sluggish – are less likely to drink heavily and progress to problem drinking.

"Although the finding that heavier drinkers enjoy the effects of alcohol more than lighter drinkers seems intuitive, there has been limited evidence thus far to support this notion. Indeed, the prevailing model, the low-level response theory, posits that persons who experience a lower level of response to alcohol will engage in heavier drinking over time because they do not feel the internal cues of intoxication" or the warning signs to stop drinking, said Andrea C. King, Ph.D., of the department of psychiatry and behavioral neuroscience at the University of Chicago and her associates.

The investigators studied drinking in 190 healthy volunteers aged 21-35 years, including 85 women and 105 men. In all, 104 of these subjects were classified as heavy drinkers, consuming 10-40 standard alcoholic drinks per week and engaging in regular binge drinking (consuming five or more drinks at one time, and doing so between one and five times per week). The remaining 86 subjects were classified as light drinkers, consuming one to five standard alcoholic drinks per week and engaging in binge drinking five or fewer times per year.

In the first phase of the study, the subjects were assigned in random order to three individual, 5-hour laboratory sessions in which they drank a placebo beverage, a low-alcohol beverage, or a high-alcohol beverage; they were then assessed at 30, 60, 120, and 180 minutes. In the second phase of the study, the subjects were followed every 3 months for 2 years to assess changes in their everyday patterns of alcohol use.

The heavy drinkers showed a markedly different acute response to alcohol than did the light drinkers.

Heavy drinkers reported feeling greater positive and rewarding effects, particularly at the high dose of alcohol. They enjoyed the stimulant effects of drinking to a greater degree, and said that they "wanted more." They did not experience much sedation. In contrast, light drinkers did not experience the positive or rewarding effects of alcohol as much, did not enjoy the stimulant effects as much, and did not "want more." They reported higher sedation and feeling tired and sluggish after drinking, particularly after drinking the high-dose beverage. Light drinkers also showed increases in salivary cortisol levels (a marker of stress) when "coming down" from the high-dose beverage, whereas heavy drinkers did not.

"Collectively, these responses may serve as a protective factor underlying [light] drinkers’ ability to ‘put the brakes on’ and limit their drinking," Dr. King and her colleagues said (Arch. Gen. Psych. 2011;68:389-99).

During the 2-year follow-up, few light drinkers increased their alcohol consumption. In contrast, heavy drinkers were likely to maintain or increase their alcohol intake, particularly to raise their frequency of binge drinking. These subjects increased their likelihood of meeting DSM-IV criteria for alcohol abuse and dependence, the researchers said.

"Taken together, [our] results indicate that the low-level response theory should be revised to include heightened sensitivity to rewarding and stimulating alcohol effects as equally important predictors as lack of sedative responses in the development and maintenance of problematic drinking among at-risk persons," they added.

"We plan to continue to follow up these participants to examine their drinking patterns over a longer time."

One important limitation of the study is the legal requirement that participants be at least aged 21 years to be given alcohol. Therefore, "it is unclear whether the findings can be generalized to younger drinkers," Dr. King and her colleagues wrote.

This study was supported by the National Institute on Alcohol Abuse and Alcoholism, the comprehensive cancer center at the University of Chicago, and the National Center for Research Resources. No conflicts of interest were reported.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.

Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.

Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.

The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.

Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.

When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.

At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.

At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.

Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.

To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.

The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.

A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.

After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.

A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.

It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.

Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.

In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.

"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.

This increase was significantly greater than that predicted by several mathematical models, they noted.

The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.

"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.

They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.

Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.

The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).

The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.

Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.

The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.

"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.

However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."

In this study, only 16% of the cohort had ever received a prescription for interferon.

"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.

The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.

Major Finding: Energy expenditure increased four- to eightfold when middle-school children played any of a variety of “exergames,” interactive video or electronic games that feature player movement similar to that in real-life games.

Data Source: A comparison of energy expenditure at rest with that during treadmill walking and 10 minutes of playing six different exergames in 19 boys and 20 girls aged 9–13 years.

Disclosures: This study was funded by the University of Massachusetts. Dr. Bailey and Dr. McInnis reported no financial disclosures.

A variety of “exergames” raised children's energy expenditure to a moderate to vigorous level of intensity, comparing favorably with treadmill walking at 3 mph, in a small study.

Middle school–aged children showed a four- to eightfold increase in energy expenditure when they played any of six interactive video or electronic games that featured player movement similar to what would occur with real-life participation in the games, said Bruce W. Bailey, Ph.D., of the department of exercise sciences at Brigham Young University, Provo, Utah, and Kyle McInnis, Sc.D., of the department of exercise and health sciences at the University of Massachusetts, Boston.

They assessed energy expenditure with three commercial and three consumer exergaming systems with multiple games, each with multiple intensity levels. These included the most aerobically challenging games available, with running, dancing, and simulated boxing.

It is the first published study to examine “commercial exergaming equipment that is currently being marketed to schools and fitness facilities as an alternative form of exercise,” the researchers wrote.

The 19 boys and 20 girls, aged 9–13 years, were healthy and of diverse ethnic backgrounds (57% African American, 11% white, 12% Hispanic, and 20% other). A total of 21 subjects (54%) were overweight or at risk for overweight, while 18 (46%) were of normal weight.

Energy expenditure was measured with indirect calorimetry and a portable metabolic cart. The subjects were evaluated at rest, during 10 minutes of activity as they rotated through all of the games, and while walking on a treadmill.

Each game significantly raised energy expenditure to a moderate to vigorous level. Four of the six games raised it above the level expended during treadmill walking. “This level of intensity is consistent with current physical activity recommendations for children and can be used to alter energy balance,” Dr. Bailey and Dr. McInnis said (Arch. Pediatr. Adolesc. Med. 2011 March 7 [doi:10.1001/archpediatrics.2011.15]).

Energy expenditure was the same between subjects in the top 15% of body mass index and subjects with lower BMI. In fact, higher-weight children enjoyed one particular system, Sportwall, more than did normal-weight children.

“Sportwall was unique in that it was played in teams [of four to five children], and the activity was intermittent and of a high intensity. Thus, the social interaction and intermittent high-intensity nature of the activity may be why the children with higher BMIs enjoyed it more,” the researchers said.

Boys and girls reported equally high levels of enjoyment with all the games. Boys tended to like the boxing game, and girls preferred the dancing game.

“Although exergaming is most likely not the solution to the epidemic of reduced physical activity in children, it appears to be a potentially innovative strategy that can be used to reduce sedentary time, increase adherence to exercise programs, and promote enjoyment of physical activity. This may be especially important for … children who carry excess body weight,” the investigators said. Future studies may assess how prolonged participation in exergaming alters energy balance and adiposity, they wrote.

Major Finding: Energy expenditure increased four- to eightfold when middle-school children played any of a variety of “exergames,” interactive video or electronic games that feature player movement similar to that in real-life games.

Data Source: A comparison of energy expenditure at rest with that during treadmill walking and 10 minutes of playing six different exergames in 19 boys and 20 girls aged 9–13 years.

Disclosures: This study was funded by the University of Massachusetts. Dr. Bailey and Dr. McInnis reported no financial disclosures.

A variety of “exergames” raised children's energy expenditure to a moderate to vigorous level of intensity, comparing favorably with treadmill walking at 3 mph, in a small study.

Middle school–aged children showed a four- to eightfold increase in energy expenditure when they played any of six interactive video or electronic games that featured player movement similar to what would occur with real-life participation in the games, said Bruce W. Bailey, Ph.D., of the department of exercise sciences at Brigham Young University, Provo, Utah, and Kyle McInnis, Sc.D., of the department of exercise and health sciences at the University of Massachusetts, Boston.

They assessed energy expenditure with three commercial and three consumer exergaming systems with multiple games, each with multiple intensity levels. These included the most aerobically challenging games available, with running, dancing, and simulated boxing.

It is the first published study to examine “commercial exergaming equipment that is currently being marketed to schools and fitness facilities as an alternative form of exercise,” the researchers wrote.

The 19 boys and 20 girls, aged 9–13 years, were healthy and of diverse ethnic backgrounds (57% African American, 11% white, 12% Hispanic, and 20% other). A total of 21 subjects (54%) were overweight or at risk for overweight, while 18 (46%) were of normal weight.

Energy expenditure was measured with indirect calorimetry and a portable metabolic cart. The subjects were evaluated at rest, during 10 minutes of activity as they rotated through all of the games, and while walking on a treadmill.

Each game significantly raised energy expenditure to a moderate to vigorous level. Four of the six games raised it above the level expended during treadmill walking. “This level of intensity is consistent with current physical activity recommendations for children and can be used to alter energy balance,” Dr. Bailey and Dr. McInnis said (Arch. Pediatr. Adolesc. Med. 2011 March 7 [doi:10.1001/archpediatrics.2011.15]).

Energy expenditure was the same between subjects in the top 15% of body mass index and subjects with lower BMI. In fact, higher-weight children enjoyed one particular system, Sportwall, more than did normal-weight children.

“Sportwall was unique in that it was played in teams [of four to five children], and the activity was intermittent and of a high intensity. Thus, the social interaction and intermittent high-intensity nature of the activity may be why the children with higher BMIs enjoyed it more,” the researchers said.

Boys and girls reported equally high levels of enjoyment with all the games. Boys tended to like the boxing game, and girls preferred the dancing game.

“Although exergaming is most likely not the solution to the epidemic of reduced physical activity in children, it appears to be a potentially innovative strategy that can be used to reduce sedentary time, increase adherence to exercise programs, and promote enjoyment of physical activity. This may be especially important for … children who carry excess body weight,” the investigators said. Future studies may assess how prolonged participation in exergaming alters energy balance and adiposity, they wrote.

Major Finding: Energy expenditure increased four- to eightfold when middle-school children played any of a variety of “exergames,” interactive video or electronic games that feature player movement similar to that in real-life games.

Data Source: A comparison of energy expenditure at rest with that during treadmill walking and 10 minutes of playing six different exergames in 19 boys and 20 girls aged 9–13 years.

Disclosures: This study was funded by the University of Massachusetts. Dr. Bailey and Dr. McInnis reported no financial disclosures.

A variety of “exergames” raised children's energy expenditure to a moderate to vigorous level of intensity, comparing favorably with treadmill walking at 3 mph, in a small study.

Middle school–aged children showed a four- to eightfold increase in energy expenditure when they played any of six interactive video or electronic games that featured player movement similar to what would occur with real-life participation in the games, said Bruce W. Bailey, Ph.D., of the department of exercise sciences at Brigham Young University, Provo, Utah, and Kyle McInnis, Sc.D., of the department of exercise and health sciences at the University of Massachusetts, Boston.

They assessed energy expenditure with three commercial and three consumer exergaming systems with multiple games, each with multiple intensity levels. These included the most aerobically challenging games available, with running, dancing, and simulated boxing.

It is the first published study to examine “commercial exergaming equipment that is currently being marketed to schools and fitness facilities as an alternative form of exercise,” the researchers wrote.

The 19 boys and 20 girls, aged 9–13 years, were healthy and of diverse ethnic backgrounds (57% African American, 11% white, 12% Hispanic, and 20% other). A total of 21 subjects (54%) were overweight or at risk for overweight, while 18 (46%) were of normal weight.

Energy expenditure was measured with indirect calorimetry and a portable metabolic cart. The subjects were evaluated at rest, during 10 minutes of activity as they rotated through all of the games, and while walking on a treadmill.

Each game significantly raised energy expenditure to a moderate to vigorous level. Four of the six games raised it above the level expended during treadmill walking. “This level of intensity is consistent with current physical activity recommendations for children and can be used to alter energy balance,” Dr. Bailey and Dr. McInnis said (Arch. Pediatr. Adolesc. Med. 2011 March 7 [doi:10.1001/archpediatrics.2011.15]).

Energy expenditure was the same between subjects in the top 15% of body mass index and subjects with lower BMI. In fact, higher-weight children enjoyed one particular system, Sportwall, more than did normal-weight children.

“Sportwall was unique in that it was played in teams [of four to five children], and the activity was intermittent and of a high intensity. Thus, the social interaction and intermittent high-intensity nature of the activity may be why the children with higher BMIs enjoyed it more,” the researchers said.

Boys and girls reported equally high levels of enjoyment with all the games. Boys tended to like the boxing game, and girls preferred the dancing game.

“Although exergaming is most likely not the solution to the epidemic of reduced physical activity in children, it appears to be a potentially innovative strategy that can be used to reduce sedentary time, increase adherence to exercise programs, and promote enjoyment of physical activity. This may be especially important for … children who carry excess body weight,” the investigators said. Future studies may assess how prolonged participation in exergaming alters energy balance and adiposity, they wrote.

Major Finding: Behavioral counseling by a nurse practitioner was no better than usual care by a primary physician in helping overweight patients prevent further weight gain.

Data Source: A randomized, controlled trial involving 457 overweight patients attending 11 primary-care practices in The Netherlands who were followed for 3 years.

Disclosures: This study was supported by The Netherlands Organization for Health Research and Development and Foundation Fund de Gavere. No conflicts of interest were reported.

Lifestyle counseling from specially trained nurse practitioners in a primary-care setting was no better at preventing weight gain than was usual care delivered by the primary-care physician, in a 3-year study of more than 400 men and women.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse practitioners (NPs) versus usual care.

The study subjects were 457 men and women aged 40–70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which NPs counseled them in four in-person 30-minute individual sessions and one telephone “feedback” session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The NP sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change.

The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%–10% of body weight.

After 1 year, 80% of the subjects in the NP group had not gained any weight, compared with only 64% in the physician group.

However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by NPs showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the NP after the first year of the intervention may not have been sufficient to help patients sustain weight loss.

However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not.

“This means that our intervention is not suitable for experienced dieters,” Ms. ter Bogt and her associates wrote.

View on the News

Primary Care Provider Is Key

In an accompanying editorial, Debra Haire-Joshu, Ph.D., and Dr. Samuel Klein noted that while this study did not demonstrate that using a nurse practitioner to provide limited lifestyle counseling within a general medical practice results in meaningful long-term weight loss, substantial data suggest “that intensive interventions achieve weight loss that improves health outcomes. …”

“The primary care provider is a critical entry point to the health care setting for the obese population. The high prevalence rate of obesity and its association with medical complications ensures that obese patients are commonly encountered in primary care practice. Patients usually make three health care visits annually, mostly to their primary care physician. Therefore, the primary care provider is uniquely positioned to consistently monitor weight, health indicators, and risk and to counsel or refer for weight management” (Arch. Intern. Med. 2011;171:313-4).

DR. HAIRE-JOSHU is director of the Obesity Prevention and Policy Research Center and DR. KLEIN is director of the Center for Human Nutrition, both at Washington University, St. Louis. They reported no conflicts of interest.

Major Finding: Behavioral counseling by a nurse practitioner was no better than usual care by a primary physician in helping overweight patients prevent further weight gain.

Data Source: A randomized, controlled trial involving 457 overweight patients attending 11 primary-care practices in The Netherlands who were followed for 3 years.

Disclosures: This study was supported by The Netherlands Organization for Health Research and Development and Foundation Fund de Gavere. No conflicts of interest were reported.

Lifestyle counseling from specially trained nurse practitioners in a primary-care setting was no better at preventing weight gain than was usual care delivered by the primary-care physician, in a 3-year study of more than 400 men and women.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse practitioners (NPs) versus usual care.

The study subjects were 457 men and women aged 40–70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which NPs counseled them in four in-person 30-minute individual sessions and one telephone “feedback” session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The NP sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change.

The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%–10% of body weight.

After 1 year, 80% of the subjects in the NP group had not gained any weight, compared with only 64% in the physician group.

However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by NPs showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the NP after the first year of the intervention may not have been sufficient to help patients sustain weight loss.

However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not.

“This means that our intervention is not suitable for experienced dieters,” Ms. ter Bogt and her associates wrote.

View on the News

Primary Care Provider Is Key

In an accompanying editorial, Debra Haire-Joshu, Ph.D., and Dr. Samuel Klein noted that while this study did not demonstrate that using a nurse practitioner to provide limited lifestyle counseling within a general medical practice results in meaningful long-term weight loss, substantial data suggest “that intensive interventions achieve weight loss that improves health outcomes. …”

“The primary care provider is a critical entry point to the health care setting for the obese population. The high prevalence rate of obesity and its association with medical complications ensures that obese patients are commonly encountered in primary care practice. Patients usually make three health care visits annually, mostly to their primary care physician. Therefore, the primary care provider is uniquely positioned to consistently monitor weight, health indicators, and risk and to counsel or refer for weight management” (Arch. Intern. Med. 2011;171:313-4).

DR. HAIRE-JOSHU is director of the Obesity Prevention and Policy Research Center and DR. KLEIN is director of the Center for Human Nutrition, both at Washington University, St. Louis. They reported no conflicts of interest.

Major Finding: Behavioral counseling by a nurse practitioner was no better than usual care by a primary physician in helping overweight patients prevent further weight gain.

Data Source: A randomized, controlled trial involving 457 overweight patients attending 11 primary-care practices in The Netherlands who were followed for 3 years.

Disclosures: This study was supported by The Netherlands Organization for Health Research and Development and Foundation Fund de Gavere. No conflicts of interest were reported.

Lifestyle counseling from specially trained nurse practitioners in a primary-care setting was no better at preventing weight gain than was usual care delivered by the primary-care physician, in a 3-year study of more than 400 men and women.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse practitioners (NPs) versus usual care.

The study subjects were 457 men and women aged 40–70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which NPs counseled them in four in-person 30-minute individual sessions and one telephone “feedback” session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The NP sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change.

The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%–10% of body weight.

After 1 year, 80% of the subjects in the NP group had not gained any weight, compared with only 64% in the physician group.

However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by NPs showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the NP after the first year of the intervention may not have been sufficient to help patients sustain weight loss.

However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not.

“This means that our intervention is not suitable for experienced dieters,” Ms. ter Bogt and her associates wrote.

View on the News

Primary Care Provider Is Key

In an accompanying editorial, Debra Haire-Joshu, Ph.D., and Dr. Samuel Klein noted that while this study did not demonstrate that using a nurse practitioner to provide limited lifestyle counseling within a general medical practice results in meaningful long-term weight loss, substantial data suggest “that intensive interventions achieve weight loss that improves health outcomes. …”

“The primary care provider is a critical entry point to the health care setting for the obese population. The high prevalence rate of obesity and its association with medical complications ensures that obese patients are commonly encountered in primary care practice. Patients usually make three health care visits annually, mostly to their primary care physician. Therefore, the primary care provider is uniquely positioned to consistently monitor weight, health indicators, and risk and to counsel or refer for weight management” (Arch. Intern. Med. 2011;171:313-4).

DR. HAIRE-JOSHU is director of the Obesity Prevention and Policy Research Center and DR. KLEIN is director of the Center for Human Nutrition, both at Washington University, St. Louis. They reported no conflicts of interest.