What factors account for hormone replacement therapy prescribing frequency?

Factors affecting shared decision-making concerning menopausal hormone therapy

Menopausal hormone therapy (MHT) is an effective treatment for menopause-related symptoms. Menopause management guidelines recommend a personalized approach to menopause care, including MHT use. Decision-making around menopause care is a complex, iterative process influenced by multiple factors framed by perspectives from both women and healthcare providers (HCPs). This narrative review aims to summarize evidence around factors affecting decision-making regarding menopause-related care. For HCPs, the provision of individualized risk estimates is challenging in practice given the number of potential benefits and risks to consider, and the complexity of the data available, especially within time-limited consultations. Women seeking menopause care have the difficult task of making sense of the benefit versus risk profiles to make choices in line with their decisional needs influenced by sociocultural/economic, educational, demographic, and personal characteristics. The press, social media, and influential celebrities also impact the perception of menopause and decision-making around it. Understanding these factors can lead to improved participation in shared decision-making, satisfaction with the decision and decision-making process, adherence to treatment, reduced decisional regret, efficient use of resources, and ultimately long-term satisfaction with care.

Differences in patient-reported hormone therapy use for menopause symptoms by provider specialty

OBJECTIVE

Hormone therapy (HT) is an effective treatment for menopause symptoms in select women. This study aimed to determine whether there is different prevalence of HT use based on patient report by women who see different provider specialties.

METHODS

This study was a cross-sectional analysis of published data from the Survey of Midlife in the United States (MIDUS), a telephone or self-administered questionnaire of 3294 participants aged 39-90 years. Postmenopausal women were included. Self-reported HT use and provider specialty seen were each assessed by one question. Univariate logistic regression assessed factors possibly related to HT use. Variables with p < 0.1 were entered into a multivariable logistic regression model.

RESULTS

Of the 938 postmenopausal respondents, 720 (76%) saw a gynecologist for care. One-hundred and thirty-one (13%) women used HT for menopausal symptoms. Of women using HT, 72 (55%) saw a gynecologist. When controlling for other factors, women who saw a gynecologist had three times higher odds of using HT. The most frequently seen provider specialty was not associated with use.

CONCLUSIONS

Women who ever see a gynecologist are more likely to use HT for menopausal symptoms, but fewer women see gynecologists as they age. Generalists are the most seen provider specialty, positioning them to counsel patients about HT.

Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey

OBJECTIVE

To evaluate the knowledge of and nature of training for menopause management in postgraduate residents.

PARTICIPANTS AND METHODS

A cross-sectional, anonymous survey was e-mailed to trainees at all postgraduate levels in family medicine, internal medicine, and obstetrics and gynecology at US residency programs between January 11, and July 4, 2017. The survey was adapted from an existing instrument and included questions regarding knowledge of hormone therapy (HT) and other menopause management strategies, availability and type of training in menopause medicine, and demographic information.

RESULTS

Of the 703 surveys sent, a total of 183 residents representing 20 US residency programs responded (26.0% response rate). Most trainees were between 26 and 30 years of age (133 of 172 [77.3%]), female (114 of 173 [65.9%]), and believed it was important or very important to be trained to manage menopause (165 of 176 [93.8%]). Although most respondents answered some of the menopause competency questions correctly, important gaps were identified. Of 183 participants, 63 (34.4%) indicated they would not offer HT to a symptomatic, newly menopausal woman without contraindications, and only 71 (38.7%) indicated they would prescribe HT until the natural age of menopause to a prematurely menopausal woman. Of 177 respondents, 36 (20.3%) reported not receiving any menopause lectures during residency, and only 12 of 177 (6.8%) reported feeling adequately prepared to manage women experiencing menopause.

CONCLUSION

Family medicine, internal medicine, and obstetrics and gynecology residency trainees recognize the importance of training in menopause management, but important knowledge gaps exist. Investing in the education of future clinicians to provide evidence-based, comprehensive menopause management for the growing population of midlife women is a priority.

Shared decision-making, health choices and the menopause

Summary

The growing influence of the mass media on public understanding of health care matters has increased both information and misinformation in patients seeking help with menopausal symptoms. The use of shared decision-making strategies provides the opportunity to engage the patient in taking some responsibility for their own treatment. It also allows the identification and correction of any distortions in the perceived balance of evidence for and against any particular treatment. Shared decision-making balances the need to respect patients’ values and autonomy with the drive towards evidence-based medicine and clinical cost-effectiveness. Although ways of achieving such a balance are much discussed, the current need is for research which can identify effective strategies that allow the principles of “shared decision-making” and “evidence-based patient choice” to be validated and applied in clinical practice. Previous research focused on hormone replacement therapy indicates that the patient's decision is the outcome of the way they balance the pros and cons of taking (or not taking) it, and that their satisfaction with the decision is strongly associated with the perception that they have been given information about the full range of treatment available. It therefore seems likely that patients will respond more positively to consultations which include discussion of hormone replacement therapy alongside alternative strategies such as natural remedies and dietary/lifestyle changes. Psychological factors influencing treatment choice and the decision making process are discussed, and clinical and research implications for clinical practice in the menopause clinic examined.

Self-reported changes in providers' hormone therapy prescribing and counseling practices after the Women's Health Initiative

BACKGROUND

Prescribing and counseling practices in hormone therapy (HT) since publication of the Women's Health Initiative (WHI) trials have changed. Our objective was to compare changes by practice field and region.

METHODS

Between December 2005 and May 2006, we mailed surveys to 938 practitioners from two large integrated health systems in the Northeastern and Northwestern United States. We received 736 responses and excluded 144 who do not prescribe/counsel about HT, leaving 592. Data included prescriber characteristics, knowledge about HT trials, and self-reported HT counseling and prescribing changes. We compared provider characteristics and HT counseling and prescribing by region and practice field (obstetrician/gynecology [OB/GYN] or primary care).

RESULTS

Respondents included 79 OB/GYNs and 513 primary care providers. OB/GYNs were more likely, than primary care providers to consider themselves experts regarding the Heart and Estrogen/progestin Replacement Study (HERS) and WHI trials (30.4% vs. 8.2%, p < 0.001). The majority (87%) were cautious about HT use, especially primary care providers (p < 0.01 compared to OB/GYNs). Respondents reported prescribing less oral unopposed estrogen (64%) and combination estrogen/progestin (81%) post-WHI. OB/GYNs were less likely to report decreases in oral unopposed estrogen use (p = 0.006). Use of lower-dose and transdermal products (low-dose estrogen, vaginal estrogen, estradiol vaginal ring) increased, especially by OB/GYNs.

CONCLUSIONS

Our study highlights numerous HT prescribing and counseling differences between primary care and OB/GYN providers. Reasons for these differences are unknown but may be related to self-reported WHI/HERS knowledge. HT formulations used in the WHI trials are being replaced by low-dose and alternate formulations. Studies to support this practice are needed.

Hormone therapy discontinuation: physician practices after the Women's Health Initiative

OBJECTIVE

No guidelines or randomized trials address best practices for hormone therapy (HT) discontinuation.

METHODS

We conducted a survey study to explore HT discontinuation practices at Group Health and Harvard Vanguard, large integrated health systems in the Northwest and Northeast United States, focusing on differences between specialties and study site.

RESULTS

The response rate to the written questionnaire (mailed between December 2005 and May 2006) was 78.5% (736/928); this article reports the results for 483 eligible physicians. To discontinue oral HT, most physicians (91%) advised tapering, not immediate cessation (8%), and most (60%) suggested decreasing both dose and days per week. Almost 60% of physicians reported no experience with tapering patches. Harvard Vanguard physicians were more likely than Group Health physicians to encourage discontinuing HT and less likely to recommend resuming HT when a woman's symptoms returned after discontinuing HT. Physicians were most strongly influenced by their own experience (48%), advice from colleagues (25%), and the woman's preference (19%) when choosing a discontinuation strategy; only 2% relied on research evidence. Physicians endorsed various approaches to manage symptoms after HT discontinuation, most often behavioral changes (44%) and increased exercise (37%), and these approaches were more often endorsed by Harvard Vanguard physicians and obstetrician/gynecologists than Group Health physicians or family practitioners or internists.

CONCLUSIONS

Two health plans in the Northwestern and Northeastern United States have no standard protocol for HT discontinuation. Physicians customized approaches, influenced by their location, colleagues, and specialty. Research is needed to guide approaches to HT discontinuation.

Provider attributes associated with hormone therapy prescribing frequency

OBJECTIVE

The aim of this study was to identify provider characteristics associated with hormone therapy prescribing.

METHODS

The study design is cross-sectional. In December 2005, we mailed surveys to providers practicing in two integrated healthcare delivery systems located in the northwestern and northeastern United States; 379 responded (74%) and 249 (49% of total) granted access to their automated data. Data included provider demographics, practice characteristics, and perceptions about hormone therapy. Provider-specific annual hormone therapy prescribing frequency was calculated as days supply of hormone therapy filled divided by the number of visits (among women aged 45-80 y). Factors associated with higher rates of hormone therapy prescribing were identified using bivariate and multivariate analyses.

RESULTS

We report results separately for primary care providers (internists and family practitioners) and obstetrician/gynecologists because significant correlates differed in these two groups. For both primary care providers and obstetrician/gynecologists, in multivariate analyses, hormone therapy prescribing varied by site (P < or = 0.002) and years at the healthcare organization (P < or = 0.01). For primary care providers only, higher hormone therapy prescribing was associated with reported expert knowledge of the hormone therapy trials (P < or = 0.001). For obstetrician/gynecologists, higher hormone therapy prescription was related to feeling well prepared to counsel women on hormone therapy (P < or = 0.007), believing that the risks of estrogen with progestogen had been exaggerated (P = 0.04), and seeing younger aged patients (P = 0.03).

CONCLUSIONS

After the release of the Women's Health Initiative findings and practicing under similar clinical guidelines, hormone therapy prescribing is associated with providers' confidence, practice location, and time with a healthcare organization.

The medical management of menopause: a four-country comparison care in urban areas

OBJECTIVE

To compare the medical management of menopause across urban areas in four countries which differ by level of income and degree of medicalization.

METHODS

Surveys of health providers who advise women on the menopausal transition were carried out in Beirut, Lebanon (n=100), Madrid, Spain (n=60), Worcester, MA, U.S. (n=59), and Rabat, Morocco (n=50) between 2002 and 2004. Physician characteristics, hormone therapy (HT) prescribing practices, and concerns about the management of menopause were compared across countries using chi(2) and logistic regression analyses.

RESULTS

Across sites, physicians were generally well informed about HT and thought that symptom alleviation and disease prevention were equally important. They had concerns about risks associated with HT, particularly breast cancer, and in 3 sites where the survey was conducted after the WHI (Beirut, Rabat, and Madrid) physicians changed their practices to prescribe HT less frequently, for shorter durations, or shifted to other medications. There were significant differences across sites in the recommended duration of HT, time spent talking with patients, perceived benefits of HT, tests recommended before prescribing HT, and concern about the risks associated with HT. Physicians in Madrid and Massachusetts were more likely to report that decisions about the management of menopause were difficult, but in all sites the main reason for difficulties was concerns about risks. The results also suggest discrepancies between physicians' perceptions and women's reports about the reasons why women consult at menopause.

CONCLUSIONS

Prescription patterns and perceived benefits of HT appear to reflect local medical culture rather than simply physician characteristics. The impact of the WHI study was seen in prescribing patterns and concerns about HT. Physicians in all four countries were generally well informed. Financial support: NIH 5 900 000196.

How the Women's Health Initiative (WHI) influenced physicians' practice and attitudes

BACKGROUND

The landmark Women's Health Initiative (WHI) Postmenopausal Hormone Therapy Trial published in 2002 showed that the health risks of combination hormone therapy (HT) with estrogen and progestin outweighed the benefits in healthy postmenopausal women. Dissemination of results had a major impact on prescriptions for, and physician beliefs about HT. No study has fully examined the influence of the widely publicized WHI on physicians' practice and attitudes or their opinions of the scientific evidence regarding HT; in addition, little is known about how physicians assist women in their decisions regarding HT.

DESIGN AND PARTICIPANTS

We conducted in-depth telephone interviews with family practitioners, internists, and gynecologists from integrated health care delivery systems in Washington State (n = 10 physicians) and Massachusetts (n = 12 physicians). Our objectives were to obtain qualitative information from these physicians to understand their perspectives on use of HT, the scientific evidence regarding its risks and benefits, and counseling strategies around HT use and discontinuation.

APPROACH

We used Template Analysis to code transcribed telephone interviews and identify themes.

RESULTS

Physicians were conflicted about the WHI results and its implications. Seven themes identified from in-depth interviews suggested that the WHI (1) was a ground-breaking study that changed clinical practice, including counseling; (2) was not applicable to the full range of patients seen in clinical practice; (3) raised concerns over the impact of publicized health information on women; (4) created uncertainty about the risks and benefits of HT; (5) called for the use of decision aids; (6) influenced discontinuation strategies; and (7) provided an opportunity to discuss healthy lifestyle options with patients. As a result of the WHI, physicians reported they no longer prescribe HT for prevention and were more likely to suggest discontinuation, although many felt women should be in charge of the HT decision.

CONCLUSIONS

Physicians varied in their opinions of HT and the scientific evidence (positive and negative). Whereas the WHI delineated the risks and benefits of HT, physicians reported that decision aids are needed to guide discussions with women about menopause and HT. Better guidance at the time of WHI study publication might have been valuable to ensure best practices.

Clinical guidelines for improving compliance with hormone therapy in Latin American women during the menopausal transition and thereafter

OBJECTIVE

To provide uniform, objective guidance for physicians and other health care workers in Latin America to enhance compliance with hormone therapy (HT), and to provide a tool for continued medical education and a source for answering clinical questions.

METHOD

Literature search using MEDLINE; identification of key relevant publications by a five-member expert committee; creation and validation of a 60-item questionnaire used to survey the opinion of 72 physicians participating in a Latin American symposium, "The Faces of Menopause".

RESULTS

On the basis of the validated responses, major points were identified to enhance compliance with HT with specific reference to Latin America, and two algorithms were created to provide practical guidance.

CONCLUSION

The present guidelines will facilitate optimal compliance with therapy in Latin American postmenopausal women who opt for HT and for whom HT is indicated.

Variation in the psychosocial determinants of the intention to prescribe hormone therapy prior to the release of the Women's Health Initiative trial: a survey of general practitioners and gynaecologists in France and Quebec

BACKGROUND

Theory-based approaches are advocated to improve our understanding of prescription behaviour. This study is an application of the theory of planned behaviour (TPB) with additional variables. It was designed to assess which variables were associated with the intention to prescribe hormone therapy (HT). In addition, variations in the measures across medical specialities (GPs and gynaecologists) and across countries (France and Quebec) were investigated.

METHODS

A survey among 2,000 doctors from France and 1,044 doctors from Quebec was conducted. Data were collected by means of a self-administered questionnaire. A clinical vignette was used to elicit doctors' opinions. The following TPB variables were assessed: attitude, subjective norm, perceived behavioural control, attitudinal beliefs, normative beliefs and power of control beliefs. Additional variables (role belief, moral norm and practice pattern-related factors) were also assessed. A stepwise logistic regression was used to assess which variables were associated with the intention to prescribe HT. GPs and gynaecologists were compared to each other within countries and the two countries were compared within the specialties.

RESULTS

Overall, 1,085 doctors from France returned their questionnaire and 516 doctors from Quebec (response rate = 54% and 49%, respectively). In the overall regression model, power of control beliefs, moral norm and role belief were significantly associated with intention (all at p < 0.0001). The models by specialty and country were: for GPs in Quebec, power of control beliefs (p < 0.0001), moral norm (p < 0.01) and cytology and hormonal dosage (both at p < 0.05); for GPs in France, power of control beliefs and role belief (both at p < 0.0001) and perception of behavioural control (p < 0.05) and cessation of menses (p < 0.01); for gynaecologists in Quebec, moral norm and power of control beliefs (both at p = 0.01); and for gynaecologists in France, power of control beliefs (p < 0.0001), and moral norm, role belief and lipid profile (all at p < 0.05).

CONCLUSION

In both countries, compared with GPs, intention to prescribe HT was higher for gynaecologists. Psychosocial determinants of doctors' intention to prescribe HT varied according to the specialty and the country thus, suggesting an influence of contextual factors on these determinants.

Physicians and the prescription of hormone replacement therapy in Spain

OBJECTIVES

The purpose of this study was to determine the frequency of hormone replacement therapy (HRT) prescription and identify women's sociodemographic and climacteric factors, as well as variables related to healthcare, associated with the treatment's prescription in women aged 45-65 years in the reference population of a primary healthcare centre in the city of Granada (Spain).

METHODS

A descriptive cross-sectional telephone survey was conducted in July 2002 with women aged 45-65 years from the reference population of a primary healthcare centre. The information was gathered using a semi-structured questionnaire specifically developed to gather information on the prescription of HRT.

RESULTS

22.3% of the sample had ever been prescribed with HRT. Regarding compliance with the treatment, 44.2% of the women prescribed with this therapy took it partially, and 8.1% did not begin with the treatment. The variables independently associated with HRT prescription were having the menopause (OR=2.81; IC 95%: 1.08-7.28), having psychological symptoms (OR=2.77; IC 95%: 1.19-6.46), going to see the gynaecologist (OR=4.41; IC 95%: 1.87-10.36), and the fact that the doctor worked in the private healthcare sector (OR=3.55; IC 95%: 0.92-13.65).

CONCLUSIONS

The frequency of HRT prescription in Spain is high, as well as the non-compliance rate. Reaching the menopause and going to the gynaecologist are determinant in HRT prescription. It would be desirable to use similar methodological approaches in studies of this controversial therapy, in order to obtain consensus on the real impact on the female population, particularly in view of the results of the latest clinical trials.

Attitudes and practices about postmenopausal hormone therapy among female gynecologists in Brazil

OBJECTIVES

The aim of this study was to investigate the attitudes and practices of Brazilian female gynecologists surrounding their personal use of menopausal/postmenopausal hormone therapy (HT).

METHODS

This study was conducted in February 2001 using a mail survey. Three thousand eighty nine (n = 3089) female gynecologists over the age of 35 years and affiliated with the Brazilian Federation of Obstetricians and Gynecologists (FEBRASGO) were sent a questionnaire inquiring about their demographic, professional, medical, and behavioral background as well as their personal use of HT.

RESULTS

The response rate was 56.3%. Information on the menopausal status was available for 1655 respondents: 755 (45.7%) were postmenopausal, 172 indicated that they had irregular menses cycles (9.2%), and 728 (44.1%) underwent regular menses. Approximately, 47% of the postmenopausal respondents had been subject to a hysterectomy and were above the age of 50 years or had undergone bilateral oophorectomy. When asked about personal HT use, 61.1% and 10.3% of the respondents indicated that they were current or former users, respectively. 28.6% of the respondents had never used HT. The highest frequency of use occurred during their fifth decade. The main reasons for their use of HT included the attenuation of vasomotor symptoms, the prevention/treatment of osteoporosis, or the prevention of cardiovascular disease. Combined estrogen/progestin therapy was the preferred choice for postmenopausal gynecologists with an intact uterus. Family or personal histories of breast cancer or smoking were reported as deterrents against HT use for the female gynecologists.

CONCLUSION

Brazilian postmenopausal gynecologists engage in a high frequency of HT use. High levels of personal use may influence the general population towards HT prescription and compliance.

Comparison of Estonian and Finnish physicians' opinions of menopause and hormone therapy

OBJECTIVE

To compare Estonian and Finnish gynaecologists' and general practitioners' (GP) opinions on and prescribing practices in hormone treatment (HT) during and after menopause.

METHODS

Data was collected using similar postal questionnaires. In 2000 in Estonia, a random sample included 212 gynaecologists and 288 GPs (68% responded); and in 1989 in Finland, 100 male and 100 female gynaecologists, 100 general practitioner specialists and 100 non-specialists (73% responded). Gynaecologists and GPs were compared to each other within the countries, and the two countries were compared within the specialities.

RESULTS

Gynaecologists' opinions of benefits were positive and similar in Estonia and Finland, and more positive than those of GPs. Gynaecologists and GPs in both countries had similar opinions about harms. Gynaecologists were in favour of longer HT than GPs, and longer treatment was recommended in Finland than in Estonia. In both countries a large proportion of physicians (48% of gynaecologists in Estonia and 65% in Finland) stated that they would routinely prescribe HT to all women at menopause without contraindication, regardless of symptoms, and some (31% of gynaecologists in Estonia and 19% in Finland) favoured routine prescribing to all postmenopausal women.

CONCLUSIONS

Estonian physicians' positive attitudes suggest increased use of HT. Comparisons of the two countries and specialities suggest that physicians' positive opinions may long predate increased use.

Understanding physicians’ attitudes towards hormone therapy

OBJECTIVE

We sought to understand the relationship among components of residency education about hormone therapy (HT), knowledge about HT, and provider attitudes toward HT during a time of rapidly changing practice guidelines.

METHODS

We surveyed residents in the University of Pittsburgh Internal Medicine residency programs between February to April 2002 (after the release of the Heart Estrogen/Progestin Replacement Study and prior to the release of preliminary Women's Health Initiative data) regarding demographics, educational (didactic and experiential) exposures to HT and menopause management, knowledge about HT, and attitudes toward HT.

RESULTS

Sixty-nine of 92 (75%) eligible residents completed the survey; 38% were women. The race and gender of responders did not differ from nonresponders. Residents had significant didactic exposure to HT and menopause management with 80% reporting more than one didactic exposure. Despite this, HT knowledge was low (mean knowledge score 47 +/- 16%) and only 26% of residents felt prepared to counsel patients about HT. We identified four factors related to provider attitudes toward HT: "persistence" in universally recommending HT, confidence in "HT benefits," concern about "HT cardiac risks," and concern about "HT noncardiac risks." More appropriate attitudes were associated with attending a lecture, having a rotation with a discussion of menopause management (i.e., Women's Health), and a continuity practice including more than 30% women. Pharmaceutical detailing and self-directed study were associated with less appropriate attitudes. Knowledge did not influence attitudes. Strongly held beliefs about the benefits of HT, appropriate or inappropriate, were associated with increasing "persistence."

CONCLUSIONS

In an area of rapidly changing information, such as the risks and benefits of HT, knowledge is low. Experiential learning appropriately influences attitudes, while pharmaceutical detailing was associated with inappropriate attitudes toward HT risks.

Pharmacy data in the VA health care system

Recent advances in Department of Veterans Affairs (VA) health care data systems have greatly increased access to operational pharmacy information. This article presents a brief guide to VA pharmacy data sources: the Veterans Health Information Systems and Technology Architecture files, the Pharmacy Benefits Management database, Decision Support System (DSS) National Data Extracts for inpatient and outpatient care, the planned DSS National Pharmacy Extract, DSS databases at local VA facilities, and the Non-VA Fee Basis files. Depending on the source, available data elements include patient demographics, clinical care information, characteristics of the medication and of the prescribing physician, and cost. Access policies are detailed for VA and non-VA researchers. Linking these sources to VA databases containing data on inpatient and outpatient services offers a comprehensive view of health care within several VA populations of general interest, including people over age 65 and those with physical and psychiatric disabilities.