There were 664 returned surveys out of 1,029 mailed (64.5%). There were 185 letters returned from the 365 Fellows that did not return a survey (50.7%). Thus there are approximately 800 obstetrician-gynecologists (not every survey responder answered both questions) whose opinions regarding the evidence from the WHI combined HT and estrogen only trials can be directly compared between the 2004–2005 study and Follow-up #1. There was no difference in the rates at which men and women responded by returning either the survey or the letter. There was no difference in age and years since completion of residency between physicians that returned the letter versus the survey, however, physicians that did not respond (i.e. returned neither the letter nor the survey) were younger (median of 43 years versus 49 years, P=.001) and had fewer years of practice (median of 11 years versus 16 years, P<.001). Among survey responders the pattern of responses to the questions did not vary between mailings.
Men and women obstetrician-gynecologists appear to disagree about how convincing they found the results from the WHI trials of HT based on data from both the survey and the letter (). Men were significantly more likely to find the evidence unconvincing. Women respondents to the letter did not differ from women respondents to the survey on these two questions (P=.152 and P=.320, respectively); however, men respondents to the letter were significantly more likely than men respondents to the survey to find the evidence unconvincing (P=.036 and P=.006, for combined HT and estrogen only trials, respectively).
Comparison of men and women among respondents to the survey and the letter.
A majority of responding obstetrician-gynecologists that finished their residency before 1985 were men (81.6%) and a majority that finished their residency after 1995 were women (69.6%); between 1985 and 1994 the proportions were equal (49.8% men and 50.2% women). There was a significant negative correlation between the year residency was completed and physician skepticism for both trials (r = -.172 and r = -.142, respectively, P<.001). Physicians that had completed their residency more recently were less skeptical. After accounting for the year residency was completed, men and women did not differ; however, only women showed a significant pattern of decreasing skepticism with more recent completion of residency, and only of their opinion of the evidence from the combined HT trial (P=.019).
The responding physicians reported that they found the estrogen only trial results significantly more convincing that the combined HT results (P<.001). In regards to the combined HT trial, only one of five men and women who completed residency before 1985 found the results convincing, increasing to about one of three for residency years 1985–1994, and about four of ten after 1995 (). For the unopposed estrogen trial, about half of the women found the results convincing. One of three men who completed residency before 1995 found the unopposed estrogen results convincing, increasing to half of the men who completed residency in 1995 or later.
Table 4 The proportion of respondents who found the evidence from the trials convincing by sex and year of residency completion. There was no statistical difference between men and women after accounting for year of residency completion. The respondents were (more ...)
Both men and women were generally confident of their ability to counsel their patients (97.4% very confident or confident) and interpret the scientific literature (95.6% very confident or confident) in regards to HT. The more confident a physician was the more likely they were to have formed an opinion about the results of the trials, either positive or negative (P<.01). However, the patterns were the opposite for the combined HT and estrogen only trials; the most confident physicians were the least likely to believe the results of the combined HT trial (52.9% not convinced; P<.001), but the most likely to believe the results of the estrogen only trial (50.3% convinced; P<.001).
About three of four (72.9%) physicians responding to Follow-up #1 reported that they believed their prescribing practices would not change in the future. Almost none of the respondents reported that they would not prescribe HT. Compared with the results from the 2004–2005 study, fewer physicians would only prescribe HT if their patient requests it (11.4% in Follow-up #1 versus 23.9% for the 2004–2005 Study, P<.05).
The respondents reported that a majority of their patients appear to be more apprehensive about HT compared with six months previously and are asking for alternatives to HT (). The physicians reported they are spending more time counseling patients about HT than previously. There were no differences between men and women and no differences across year of residency for these questions about the physicians’ patients.
Follow-up #1 physicians’ opinions regarding patient behavior compared with six months prior to the survey. 95% confidence interval is ± 3.8%. Rows do not add to 100% because some physicians did not answer every question.
Patients are asking about alternatives to HT () and the physicians appear to have a generally positive opinion of alternative therapies; very few consider them harmful and should not be prescribed (0.4%). Almost half of the responding physicians consider alternatives to HT to be either viable treatment options (26.5%) or that they probably do more good than harm (23.2%); 41% consider them at best a placebo. Women were more likely than men to answer that alternative therapies were viable treatment options (37.9% versus 18.9%; P<.001).
The responding physicians reported that HT was a viable treatment for menopausal symptoms (hot flashes 97.4%; vaginal atrophy 92.2%) and osteoporosis (73.6%). Few consider HT a viable treatment for dementia (5.4%) or cardiovascular disease (3.5%). About one of four (26.8%) did consider it a viable treatment for depression; physicians who had completed residency more recently were less likely to respond that HT was a viable treatment for depression.
2004–2005 Study and Follow-Up #1 Analyses
By combining the answers to the survey and the two-question letter in Follow-up #1 there are approximately 800 obstetrician-gynecologists (not every survey responder answered the questions) whose opinions regarding the evidence from the WHI combined HT and estrogen only trials can be directly compared between the 2004–2005 Study and Follow-up #1. Not surprisingly, the general pattern for opinion on both the combined HT and estrogen only trials was for there to be a decrease in the proportion of respondents who were unsure about the evidence. Opinion regarding the estrogen only trial was more variable between the two studies; 71% of responders gave the same answer in each survey regarding the combined HT trial compared to 56.9% who answered the same in both surveys regarding the estrogen only trial. Regarding the combined HT trial, there was a net 10% decease in the number of responders that were unsure whether they found the evidence convincing, a 10% increase in the number who answered yes, and a 2% decrease in the number who said no. The corresponding values for the estrogen only trial were a net 23% decrease in the number of physicians who were unsure about the evidence, a 6% increase in the number of physicians who answered yes, and a 13% increase in the number who answered no.
Follow-up #2 CARN
A total of 286 (150 male and 136 female) CARN members returned the survey for a response rate of 58.8% after the three mailings. There was no difference in the rate in which men (59.5%) and women (58.1%) returned the survey and the response rates for each region varied between 50% in the mid-west to 64.7% in the mid-east. The median age of responders was 47.5 years with men being significantly older than the women (53 years versus 41.5 years, p < .001). This age distribution was comparable to the values from 2004–2005 Study (overall median of 47 years; 52 years for men and 42 years for women). There was no significant difference between respondents and non-respondents by age, year of birth, or geographic region. Answers to the questions did not differ by mailing.
Most CARN obstetrician-gynecologists reported that the training they received during residency concerning hormone therapy was comprehensive or adequate (22.5% and 50.5% respectively). Most respondents reported HT has a positive effect on hot flashes (100%), vaginal dryness (99%), bone fractures (98.6%), sleep disturbance (92%), colon cancer (87%), quality of life (85%), overall wellbeing (78%), and sexual desire (72.3%). About half of respondents reported HT has a neither a positive nor negative effect on mental activity (52%), memory (50%), and depression (49%), and the majority of other respondents thought HT had positive effects on mental activity (33%), memory (33%), and depression (41%).
Virtually all (99%) the physicians were aware of the findings from the Women’s Health Initiative (WHI) concerning the risks and benefits of combined estrogen and progestin therapy. Similarly, nearly all (99%) of ob-gyns were aware that the WHI estrogen and progestin trial was stopped in 2002 due to the preliminary results. The majority of responding physicians (59.9%) did not find the reported research about the combined trials convincing; only 27.7% did find the reported research convincing, 12.1% were not sure and .03% were not aware of the findings. Physicians’ opinions about the results of the estrogen only trial were more split; 45.5% were convinced, 33.7% were not convinced, 17.0% were not sure, and 3.8% were not aware of the finding. In contrast to the results from the previous studies, no age group was any more or less convinced (when running separate analyses with males and females to control for gender). There were no significant gender differences (when controlling for age) in their awareness or opinions about the HT trail results.
Compared to the 2004–2005 Study, fewer CARN physicians responded that they were unsure whether they found the results of either trial convincing. The percentage of CARN physicians that responded that they did not find the results of the combined HT trial convincing was higher than in previous surveys for both men and women (); for the estrogen only trial the percentage that were not convinced was higher for women but lower for men, resulting in no significant difference between men and women ().
Responses to: “Do you find the evidence from the WHI trial convincing?” for 2004–2005 Study, Follow-up #1, and Follow-up #2 CARN.
Almost half of the CARN members (48.8%) did not agree with the decision to stop the combined trial (48.8%) or the estrogen only trial (45.0%). In all age categories a substantial proportion of physicians were critical of the decision to stop either trial; however, younger physicians were more likely to agree with the decision to stop the trials than were older physicians (combined HT, p = .030; estrogen only, P=.046). There was no difference in opinion between men and women.
The surveyed obstetrician-gynecologists were asked to rate the current state of knowledge of both HT and alternatives to HT. Those who reported believing that the current state of knowledge concerning hormone therapy was comprehensive tended to rate the current state of knowledge concerning alternatives to hormone therapy comprehensive as well ( r = .331, p < .001); however, more physicians rate knowledge of HT as either comprehensive (13.3%) or adequate (48.6%) compared to their collective opinion about knowledge about alternatives to HT (0.7% comprehensive and 22.9% adequate). When asked about the viability of alternatives to HT, 39.9% reported that alternatives to HT are viable treatment options, 20.6% reported they probably do more good than harm, 38.5% reported they are at best placebo, and 1% reported they are probably do more harm than good.
Opinions about the alternatives to HT treatments were not associated with whether obstetrician-gynecologists find the results of the combined trial convincing in males or females; however, if the analysis is restricted to only those physicians who had an opinion about the results of the trial (excluding those who answered not sure), physicians who viewed alternatives as viable treatment options were more likely to find the results of the trial convincing, though in men this was only a trend (women p=.019; men p=.068; ).
Physicians who responded that alternative therapies to HT are viable treatment options were more likely to respond that they found the WHI combined HT evidence convincing.
Most physicians reported that their patients were apprehensive about HT (84.7%) and ask about alternatives (86.9%). A majority (63.6%) reported that many of their patients were choosing to stop using HT. Obstetrician-gynecologists in the east were the least likely to have patients request HT (8.9% indicating that few of my patients are requesting HT; ) and the least likely to prescribe HT to over half of their eligible patients (10.9%; ). The percent of respondents that would only prescribe HT upon patient request (23.9%) was similar to the result from the 2004–2005 Study (21.2%). Obstetrician-gynecologists in the mid-west were the least likely to only prescribe HT if it was requested by the patient (10.7% indicating doing so, compared with 21.3% in the south, 22.2% in the mid-east, 30.2% in the west, and 32.3% in the east).
There was consistent geographic variation in the following responses from survey used in Follow-up #2 CARN: “Few of my patients are requesting HT”, and “I prescribe HT to more than half of my eligible patients.”
Most (85.4%) respondents were aware that ACOG produces a Patient Education pamphlet on HT. Of those who were aware, 16.3% indicated it was very useful in their practice, 54.9% indicated somewhat useful, 8.1% indicated not useful and 20.7% indicated that they do not use the pamphlet. Similarly, most respondents (70.7%) were aware of the published report from the ACOG Task Force on Hormone Therapy (ACOG, 2004); of those who were aware, 43.3% found the report very useful, 53.2% found it somewhat useful and 3.4% found it not useful. Awareness of the ACOG Task Force report was not associated with either the respondents’ opinions regarding the evidence from the trials or whether the trials should have been stopped.
Most obstetrician-gynecologists reported they were very confident (64.7%) or confident (32.9%) in counseling their patients about hormone therapy. They were similarly very confident (45.3%) or confident (52.6%) in their ability to understand and interpret the scientific literature concerning hormone therapy. Fewer were very confident (11.1%) or confident (54.7%) in their ability to counsel patients about alternatives to hormone therapy. There was no association between the level of confidence and how convinced they were about the combined or the estrogen only trial results.
Of all the CARN obstetrician-gynecologists, 65.1% fit the conditions for the confident group and 33.6% not confident group. Those who reported being confident or not confident did not significantly differ by gender, birth year, region, reported adequacy of training in residency, family or personal experience with HT, or opinion about the current state of knowledge concerning HT. Those who were aware of ACOG’s patient education pamphlet and supplement published by the ACOG Task Force on Hormone Therapy in October of 2004 were more likely to be confident (p = .013). Those who were more likely to be confident reported that their prescribing patterns were unlikely to change in the near future (p = .008). Those who were confident were more likely to disagree with the decision to stop the combined estrogen and progestin trials (p = .041) and the estrogen only trial (p = .010).