The value of serum iron studies as a test for iron-deficiency anemia in a county hospital

To evaluate the performance of serum iron studies as a diagnostic test for iron-deficiency anemia in a county hospital, the authors identified retrospectively all general medicine patients who had had bone-marrow aspirates for the work-up of non-macrocytic anemias from 1978 through 1983. Re-reading a sample of aspirates from the 254 study patients (42 with iron deficiency) verified the presence of absence of iron. Analysis with logistic regression, likelihood ratios, and receiver operating characteristic curves demonstrated that the total iron-binding capacity (TIBC) performed markedly better as a diagnostic test than did the transferrin saturation test. While no single TIBC level was diagnostic, the TIBC provided a good estimate of the probability of iron-deficiency anemia. Presented at the national meeting of the American Federation for Clinical Research, Washington, D.C., May 4, 1985. Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, N.J.; and by the Health Services Research and Development Program, VA Medical Center, Seattle, and by the National Center for Health Services Research, DHHS, under research grant numbers HS-04080 HS-04996. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation, the VA Medical Center, or the National Center for Health Services Research.     

A survival guide for generalist physicians in academic fellowships

Summary  Generalist physicians pursuing fellowship training should develop an early strategic plan to guide them through their fellowship years. Though each fellow’s plan must be individualized, fellows should get started on independent projects early, decide how much time to allocate to various activities, strike an individualized balance between course work and independent projects, and learn how to choose and maintain relationships with mentors. Early decision making with regard to these aspects of fellowship will allow trainees to maximize their learning, development, and progress toward career goals. Presented in part as a precourse at the National Meeting of the Society of General Internal Medicine, San Francisco, Calif, April 1999. Dr. Whooley is supported by a Research Career Development Award from the Department of Veterans Affairs, Health Services Research and Development Service. Dr. Saha was a fellow in the Robert Wood Johnson Clinical Scholars Program, University of Washington, and Health Services Research and Development, VA Puget Sound Health Care System. Drs. Christakis and Saint were fellows in the Robert Wood Johnson Clinical Scholars Program, University of Washington, Dr. Whooley was a fellow in the Clinical Epidemiology Fellowship, San Francisco VA Medical Center and University of California, San Francisco, Dr. Simon was a fellow in the Harvard General Internal Medicine Fellowship and Faculty Development Program, and the Thomas O. Pyle Fellowship in Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care.     

The association between hypertension treatment,control, and functional status

The authors examined the relationship between hypertension treatment, control, and functional status among 356 “uncomplicated” hypertensive patients receiving care in 16 teaching hospital group ractices. Antihypertensive drug therapy and blood pressure control were determined from a medical record review. Functional status (health perceptions, mental health, role, and physical functioning) was assessed with a questionnaire. After adjustment for potential confounders, hypertensive patients without drug therapy were less likely to have impairment in mental health functioning, compared with patients receiving one or more than one antihypertensive medication (9% versus 25% and 20%, respectively, p<0.05). However, uncontrolled hypertensive patients were more likely to have role limitations than patients controlled only at the end or throughout the record review period (51% versus 39% and 36%, respectively, p<0.05). Patients controlled throughout the review period had the least impairment for each measure of functional status. These preliminary findings suggest that pharmacologic therapy may have a negative influence on the mental health of “uncomplicated” hypertensive patients, but that the dual goals of blood pressure control and positive functional status are not incompatible. Presented in part at the American Federation for Clinical Research Annual Meeting, May 1986. Supported by a grant from the Robert Wood Johnson Foundation. The conclusions are those of the authors and do not necessarily reflect the opinion of the Robert Wood Johnson Foundation or the Rand Corporation. Dr. Siscovick was a Teaching and Research Scholar of the American College of Physicians and an NHLBI Preventive Cardiology Academic Awardee.     

In pursuit of the abnormal serum alkaline phosphatase

The serum alkaline phosphatase (ALP) is often included among the tests used for case-finding among ambulatory patients. To determine the positive predictive value of the ALP, test results for all adults screened by a health maintenance organization between March and December 1969 were obtained by computer. The authors reviewed the charts of all 661 patients with abnormal tests whose primary source of medical care was at this facility. Complete two-year follow-up data were available for 91% of these patients. There were 56 patients (9%) with a diagnosis that could have explained an abnormal ALP. Of those cases in which ALP would have been clinically useful all but one could have been diagnosed by a simple, noninvasive work-up, and in that one case, no management change would have occurred. The authors conclude that in the absence of a small number of specific indications, extensive testing need not be performed to evaluate an isolated abnormal ALP obtained from a screening examination. Received from the Department of Medicine and the School of Public Health, University of California, Los Angeles, Los Angeles, California. Supported in part by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein do not necessarily represent those of the Robert Wood Johnson Foundation.     

The effects of a cost-education program on hospital charges

An educational intervention designed to change physicians’ use of inpatient services was implemented on two general medical services for a year. The intervention consisted of a brief orientation to cost containment issues, a pamphlet that outlined practical cost containment strategies and listed the charges for commonly ordered tests and services, and access to detailed interim patients’ bills generated during the hospitalization. Two concurrent control services received no intervention. Over 1,600 admissions were evaluated. The geometric mean length of stay was 0.61 days shorter on intervention services compared with control (5.15 vs. 5.76 days, p<0.01). The geometric mean hospital charges were $388 less for intervention patients ($3,199 vs. $3,587, p<0.005). Neither patients’ demographic characteristics nor case mix could explain the reductions. The authors conclude that a simple program utilizing information already in existence in most hospitals can result in a significant and meaningful reduction in length of stay and charges. Received from the Department of Internal Medicine, 3116 Taubman Center, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0376. Presented in part at the American Federation for Clinical Research National Meeting, May 1984. Supported in part by a grant from the Robert Wood Johnson Foundation.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP. Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993. Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.     

A consumer/medical educator conference

The authors discuss the development and proceedings of a highly structured conference at which 17 representatives from diverse non-medical groups and 14 medical educators from one medical school identified objectives needing greater emphasis in the medical curriculum. The conference emulated industry’s use of consumer advisory panels. Using the nominal group technique, a group process used in business, the non-medical group developed independently a priority list of areas in which physicians might be better educated to serve society. The medical educators then joined the non-medical group to discuss and clarify the concerns given highest priority. The authors describe subsequent initiatives by the medical school to address aspects of the general concerns raised by the non-medical group. The conference represents an approach to seeking input from non-traditional sources in the development of the medical curriculum. Received from the University of Pennsylvania Robert Wood Johnson Clinical Scholars Program, the Philadelphia VA Medical Center, and the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.     

Professional satisfaction experienced when caring for substance-abusing patients

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients’ family history. Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions. This work was presented in part at the annual meeting of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, Tucson, Ariz, December 4, 1998, the annual meeting of the Society of General Internal Medicine, San Francisco, Calif, April 29, 1999, and at the annual meeting of the Association of Medical Education and Research on Substance Abuse, Alexandria, Va, November 5, 1999. Deceased. Dr. Saitz received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar (Grant No. 031489) for this work. He and Dr. Samet were also supported in this work by the Center for Substance Abuse Prevention (Faculty Development Grant T26-SP08355). Drs. Samet, Saitz, and Sullivan, and Mr. Winter and Ms. Lloyd-travaglini receive support from the National Institute on Alcohol Abuse and Alcoholism (R01-AA10870). Dr. Friedmann was supported by a Mentored Clinical Scientist Career Development Award (K08-DA 00320).     

Timing of referral of terminally Ill patients to an outpatient hospice

Objective: Since inordinately long or short lengths of stay at hospice can create problems for patients, providers, and payers, the author sought to identify predictors of timing of patient referral. Methods: A retrospective cohort of 405 hospice outpatients was analyzed with Cox regression to evaluate the effect on length of stay of patient age, gender, race, diagnosis, activity level, mental status, dyspnea, insurance, income, religion, and home support, and of referring physician specialty. Results: Median survival time at the hospice was 29 days; 15% of the patients died within seven days and 12% lived longer than 180 days. A one-unit increment in a six-unit activity-level scale was associated with a 19% reduction in the rate of death. Compared with reference groups, oriented patients and depressed patients had 57% and 35% lower death rates; patients with prostate cancer and cardiovascular disease had 50% and 58% lower death rates. There was no significant gender, race, religion, insurance, or income difference among the patient groups. Conclusions: Inappropriately early or late referral occurs in a substantial minority of patients referred to the hospice under study. Closer attention to accurate prognostication in different types of terminally ill patients and more timely referral to hospice might help to optimize the use of this health care resource from both patient and societal perspectives. Received from the Division of General Internal Medicine, Leonard Davis Institute of Health Economics, Department of Sociology, University of Pennsylvania, Philadelphia, Pennsylvania. Supported by the Robert Wood Johnson Foundation Clinical Scholars Program and by the Warren-Whitman-Richardson Fellowship from Harvard Medical School. Dr. Christakis is the recipient of a NRSA Fellowship from the Agency for Health Care Policy and Research. Computer facilities were provided by the Department of Sociology, University of Pennsylvania. The opinions and conclusions herein are the author’s and do not necessarily represent the views of the Robert Wood Johnson Foundation.     

Work satisfaction and career aspirations of internists working in teaching hospital group practices

This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training. assisted in preparing this report. Received from the Department of Medicine and the School of Public Health, UCLA Center for the Health Sciences. Los Angeles. California. Supported by Grant #59082 from the Robert Wood Johnson Foundation. The views expressed herein do not necessarily represent those of the Robert Wood Johnson Foundation.     

Visual impairment and cognitive dysfunction in Alzheimer’s disease

Objective:To determine whether impaired visual acuity is associated with dementia and cognitive dysfunction in older adults. Design:Paired case-control comparisons of the relative frequencies of visual impairment in demented cases and nondemented controls. Cohort analyses of correlation between visual acuity and cognitive functioning in demented cases. Setting:Internal medicine clinics at two academically affiliated medical centers. Participants:Eighty-seven consecutively selected patients ≥65 years of age with mild-to-moderate, clinically diagnosed Alzheimer’s disease (cases) and 87 nondemented controls matched to the cases by age, sex, and education. Measurements and main results:The prevalence of visual impairment was higher in cases than in controls [unadjusted odds ratio for near-vision impairment =2.7 (95% CI=1.4, 5.2); unadjusted odds ratio for far-vision impairment =2.1 (95% CI=1.02, 4.3); odds ratios adjusted for family history of dementia, depression, number of medications, and hearing loss were 2.5 (95% CI=1.1, 10.5) for near-vision impairment and 1.9 (95% CI=0.8, 4.6) for far-vision impairment]. When further stratified by quartiles of visual acuity, no statistically significant “dose-response” relationship between vision impairment and dementia risk was observed. Among cases, the degree of visual impairment was significantly correlated with the severity of cognitive dysfunction for both near and far vision (adjusted ps<0.001). Conclusions:Visual impairment is associated with both an increased risk and an increased clinical severity of Alzheimer’s disease, but the increased risk may not be consistent with a progressive dose-response relationship. Further studies are needed to determine whether visual impairment unmasks and exacerbates the symptoms of dementia or is a marker of disease severity. Supported by the Robert Wood Johnson Foundation Research and Development Program to Improve Patient Functional Status, the University of Washington Alzheimer’s Disease Research Center (National Institutes of Health grant No. AG 05136) and Alzheimer’s Disease Patient Registry (National Institutes of Health grant No. AG 06781), and National Institute on Aging Academic Award No. K08 AG00265 (Dr. Uhlmann). The views expressed here are not necessarily those of the Robert Wood Johnson Foundation.     

Clinical predictors of treatment reduction in hypertensive patients

Objective:To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction. Design:Observational study with 11-month follow-up. Setting:Outpatient hypertension clinic at the Seattle Veterans Administration Hospital. Patients:59 males (51% of those eligible) with diastolic BP<95 mm Hg for ≥6 months; 57 patients (97%) completed the study. Intervention:Gradual reduction of medications unless diastolic BP rose above 95 mm Hg. Measurements and main results:Intensity of treatment with BP medications was assessed using a scale of their comparative “vigors.” 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2±12.3 mm Hg (mean±SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7±1.7 vs. 1.3±0.5 “vigor units,” p=0.0001), and they had been enrolled in the clinic longer (5.5±3.0 vs. 3.1±2.3 years, p=0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age≤65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more “vigor units” had the highest specificity (79%) and likelihood ratio (3.3). Conclusions:Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 1988, and the annual meeting of the Robert Wood Johnson Clinical Scholars Program, Miami, Florida, October 1988. This study was conducted while Dr. Steiner was a Robert Wood Johnson Clinical Scholar at the University of Washington. Support was provided by the Northwest Health Services Research and Development Program of the Veterans Administration. The opinions, conclusions, and proposals in this paper are those of the authors, and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Veterans Administration.     

Long-term care preferences of hospitalized persons with AIDS

Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3) the impact of these views on the resulting discharge dispositions. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care providers. Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care. Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers. Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1; 95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy emerged as important factors to persons with AIDS considering long-term care. Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability, preference, and appropriateness for long-term care. Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood Johnson Clinical Scholars Program during this project. The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Journal reading habits of internists

We assessed the reading habits of internists with and without epidemiological training because such information may help guide medical journals as they make changes in how articles are edited and formatted. In a 1998 national self-administered mailed survey of 143 internists with fellowship training in epidemiology and study design and a random sample of 121 internists from the American Medical Association physician master file, we asked about the number of hours spent reading medical journals per week and the percentage of articles for which only the abstract is read. Respondents also were asked which of nine medical journals they subscribe to and read regularly. Of the 399 eligible participants, 264 returned surveys (response rate 66%). Respondents reported spending 4.4 hours per week reading medical journal articles and reported reading only the abstract for 63% of the articles; these findings were similar for internists with and without epidemiology training. Respondents admitted to a reliance on journal editors to provide rigorous and useful information, given the limited time available for critical reading. We conclude that internists, regardless of training in epidemiology, rely heavily on abstracts and prescreening of articles by editors. This study was supported by the University of Washington Robert Wood Johnson Clinical Scholars Program and the Department of Veterans Affairs. Drs. Christakis and Elmore are supported by Robert Wood Johnson Generalist Faculty Awards. Drs. Saint, Christakis, and Saha were Robert Wood Johnson Clinical Scholars at the time this work was conducted.     

Determinants of resource utilization for patients admitted for evaluation of acute chest pain

Objective:To identify determinants of resource utilization among patients with suspected acute myocardial infarction. Design:Prospective cohort study, with prospective collection of detailed clinical data and retrospective collection of nonclinical data and resource utilization data. Setting:Urban, tertiary-care, teaching hospital. Patient population:992 consecutive patients over the age of 30 years, admitted from the emergency department for evaluation of acute chest pain unexplained by obvious trauma or chest roentgenographic abnormality, were eligible for the study. After excluding patients who had left against medical advice, who had been transferred to another bospital, or who had incomplete utilization data, 903 patients were included in the analyses. Measurements and outcomes:The authors evaluated the effects of 22 clinical and nonclinical factors on resource use. Resource use was primarily evaluated by length of stay; charges were evaluated in secondary analyses. Results:In the entire study population, increased length of stay was associated with a diagnosis of acute myocardial infarction or angina, severity of complications, use of invasive and noninvasive testing, and initial triage to the coronary care unit. In the 424 (47%) patients who had had completely uncomplicated courses after admission, high coefficients of variability were found for length of stay (0.88) and for total charges (0.78). In these uncomplicated patients, increased length of stay was associated with the use of noninvasive cardiac testing (66% longer for patients undergoing echocardiography or radionuclide ventriculography, and 46% longer for patients undergoing exercise tests or ambulatory arrhythmia monitoring), initial triage to the coronary care unit (23% longer), admission at the end of the week (21% longer), and insurance coverage other than Blue Cross/Blue Shield or a commercial carrier (21% for self-pay, 25% for Medicaid, and 48% for Medicare). Conclusions:These findings indicate that after adjustment for important clinical factors, nonclinical factors had a significant impact on length of stay among a large group of uncomplicated patients. Interventions aimed at reducing logistic difficulties in the performance of noninvasive testing and decreasing the number of low-risk patients who are triaged to coronary care unit beds may decrease resource utilization. Received from the Divisions of Clinical Epidemiology and General Medicine and the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School; and the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. Presented in part at the annual meeting of the American Federation for Clinical Research, April 28 – May 2, 1989, Washington, DC. Supported in part by grants from the National Center for Health Services Research (HS 05927), the Robert Wood Johnson Foundation, Princeton, NJ (678105), the John A. Hartford Foundation, New York, NY (83102-2H), and the Agency for Health Care Policy and Research (1-PO1-HS06431-02 and HS 06452-02). Dr. Lee is the recipient of an Established Investigator Award (900119) from the American Heart Association. Dr. Udvarhelyi is the recipient of a Medical Foundation Fellowship award.     

Lumbar spine films in primary care

Low back pain (LBP) often prompts radiography, although the diagnostic yield of lumbar spine films is low, and many radiographic abnormalities are unrelated to symptoms. Criteria have been proposed for selective x-ray use, but their value and safety are uncertain. To evaluate these criteria, the authors prospectively studied 621 walk-in patients with LBP. The yield of explanatory x-ray findings was over three times greater among patients with indications for radiography than among those without. Furthermore, an indication for x-rays existed for all patients found to have a malignancy, and for 13 of 14 patients with an identified fracture. Actual physician ordering, however, did not correspond well with the recommended indications. Application of selective criteria appears safe and may improve the yield of useful findings. It may not, however, reduce x-ray utilization from current levels without further refinement in the criteria. Received from the Division of General Internal Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Presented in part at the 48th Annual Scientific Meeting of the American Rheumatism Association, Minneapolis, June 8, 1984. Published in abstract form in Arthritis and Rheumatism 1984;27(No. 4. Supplement): p. S39. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation.     

Measuring the Quality of Colorectal Cancer Screening: The Importance of Follow-Up

Purpose As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration. Methods We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test. Results A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9–0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89–0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test. Conclusions The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process. Supported by the Robert Wood Johnson Foundation Clinical Scholars Program (Etzioni), Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), and National Cancer Institute Colorectal Cancer (CRC) Quality Enhancement Research Initiative (QUERI) Service Directed Research (Project # CRS 02-163). The views expressed in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Long-term care needs of hospitalized persons with AIDS

Objective:As the treatment for HIV infection has improved, AIDS has become a chronic disease, and the demand for long-term care has increased. The authors studied a cohort of hospitalized persons with AIDS to determine the proportion and characteristics of AIDS patients who could appropriately be cared for in long-term care facilities with skilled nursing. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care physicians, nurses, and social workers. Measurements and main results:Appropriateness for long-term care was determined by the patients’ physicians, nurses, and social workers. Persons with AIDS who were appropriate for long-term care constituted 32% of the cohort (38 of 120), accounting for 35% of hospital days (11 of these 38 were discharged to long-term care facilities). Four admission characteristics were independently related to appropriateness: impaired activities of daily living, diagnosis of central nervous system illness or poor cognition, living alone, and weight loss. A discriminant function correctly classified over 80% of patients for appropriateness and was developed into a predictive index for planning patient care (sensitivity =0.74, specificity =0.85). Conclusions:The authors conclude that one-third of hospitalized persons with AIDS may be appropriate for care in long-term care settings, accounting for one-third of the days AIDS patients currently spend in hospitals. These patients can be identified early in hospital stays using a simple predictive index at the bedside. Presented at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 28, 1989. Supported by the Northwest Health Services Research and Development Field Program (Seattle Veterans Affairs Medical Center) and the Seattle King County Department of Public Health, AIDS Prevention Project. The views stated herein are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Physicians’ reasons for failing to comply with computerized preventive care guidelines

The objective of this study was to assess reasons for physicians’ noncompliance with computer-generated preventive care reminders. In an academic general internal medicine practice, a survey of physicians’ reasons for noncompliance found that 55% of reminders were not complied with. Reasons included “not applicable” in 22.6% (test done elsewhere, patient too ill, no uterus), “next visit” in 22.5% (physician too busy, patient too ill), and “patient refuses” in 9.9% (test not necessary or too costly, patient too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for prevention and patient education may augment preventive care. Received from the Department of Medicine, Wishard Memorial Hospital, and the Indiana University School of Medicine, the Regenstrief Institute for Health Care, and the Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, Indianapolis, Ind. Supported in part by grants HS07632, HS07763, and HS07719 from the Agency for Health Care Policy and Research (AHCPR). Dr. Litzelman was supported in part by a Robert Wood Johnson Generalist Physician Faculty Scholar Award (022318). The opinions expressed herein are solely those of the authors and do not necessarily represent the authors’ institutions, AHCPR, or the Robert Wood Johnson Foundation.     

Differences in end-of-life decision making among black and white ambulatory cancer patients

OBJECTIVE: African-American (black) and white individuals have been shown to differ in their desire for life-sustaining treatments and their use of living wills for end-of-life care, but the reasons for these differences are unclear. This study-was designed to test the hypothesis that these ethnic differences exist because black patients trust the health care system less, fear inadequate medical treatment more, and feel less confident that living wills can give them more control over their terminal care. DESIGN: Cross-sectional, in-person survey conducted from November 1993 to June 1994. SETTING: Two medical oncology clinics with 40% to 50% black patient representation. PARTICIPANTS: Ambulatory cancer patients, 92 black and 114 white, who were awaiting their physician visits and agreed to participate (76% of those eligible). Patients were excluded if they were under age 40 or if they had nonmelanoma skin cancer only. MEASUREMENTS AND MAIN RESULTS: Black ambulatory cancer patients wanted more life-sustaining treatments (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.4–5.3), and were less likely to want to complete a living will at some time in the future (OR 0.36; 95% CI 0.17–0.75) than were white patients after controlling for socioeconomic variables. However, these differences were not related to lack of trust or fear of inadequate medical treatment in this study population. Both groups of patients trusted the health care system and felt that physicians treated patients equally well. Neither group feared inadequate or excessive medical care, and the majority of both groups agreed that living wills would help them keep control over their terminal care. CONCLUSIONS: Black and white cancer patients make different end-of-life choices, even after adjusting for likely explanatory variables. The other factors that influence decision making remain unclear and need to be further explored if physicians are to understand and help their patients make choices for end-of-life care. Abstract presented at the Robert Wood Johnson Clinical Scholars Program National Meeting, November 1994. Funded by Robert Wood Johnson Clinical Scholars Program while Dr. McKinley was a Clinical Scholar (July 1992–June 1994).