Physician Factors Affecting Cardiac Rehabilitation Referral and Patient Enrollment: A Systematic Review

Physicians play an important role in CR referral and enrollment. Despite established benefits and recommendations, cardiac rehabilitation (CR) enrollment rates are pervasively low. The reasons cardiac patients are missing from CR programs are multifactorial and include provider factors. A number of studies have now investigated physician factors associated with referral to CR programs and patient enrollment. The objective of this study was to qualitatively and systematically review this literature. A literature search of MEDLINE, PsycINFO, CINAHL, Embase, and EBM was conducted for published articles from database inception to October 2011. Overall, 17 articles were included following a process of independent review of each article by 2 authors. Seven (41.2%) were graded as good quality according to Downs and Black criteria. There were no randomized controlled trials. Results showed that medical specialty (ie, cardiac specialists more likely to refer; n = 8 studies) and other physician‐reported reasons (eg, physician report of their reasons for CR referral and physician sex) were related to referral. Physician factors related to patient enrollment in CR were physician endorsement, medical specialty, being referred, and physician attitudes toward CR. Physician factors are consistently related to CR referral and enrollment. The role of physician endorsements in promoting patient enrollment should be optimized and exploited.     

Physician management preferences for cardiac patients: factors affecting referral to cardiac rehabilitation

BACKGROUND: Cardiac rehabilitation (CR) is an evidence-based intervention that has been shown to reduce both morbidity and mortality. However, CR is widely underused due to multiple factors, including physician referral practices. OBJECTIVES: To describe physicians' preferences in managing cardiac patients and the barriers they face in referring patients to CR. METHODS: A cross-sectional survey of a stratified random sample of 510 primary care physicians, cardiologists and cardiovascular surgeons in Ontario was conducted. One hundred seventy-nine physicians responded (40% response rate through repeat mailings) to the survey that investigated medical, demographic and attitudinal factors affecting referral. A hypothetical case scenario that elicited open-ended factors affecting physician management preferences was incorporated. RESULTS: Physicians identified geographic access, uncertainty regarding which provider was responsible for referral and perceptions of patient motivation as important factors affecting referral to CR. Through principal components analysis, several attitudes affecting referral emerged, including beliefs about the efficacy of CR, referral norms, ease of the referral process and desire to manage the patient independently. A hierarchical logistic regression analysis showed that 75% of the variance in referral was attributable to medical specialty, availability of CR and practice norms. CONCLUSIONS: Increased communication among health care providers is needed to ensure CR referral. Due to geographic dispersion, alternatives to site-based CR are necessary to meet the needs of cardiac patients.     

The effect of discussions about advance directives on patients’ satisfaction with primary care

BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians' anxiety that patients might react negatively to such discussions. OBJECTIVE: To assess the impact of discussions of advance directives on patients' satisfaction with their primary care physicians and outpatient visits. DESIGN: Prospective cohort study of patients enrolled in a randomized, controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly, chronically ill patients. SETTING: Academic primary care general internal medicine practice affiliated with an urban teaching hospital. PARTICIPANTS: Six hundred eighty-six patients who were at least 75 years old, or at least 50 years old with serious underlying disease, and their 87 primary care physicians (57 residents, 30 faculty general internists) participated in the study. MEASUREMENTS AND MAIN RESULTS: We assessed patients' satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and physician, patient, and visit factors, discussing advance directives was associated with greater satisfaction with the physician (P =.052). At follow-up, the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician (P =.004), with a trend towards greater visit satisfaction when discussions were held during that visit (P =.069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits without prior advance directive discussions to 51% for visits with such discussions (P =.003). CONCLUSIONS: Elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussions to overcome communication barriers might result in reduced patient satisfaction levels.     

A controlled trial of including symptom data in computer-based care suggestions for managing patients with chronic heart failure

BACKGROUND: Heart failure is common and associated with considerable morbidity and cost, yet physician adherence to treatment guidelines is suboptimal. We conducted a randomized controlled study to determine if adding symptom information to evidence-based, computer-generated care suggestions would affect treatment decisions among primary care physicians caring for outpatients with heart failure at two Veterans Affairs medical centers. METHODS: Physicians were randomly assigned to receive either care suggestions generated with electronic medical record data and symptom data obtained from questionnaires mailed to patients within 2 weeks of scheduled outpatient visits (intervention group) or suggestions generated with electronic medical record data alone (control group). Patients had to have a diagnosis of heart failure and objective evidence of left ventricular systolic dysfunction. We assessed physician adherence to heart failure guidelines, as well as patients' New York Heart Association (NYHA) class, quality of life, satisfaction with care, hospitalizations, and outpatient visits, at 6 and 12 months after enrollment. RESULTS: Patients in the intervention (n = 355) and control (n = 365) groups were similar at baseline. At 12 months, there were no significant differences in adherence to care suggestions between physicians in the intervention and control groups (33% vs. 30%, P = 0.4). There were also no significant changes in NYHA class (P = 0.1) and quality-of-life measures (P >0.1), as well as no differences in the number of outpatient visits between intervention and control patients (6.7 vs. 7.1 visits, P = 0.48). Intervention patients were more satisfied with their physicians (P = 0.02) and primary care visit (P = 0.02), but had more all-cause hospitalizations at 6 months (1.5 vs. 0.7 hospitalizations, P = 0.0002) and 12 months (2.3 vs. 1.7 hospitalizations, P = 0.05). CONCLUSION: Adding symptom information to computer-generated care suggestions for patients with heart failure did not affect physician treatment decisions or improve patient outcomes.     

Obstructive Sleep Apnea and Acute Coronary Syndromes: Etiology,Risk, and Management

Growing evidence highlights the important role of post-hospitalization care (i.e., secondary prevention) for patients with an acute coronary syndrome (ACS). While secondary prevention therapies are available that improve patient outcomes, receipt of those treatments by patients is suboptimal. Cardiac rehabilitation/secondary prevention (CR/SP) services are systematic, effective models of care that improve delivery of preventive therapies and patient outcomes after ACS, but unfortunately, patient participation in CR/SP has been suboptimal, due to patient-, provider-, and system-based barriers. Systematic processes, including automatic referral processes, help reduce these barriers and improve CR/SP participation, along with the associated health benefits. Strength of physician endorsement of CR/SP participation is another key step in improving CR/SP participation and patient outcomes following ACS. Accountability measures for CR/SP referral and enrollment, including performance measures and other quality of care methods, may help improve CR/SP delivery. Early evidence suggests that these measures have helped improve referral of eligible patients to CR/SP programs.     

What are the barriers to warfarin use in atrial fibrillation?: Development of a questionnaire

Background: Despite evidence of their benefit and efforts to increase usage, anticoagulation for stroke prophylaxis in atrial fibrillation (AF) patients remains underutilized. Previous surveys have assessed reasons for underuse of anticoagulation but have limitations including non-structured approach for eliciting barriers and use of clinical vignettes and not patient-level data. The objectives of this study were to develop a questionnaire to assess barriers to anticoagulation use for stroke prophylaxis in AF patients at a patient- and physician-level and to conduct a preliminary field-test of the instrument. Methods: Barriers to warfarin use were identified from a literature review, input from clinical experts, and a physician focus group. A sample of US physicians who treat AF patients completed the questionnaire. Physicians ranked their reluctance on a 1–10 scale (10 = very reluctant) in general to prescribe warfarin if a specific barrier was present in a patient and then indicated critical barriers to prescribing warfarin in a sample of their own AF patients not receiving warfarin. Results: Forty-one barriers to warfarin use were identified and classified into 4 groups: patient medical characteristics (n = 17), health care system factors (n = 7), patient capability (n = 12), and patient preferenc (n = 5). Several new items were developed (e.g., difficulty in obtaining venous access), existing items were revised (e.g., timeframe for bleeding episodes subdivided into > or ≤ 3 months), and multi-factorial barriers (e.g., dementia, epilepsy) were explored. The factor that most strongly influenced physicians' (n = 30) decisions not to prescribe warfarin was severe bleeding < 3 months ago (mean ± SD: 9.2 ± 1.3) while the most prevalent critical barriers to prescribing warfarin in specific AF patients (n = 24) was patient unwilling to undergo repeat testing (29%). Conclusion: This questionnaire has the potential to assist in better understanding barriers to warfarin use with a view to addressing and then overcoming warfarin underutilization. Preliminary data suggest patient preference and capabilities are at least as important as medical characteristics as barriers to prescribing warfarin in AF patients.     

Concordance of self- and program-reported rates of cardiac rehabilitation referral, enrollment and participation

BACKGROUND:

Despite potential bias, researchers often rely on patient self-reported data of health care use. However, the validity and accuracy of self-reported data on cardiac rehabilitation (CR) use are unknown.

OBJECTIVE:

To assess the concordance between patient self-report and site-verified CR referral, enrollment and participation.

METHODS:

A consecutive sample of 661 coronary artery disease inpatients (mean [± SD] age 61.27±1.31 years; 157 women [23.8%]) treated at three acute care sites was recruited (75% response rate) as part of a larger study comparing automatic with usual referral methods. CR referral, enrollment (attendance at intake assessment) and participation (percentage of program attended) were discerned in a mailed survey nine months following discharge (n=506; 84.3% retention). A total of 24 CR sites were contacted for verification.

RESULTS:

A total of 276 participants (54.5%) self-reported CR referral, and CR sites verified receipt of 262 referrals (51.8%) (Cohen’s kappa 0.899). A total of 232 participants (45.8%) self-reported CR enrollment, with site-verification for 208 participants (41.1%) (Cohen’s kappa 0.846). Self-reported data indicated that participants attended a mean of 81.78±25.84% of prescribed CR sessions, with CR sites reporting that participants completed 80.75±31.27% of the program (r=0.662; P<0.001). Equivalency testing revealed that the self-reported and site-verified rates of program participation were equivalent (z<1.96).

CONCLUSIONS:

The almost perfect agreement between the self-reported and site-verified use of CR services suggests that self-administered items are highly valid in this population.     

Pre-coronary artery bypass graft measures and enrollment in cardiac rehabilitation

PURPOSE: The aim of this study was to examine the relationship between exercise tolerance, functional status, exercise behavior, and enrollment in cardiac rehabilitation (CR), preoperatively in individuals undergoing coronary artery bypass graft (CABG) surgery. METHODS: Seventy-eight individuals undergoing CABG were evaluated 1 to 7 days preoperatively using the following measures: 2-minute walk test (2MWT), Duke Activity Status Index (DASI), Cardiac Exercise Self-Efficacy Instrument (CESEI), Stages of Change Questionnaire (SCQ), Short-Form 12 (SF-12), Hospital Anxiety Depression scale, location of residence, and education level. Participants were contacted via telephone 10 to 12 weeks postoperatively to determine if they were referred and enrolled in CR. Participants completed mailed questionnaires for follow-up. In subsequent telephone interviews, individuals who were not enrolled in CR were asked to provide reasons for nonenrollment. RESULTS: Overall enrollment in CR was 46%. No significant differences were found in 2MWT, CESEI, and DASI scores between enrolled and nonenrolled participants. Fifty-seven percent of urban-dwelling participants enrolled in CR compared to 29% of rural-dwelling participants (P < .01). Similarly, 65% of individuals with post-secondary education enrolled in CR compared to 38% of individuals without a post-secondary education (P = .05). The primary reasons for nonenrollment were behavioral intentions toward exercise and CR, accessibility, and healthcare team recommendation. Individuals who enrolled in CR demonstrated a larger postoperative improvement in CESEI score. CONCLUSIONS: Location of residence and education level predicted CR enrollment, whereas preoperative exercise tolerance, functional status, and exercise attitudes did not predict enrollment.     

Six-minute walk performance and quality of life comparisons in North Carolina cardiac rehabilitation programs

OBJECTIVE: The purposes of this study were (1). to determine if six-minute walk (6MW) performance improved after short-term cardiac rehabilitation (CR) across multiple outpatient programs; (2). to examine differences in 6MW performance by patient age, sex, and race; and (3). to determine what relationships existed, if any, between 6MW performance and subscales of the Ferrans and Powers' Quality of Life Index-Cardiac Version III (QOLI). DESIGN: Study design was nonexperimental, prospective, and comparative. SETTING: Study setting included 14 outpatient CR programs from urban and rural settings across North Carolina. PATIENTS: Adults aged 40 to 89 years (N = 630; men = 424 [67%], women = 206 [33%]; mean age, 61 +/- 10.32 years) with medically or surgically treated coronary heart disease enrolled in outpatient CR. Outcome Measures: Study measures included scores on the QOLI and distance walked (feet) on the 6MW test. RESULTS: Six-minute walk tests and QOLI surveys were administered before and immediately after short-term CR participation. Six-minute walk distance increased for all patients in all age categories across programs after CR (P <.0001). As a group, women improved 6MW distance by 15% (1243.9 +/- 301.2 to 1435.3 +/- 298.1; P <.001). Men also improved 6MW distance by 15% (1463.3 +/- 339.5 to 1683.7 +/- 346.9; P <.001) and walked farther than women on both the initial and follow-up 6MW tests (P <.0001). By age, there were no differences in 6MW scores between men and women aged 40 to 49 years (n = 58) and 50 to 59 years (n = 140; P = 0.54). Both of these age groups had greater initial and discharge 6MW scores than those aged 70 to 79 years (n = 183) and 80 to 89 years (n = 22; P <.001). Those aged 60 to 69 years (n = 227) had lower 6MW scores than those aged 40 to 49 years (P = 0.001) and 50 to 59 years (P <.05), and greater scores than those aged 70 to 79 years (P <.05) and 80 to 89 years (P <.05). Those aged 70 to 79 years had greater initial and follow-up 6MW scores than those aged 80 to 89 years(P <.001). Overall improvements in 6MW performance were found in both white subjects (n = 575; P <.001) and African-Americans (n = 54; P <.001). There were no apparent relationships between 6MW performance and overall or Health and Function QOLI scores (r <.21). CONCLUSIONS: Participation in short-term outpatient CR improved 6MW performance in patients aged 40 to 89 years across 14 programs in North Carolina. No relationships were found between 6MW performance and any domain of the QOLI, including the Health and Function domain.     

Factors influencing patient satisfaction with GI endoscopy

BACKGROUND: A modified Group Health Association of America-9 survey (mGHAA-9) was recently proposed for measurement of patient satisfaction with endoscopy. It is unknown whether the mGHAA-9 addresses the issues most important to this outcome. METHODS: A 15-item survey of factors potentially important to patient satisfaction with endoscopy was developed, including the 6 core mGHAA-9 items. Respondents were asked to rank the factors from 1 to 15 (1 = most important to l5 = least important to satisfaction). Two groups were surveyed: (1) patients with prior endoscopy experience and (2) physician endoscopists. Item rank distributions overall and by patient age, gender, and procedure experience were examined. RESULTS: Of 559 outpatients surveyed, 437 (78%) provided complete responses. The mean patient age was 59 years (48.7% female, 45.3% male, 6% not stated). The number 1 ranked factor was the endoscopist's technical skills (median ranking (mr) = 1), an item included in the mGHAA-9. Pain control, a factor not assessed by the mGHAA-9, was second (mr = 4), and ranked number 1 by 16% of patients. Item rankings were consistent across patient subgroups. Relative to patients, endoscopists underprioritized preprocedure and postprocedure communication. CONCLUSIONS: The mGHAA-9 has inadequate content validity for measurement of patient satisfaction with endoscopy because it does not assess pain control. However, endoscopy satisfaction measurement with a single, universally applied instrument appears feasible.     

Referral sources to a weight management program: relation to outcome

OBJECTIVE: To examine the characteristics and outcomes of physician-referred weight management patients relative to self-referred patients. DESIGN: Review of clinic records of all individuals contacting a weight control program during a 2-year period with follow-up throughout consecutive levels of treatment (i.e., enrollment, completion, and outcome). SETTING: Medical school weight management center. PARTICIPANTS: A consecutive sample (N = 1,392) of overweight and obese callers was categorized as physician-initiated (n = 345), media (n = 653), or personal (n = 394) referrals. Attendees at initial consultation (n = 571) were age 41.7 +/- 12.8 years, weight 113.9 +/- 36.1 kilograms, and body mass index (BMI) 40.3 +/- 11.3 kg/m(2) (data expressed as mean +/- standard deviation). INTERVENTIONS: Low-calorie-diet and very-low-calorie-diet programs. MAIN OUTCOME MEASURES: Gender comparisons, attendance at initial consultation, body mass index, motivation, comorbidities, enrollment and completion rates, and weight loss. RESULTS: Compared to callers from other referral sources, physician referrals included a larger minority of males (25.2%) and were more likely to attend an initial consultation (63.5%; P < .001). Among consultation attendees, physician referrals were heavier (mean BMI = 44.8), reported more comorbidities, were less likely to join programs (16.9%), and scored as less motivated than other referrals (P < .007). Completion rates for physician referrals were higher than for self-referrals in the very-low-calorie-diet program (85.7%; P < .04) but not in the low-calorie-diet program (P > .05). Among completers, physician referrals did not differ on weight loss in either program (P > .05). CONCLUSIONS: Compared to self-referrals, physician-referred individuals are in greater need of weight loss, less motivated, less likely to enter treatment, but equally likely to profit from it. Therefore, physician referral for weight loss is beneficial for at least some patients and should be encouraged.     

Barriers to the treatment of hepatitis C

BACKGROUND: Hepatitis C virus (HCV) infection is both prevalent and undertreated. OBJECTIVE: To identify barriers to HCV treatment in primary care practice. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A cohort of 208 HCV-infected patients under the care of a primary care physician (PCP) between December 2001 and April 2004 at a single academically affiliated community health center. MEASUREMENTS: Data were collected from the electronic medical record (EMR), the hospital clinical data repository, and interviews with PCPs. MAIN RESULTS: Our cohort consisted of 208 viremic patients with HCV infection. The mean age was 47.6 (+/-9.7) years, 56% were male, and 79% were white. Fifty-seven patients (27.4% of the cohort) had undergone HCV treatment. Independent predictors of not being treated included: unmarried status (adjusted odds ratio [aOR] for treatment 0.36, P=.02), female gender (aOR 0.31, P=.01), current alcohol abuse (aOR 0.08, P=.0008), and a higher ratio of no-shows to total visits (aOR 0.005 per change of 1.0 in the ratio of no-shows to total visits, P=.002). The major PCP-identified reasons not to treat included: substance abuse (22.5%), patient preference (16%), psychiatric comorbidity (15%), and a delay in specialist input (12%). For 13% of the untreated patients, no reason was identified. CONCLUSIONS: HCV treatment was infrequent in our cohort of outpatients. Barriers to treatment included patient factors (patient preference, alcohol use, missed appointments), provider factors (reluctance to treat past substance abusers), and system factors (referral-associated delays). Multimodal interventions may be required to increase HCV treatment rates.     

Prognostic factors in a multicenter study for treatment of acute lymphoblastic leukemia in adults

In a prospective multicenter study, 368 acute lymphoblastic leukemia (ALL) patients aged 15 to 65 years were treated with an intensified induction and reinduction regimen; 272 (73.9%) achieved complete remission (CR). The median remission duration (MRD) is 24.3 months, and the probability of being in continuous CR (CCR) at greater than 5 years is .37. The median survival for all 368 patients is 27.5 months, and the probability of being alive at 5 years is .39. For the 272 patients in remission the median survival is 58.4 months, and the probability of being alive at 5 years is .49. A lower CR rate was seen for patients with bleeding at diagnosis or with splenomegaly/hepatosplenomegaly. The prognostic factors unfavorable for remission duration were time to CR greater than 4 weeks v less than 4 weeks (P = .0002), age greater than 35 years v less than 35 years (P = .0008), leukocyte count greater than 30,000/microL v less than 30,000/microL (P = .0112), and null ALL v common ALL (c-ALL)/T cell ALL (T-ALL) (P = .05). The remission duration correlated strongly (P = .0001) with the number of these independent prognostic factors. In patients with none of these adverse factors the MRD has not yet been reached, with one adverse factor the MRD is 21.9 months, and with two or three adverse factors the MRD is only 9.6 months. For the immunologic subtype T-ALL, the probability of being in CCR at greater than 5 years is .55; for c-ALL, .34; and for null ALL, .24. According to these results, patients were stratified into a low- risk group with a CCR rate of .62 and a high-risk group with a CCR rate of .28, with the latter now allocated to either further chemotherapy or bone marrow transplantation in first remission.     

Brief report: Training internists in shared decision making about chronic opioid

BACKGROUND: The use of chronic opioids for noncancer pain is an increasingly common and difficult problem in primary care. OBJECTIVE: To test the effects on physicians' self-reported attitudes and behavior of a shared decision-making training for opioid treatment of chronic pain. DESIGN: Randomized-controlled trial. PARTICIPANTS: Internal Medicine residents (n=38) and attendings (n=7) were randomized to receive two 1-hour training sessions on a shared decision-making model for opioid treatment for chronic pain (intervention, n=22) or written educational materials (control, n=23). MEASUREMENTS: Questionnaires assessing physician satisfaction, physician patient-centeredness, opioid prescribing practices, and completion rates of patient treatment agreements administered 2 months before and 3 months after training. RESULTS: At follow-up, the intervention group reported significantly greater overall physician satisfaction (P=.002), including subscales on relationship quality (P=.03) and appropriate use of time (P=.02), self-reported completion rates of patient treatment agreements (P=.01), self-reported rates of methadone prescribing (P=.05), and self-reported change in care of patients with chronic pain (P=.01). CONCLUSIONS: Training primary care physicians in the shared decision-making model improves physician satisfaction in caring for patients with chronic pain and promotes the use of patient treatment agreements. Further research is necessary to determine whether this training improves patient satisfaction and outcomes.     

A Preliminary Comparison of Major Kinds of Obstacles to Enrolling in Substance Abuse Treatment (AOD) Reported by Injecting Street Outreach Clients and Other Stakeholders

Injecting drug users (IDU) (n = 144), street outreach (n = 55), and treatment program (n = 71) staff and managers in stakeholder government agencies (n = 11) cited or mentioned many barriers to enrolling in substance abuse treatment (AOD), using varied assessment instruments (). Here, we aimed to investigate a possible overemphasis on individual client factors (e.g., “readiness,” denial) as barriers to enrollment and the relative importance of other kinds of barriers, e.g., limitations using a four-category classification of: individual client factors (IC), treatment accessibility (TAX), treatment availability (AVL), and (lack of) client acceptability (CA), reflecting stigmatization of IDUs. TAX responses predominated for outreach staff (51%), government managers (39%), and barriers implied by client suggestions (52%). IC (60%) followed by TAX (36%) factors characterized barriers clients generated directly. The IC factor thus appears overrepresented among IDUs and TAX is important for all groups suggesting a greater focus on access may be more cost-effective than on individual treatment motivation interventions.     

Cardiac Rehabilitation Series: Canada

Cardiovascular disease is among the leading causes of mortality and morbidity in Canada. Cardiac rehabilitation (CR) has a long robust history here, and there are established clinical practice guidelines. While the effectiveness of CR in the Canadian context is clear, only 34% of eligible patients participate, and strategies to increase access for under-represented groups (e.g., women, ethnic minority groups) are not yet universally applied. Identified CR barriers include lack of referral and physician recommendation, travel and distance, and low perceived need. Indeed there is now a national policy position recommending systematic inpatient referral to CR in Canada. Recent development of 30 CR quality indicators and the burgeoning national CR registry will enable further measurement and improvement of the quality of CR care in Canada. Finally, the Canadian Association of CR is one of the founding members of the International Council of Cardiovascular Prevention and Rehabilitation, to promote CR globally.     

Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics

OBJECTIVE: To determine the independent effect of hospitalist status upon inpatient length of stay after controlling for case mix, as well as patient-level and provider-level variables such as age, years since physician medical school graduation, and volume status of provider. DESIGN: Observational retrospective cohort study employing a hierarchical random intercept logistic regression model. SETTING: Tertiary-care teaching hospital. PATIENTS: All admissions during 2001 to the department of medicine not sent initially to the medical intensive care unit or coronary care unit. MEASUREMENTS: Observed length of stay (LOS) compared to principle diagnosis related group (DRG)-specific mean LOS for hospitalist and nonhospitalist patients adjusting for patient age, gender, years since physician graduation from medical school, and physician volume status. MAIN RESULTS: The 9 hospitalists discharged 2,027 patients while the nonhospitalists discharged 9,361 patients. On average, hospitalist patients were younger, 63.3 versus 73.3 years (P < .0001). Hospitalists were more recently graduated from medical school, 13.8 versus 22.5 years (P= .02). Each year of patient age was found to increase the likelihood of an above average LOS (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.01 to 1.02; P < .001). In unadjusted analysis, hospitalists were less likely to have an above average LOS (OR, 0.51; 95% CI, 0.28 to 0.93; P= .03). Adjustment for effects of patient age and gender, physician gender, years since medical school graduation, and quintile of physician admission volume did not appreciably change the point estimate that hospitalist patients remained less likely to have above average LOS (OR, 0.60; 95% CI, 0.32 to 1.11; P= .11). CONCLUSIONS: For a given principle DRG, hospitalist patients were less likely to exceed the average LOS than were nonhospitalist patients. This effect was rather large, in that hospitalist status reduced the likelihood of above average LOS by about 49%. Adjustment for patient age, years since physician graduation, and admission volume did not significantly alter this finding. Further research should focus on identifying specific practices that account for hospitalism's effects.     

Physician and public opinions on quality of health care and the problem of medical errors

BACKGROUND: The 1999 Institute of Medicine report on medical errors proposed major changes to the health care system and gained widespread media attention, yet there is limited information on physician or public opinion regarding recommendations from that report. METHODS: Mail survey of 1000 Colorado physicians (n = 594) and 1000 national physicians (n = 304), and telephone survey of 500 Colorado households to assess agreement with several proposals and conclusions from the 1999 Institute of Medicine report. RESULTS: Most physicians believed that reduction of medical errors should be a national priority (69.7% of Colorado physicians). However, physicians were much less likely than the public to believe that quality of care is a problem (29.1% vs 67.6%; P<.001) or that a national agency is needed to address the problem of medical errors (24.1% vs 59.8%; P<.001). Uniformly, physicians believed that fear of medical malpractice is a barrier to reporting of errors and that greater legal safeguards are necessary for a mandatory reporting system to be successful. Nearly all physicians (92.9%) believed that more training in how to handle medical errors is needed, and 60.1% agreed that it is difficult to differentiate errors due to negligence from unintended errors. CONCLUSIONS: There appears to be widespread concern among physicians regarding medical errors, but only a minority in this survey believed that the problem is as significant as the Institute of Medicine and the public believe it to be. Our results suggest that physicians see several barriers to successful error reduction including difficulty defining errors, the need for more training in handling errors, and fear of malpractice litigation. Addressing these barriers will be a necessary step to increasing physician support for many of the changes proposed by the Institute of Medicine.     

Comparable results in patients with acute lymphoblastic leukemia after related and unrelated stem cell transplantation

We report the results of 84 patients with ALL after related (n = 46) or unrelated (n = 38) allogeneic SCT. Mean recipient age was 23 years (range: 1-60) and median follow-up was 18 months (range: 1-133). Forty-three patients were transplanted in CR1; 25 in CR2 or CR3; four were primary refractory; four in PR; eight in relapse. The conditioning regimen consisted of TBI/VP16/CY (n = 76), TBI/VP16 (n = 2), TBI/CY (n = 2), Bu/VP16/CY (n = 4). The OS at 3 years was 45% (44% unrelated, 46% related). Univariate analysis showed a significantly better OS for patients <18 years (P=0.03), mismatched sex-combination (P = 0.03), both with a stronger effect on increasing OS after unrelated SCT. Factors decreasing TRM were patient age <18 years (P = 0.004), patient CMV-seronegativity (P = 0.014), female recipient (P = 0.04). There was no significant difference in TRM and the relapse rate was similar in both donor type groups. Multivariate analysis showed that factors for increased OS which remained significant were mismatched sex-combination (RR: 0.70,95% CI: 0.51-0.93, P = 0.015), patient age < 18 years (RR: 0.66, 95% CI: 0.47-0.93, P = 0.016). A decreased TRM was found for female patients (RR: 0.56, 95% CI: 0.33-0.98, P=0.042), negative CMV status of the patient (RR: 0.57, 95% CI: 0.36-0.90, P = 0.015). Unrelated stem cell transplantation for high-risk ALL patients with no HLA-compatible family donor is justifiable.     

A preliminary comparison of major kinds of obstacles to enrolling in substance abuse treatment (AOD) reported by injecting street outreach clients and other stakeholders

Injecting drug users (IDU) (n=144), street outreach (n=55), and treatment program (n=71) staff and managers in stakeholder government agencies (n=11) cited or mentioned many barriers to enrolling in substance abuse treatment (AOD), using varied assessment instruments (1). Here, we aimed to investigate a possible overemphasis on individual client factors (e.g., "readiness," denial) as barriers to enrollment and the relative importance of other kinds of barriers, e.g., limitations using a four-category classification of: individual client factors (IC), treatment accessibility (TAX), treatment availability (AVL), and (lack of) client acceptability (CA), reflecting stigmatization of IDUs. TAX responses predominated for outreach staff (51%), government managers (39%), and barriers implied by client suggestions (52%). IC (60%) followed by TAX (36%) factors characterized barriers clients generated directly. The IC factor thus appears overrepresented among IDUs and TAX is important for all groups suggesting a greater focus on access may be more cost-effective than on individual treatment motivation interventions.