Is patients' perception of time spent with the physician a determinant of ambulatory patient satisfaction?

BACKGROUND: Time management in ambulatory patient visits is increasingly critical. Do patients who perceive a longer visit with internists report increased satisfaction? METHODS: Prospective survey of 1486 consecutively encountered ambulatory visits to 16 primary care physicians (PCPs) in an academic primary care clinic. Patients were queried regarding demographics, health status, perception of time spent before and after ambulatory visits, whether the physician appeared rushed, and visit satisfaction. Physicians were queried regarding time spent, estimated patient satisfaction, and whether they felt rushed. RESULTS: In 69% of 1486 consecutive visits, patient previsit expectation of visit duration was 20 minutes or less. Patient and PCP postvisit estimates of time spent significantly exceeded patient previsit time expectation. Patients who estimated that they spent more time than expected with the PCP were significantly more satisfied with the visit. When patient postvisit estimate of time spent was less than the previsit expectation, visit satisfaction was significantly lower independent of time spent. Patient worry about health and lower self-perceived health status were significantly associated with patient expectation for longer visits. Primary care physicians felt rushed in 10% of encounters. Although PCPs estimated patient satisfaction was significantly lower when they felt rushed, patient satisfaction was identical when PCPs did and did not feel rushed. Patients indicated that PCPs appeared rushed in 3% of encounters, but this perception did not affect patient satisfaction. CONCLUSION: Perceived ambulatory visit duration and meeting or exceeding patient expectation of time needed to be spent with the physician are determinants of patient satisfaction in an ambulatory internal medicine practice.     

Is the use of benzodiazepines associated with incident disability?

OBJECTIVES: This study examined the association between benzodiazepine use and incident disability with an emphasis on elucidating whether the underlying health conditions that result in benzodiazepine use (confounding factors) or intrinsic adverse effects of benzodiazepine use were responsible for functional decline. DESIGN: Cohort study with follow-up of 4 to 5 years. SETTING: A health maintenance organization (HMO) in western Washington. PARTICIPANTS: Individuals aged 65 and older from a random sample of HMO enrollees who participated in a health promotion intervention trial (n = 1,519). MEASUREMENTS: Benzodiazepine use was ascertained from computerized pharmacy records. Self-reported functional status was assessed using a six-item physical function scale ranging from vigorous activity to self-care activities of daily living (ADLs). Two outcomes were examined: decline in overall physical function and limitations in self-care ADLs. Multivariate models were examined that included demographic characteristics, health status, and health behaviors that were likely to be confounders. Several analyses were conducted to examine whether benzodiazepine use or confounding factors were responsible for functional decline. RESULTS: Benzodiazepine use was significantly associated with incident loss of physical function (hazard ratio (HR) = 1.51, 95% confidence interval (CI) = 1.02-2.24) in the fully adjusted model. Although use of benzodiazepines was associated with limitations in ADLs, it was not significant when adjusting for other factors (HR = 1.71, 95% CI = 0.87-3.34). Several of our findings suggest that the health conditions leading to benzodiazepine use may partly or fully explain these associations: (1) use of anxiolytic benzodiazepines (HR = 1.95, 95% CI = 1.24-3.07), but not hypnotic agents (HR = 1.21, 95% CI = 0.73-2.00), was associated with functional decline; (2) adjustment for health status variables minimized these associations; and (3) there was little evidence of dose response. CONCLUSIONS: A modestly increased risk for decline in physical function was associated with benzodiazepine use, especially of anxiolytic agents. The health conditions that result in benzodiazepine use may be more important in the pathogenesis of disability than benzodiazepine use itself. Although there are many reasons for avoiding benzodiazepines in older adults, it is still unclear whether use contributes independently to functional decline.     

Is the use of high-intensity atorvastatin associated with memory impairment?

High-intensity statins are the cornerstone of medical management in Acute Coronary Syndromes (ACS). However, their effect on neurocognition are less clear. In this prospective observational study, we gave guideline-directed high-intensity atorvastatin 40 mg to middle-aged statin-naïve ACS patients. Memory assessments were performed before and 6 months after statin therapy using 2 validated scales-the Post-Graduate Institute Memory Scale (PGI-MS), and the Logical Memory Passage Test (LMPT). There was no significant difference in the mean PGI-MS test scores (baseline 75.4 ± 7.9, 6months 76.5 ± 8.2;p = 0.26) or the overall composite scores (baseline 32.02 ± 3.2, 6months 32.8 ± 3.1; p = 0.20), after 6 months of statin use. There was a small improvement in immediate recall (baseline score 8.5 ± 2.5, 6 months 9.04 ± 1.8; p = 0.05), and delayed recall (baseline 6.1 ± 2.6, 6 months 6.9 ± 1.9, p = 0.002). High-intensity atorvastatin use did not affect memory at 6 months among statin-naïve middle-aged patients with ACS.     

Is alcohol ablation of the septum associated with recurrent tachyarrhythmias?

QUESTIONS UNDER STUDY: Alcohol ablation (AA) of the septum has been introduced as new therapy in hypertrophic cardiomyopathy (HCM). It was feared that iatrogenic myocardial infarction due to AA may induce re-entry tachyarrhythmias and increase sudden cardiac death. METHODS AND RESULTS: Twenty-four patients (mean age 52 years) underwent successful AA. Clinical follow-up (FU) ranged from 0.3 to 0.7 years (mean 2.8). One patient died (suicide) 4 years after AA. Left ventricular (LV) outflow gradient (peak-to-peak) decreased (median) after AA from 43 (IQR 25 to 4) mmHg to 1 (IQR 0 to 12) mmHg (rest) (p <0.001) and from 130 (IQR 75 to 165) mmHg to 13 (IQR 0 to 31) mmHg (postextrasystolic) (p <0.001). Transient AV block occurred in 22% (5/24) necessitating temporary pacing. A permanent pacemaker was implanted in 4% (1/24). NYHA-class was 2.5 (IQR 2.0 to 3.0) before and 1.5 (IQR 1.3 to 2.0) (p <0.001) after AA. During FU, 2 pacemakers were implanted due to bradycardia (no AV block). A right bundle branch block was found in 13% (2/24) before and 46 % (11/24) after AA (p = 0.003). Non-sustained ventricular tachycardia (NSVT) was observed in 13% (2/16) before and 22% (5/23) (p = 0.46) after AA. Two patients required ICD implantation. CONCLUSIONS: Long-term FU is excellent in HCM after AA. The pressure gradient drops below 25 mm Hg in 95% (23/24) of all patients. Transient AV block occurs in 22% (5/24), but permanent pacemaker implantation is rarely needed (13%, 2/24). Severe NSVT occurs in 13% (2/16) before and 22% (5/23) after AA but ICD implantation is only occasionally required.     

Is patient assessment of asthma care delivery associated with publicly reported performance measures?

Abstract

Objective: To determine the association between patient assessment of healthcare delivery and publicly reported asthma performance measures. Methods: We identified individuals 5–50 years old who had asthma quality measures reported to the Minnesota Community Measurement© (MCM©) by their clinic and sent them a postal survey which included within it the Patient Assessment of Chronic Illness care (PACIC), a validated measure of patient perception of the quality of healthcare delivery. We performed a multivariable analysis to examine the association between PACIC scores and achievement of asthma care quality measures. Results: The response rate for the ACS was 102/367 (28%); a non-response bias analysis revealed no differences between responders and non-responders for age, gender and asthma control. Most responders (73%) reported taking asthma medications daily and most (71%) had poorly controlled asthma. The PACIC score was not associated with any of the asthma quality measures based on the data reported to MCM© by the clinic. A higher PACIC score was, however, associated with having an asthma action plan based on patient-reported data in the ACS (p?<?0.0001) but not with patient-reported asthma control or emergency department/hospitalizations for asthma. Conclusions: Patient assessment of high quality asthma care delivery was associated with patient self-report of having an asthma action plan but was not associated with any of the publicly reported asthma performance measures.     

Is hepatic steatosis associated with left ventricular mass index increase in the general population?

AIM To investigate the association between hepatic steatosis and change in left ventricular mass index(LVMI) over five years, and examine whether systolic and diastolic blood pressures are mediators of the association between hepatic steatosis and LVMI using a general population sample.METHODS We analyzed data from the Study of Health in Pomerania. The study population comprised 1298individuals aged 45 to 81 years. Hepatic steatosis was defined as the presence of a hyperechogenic pattern of the liver together with elevated serum alanine transferase levels. Left ventricular mass was determined echocardiographically and indexed to height2.7. Path analyses were conducted to differentiate direct and indirect paths from hepatic steatosis to LVMI encompassing systolic and diastolic blood pressure as potential mediating variables.RESULTS Hepatic steatosis was a significant predictor for all measured echocardiographic characteristics at baseline. Path analyses revealed that the association of hepatic steatosis with LVMI change after five years was negligibly small(β =-0.12, s.e. = 0.21, P = 0.55). Systolic blood pressure at baseline was inversely associated with LVMI change(β =-0.09, s.e. = 0.03, P 0.01), while no association between diastolic blood pressure at baseline and LVMI change was evident(β = 0.03, s.e. = 0.05, P = 0.56). The effect of the indirect path from hepatic steatosis to LVMI via systolic baseline blood pressure was small(β =-0.20, s.e. = 0.10, P = 0.07). No indirect effect was observed for the path via diastolic baseline blood pressure(β = 0.03, s.e. = 0.06, P = 0.60). Similar associations were observed in the subgroup of individuals not receiving beta-blockers, calcium channel blockers, or drugs acting on the reninangiotensin system.CONCLUSION Baseline associations between hepatic steatosis and LVMI do not extend to associations with LVMI change after five years. More studies are needed to study the longitudinal effects of hepatic steatosis on LVMI.     

Is vitamin D level associated with the natural course of atopic dermatitis?

Introduction and objectives

Atopic dermatitis (AD) is a chronic inflammatory disease of the skin. Apart from its well-known role on calcium metabolism, vitamin D is reported to affect skin functions. The study aims were to: compare the vitamin D levels of children with AD and healthy children; investigate the relationship between the severity of AD and vitamin D levels; and investigate the effect of vitamin D on the natural course of AD.

Is patient satisfaction sufficient to validate endoscopic anti-reflux treatments?

Endoscopic anti-reflux treatment is emerging as a new option for gastro-esophageal reflux disease (GERD) treatment in patients with the same indications as for laparoscopic fundoplication. There are many techniques, the first of which are transoral incisionless fundoplication (TIF) and nonablative radio-frequency (STRETTA) that have been tested with comparative studies and randomized controlled trials, whereas the other more recent ones still require a deeper evaluation. The purpose of the latter is to verify whether reflux is abolished or significantly reduced after intervention, whether there is a valid high pressure zone at the gastroesophageal junction, and whether esophagitis, when present, has disappeared. Unfortunately in a certain number of cases, and especially in the more recently introduced ones, the evaluation has been based almost exclusively on subjective criteria, such as improvement in the quality of life, remission of heartburn and regurgitation, and reduction or suspension of antacid and antisecretory drug consumption. However, with the most studied techniques such as TIF and STRETTA, an improvement in symptoms better than that of laparoscopic fundoplication can often be observed, whereas the number of acid episodes and acid exposure time are similar or higher, as if the acid refluxes are better tolerated by these patients. The suspicion of a local hyposensitivity taking place after anti-reflux endoscopic intervention seems confirmed by a Bernstein test at least for STRETTA. This examination should be done for all the other techniques, both old and new, to identify the ones that reassure rather than cure. In conclusion, the evaluation of the effectiveness of the endoscopic anti-reflux techniques should not be based exclusively on subjective criteria, but should also be confirmed by objective examinations, because there might be a gap between the improvement in symptoms declared by the patient and the underlying pathophysiologic alterations of GERD.     

Is the self-perception of the built neighborhood associated with fear of falling in community-dwelling older adults?

IntroductionCharacteristics of a built neighborhood may aggravate agravett to fear of falling in older adults and this knowledge are important to contribute to developing strategies aimed at reducing fear of falling and their consequences.ObjectiveTo verify the association between self-perception of built neighborhood characteristics and fear of falling in community-dwelling older adults.Materials and MethodsThis was a cross-sectional study including 308 community-dwelling older adults. The outcome was fear of falling evaluated through Falls Efficacy Scale International. Older adults were classified with high fear of falling when they obtained values ≥ 23 points and classified as low fear of falling with score < 23 point. The built neighborhood variables were evaluated by the adapted Neighborhood Environment Walkability Scale. Multivariable logistic regression was performed to verify associations between the variables.ResultsThe prevalence of fear of falling was 48.40%. Significant negative associations were observed between residing near a bus stop, outdoor gyms, safe places to walk during the day, and positive associations between garbage accumulation and/or open sewers and high crime rates and fear of falling.ConclusionThe association between self-perceived characteristics of built neighborhoods and fear of falling points to the need for improvements in urban infrastructure, especially public spaces, in order to reduce fear of falling in community-dwelling older adults.     

Is the consumption of fast foods associated with asthma or other allergic diseases?

The associations between the consumption of fast foods and asthma or allergic diseases have not been clarified. The aim of this study was to determine whether fast foods consumption is associated with asthma or allergic diseases. Databases were searched up to February 2018. Studies investigating the associations between fast foods consumption and asthma or allergic diseases were considered eligible. Included studies were assessed for quality using standardized critical appraisal checklists. The quality scores were 5.33 ± 1.16 in case–control studies and 5.69 ± 1.55 in cross‐sectional studies. Adjusted odds ratios (aOR) with 95% confidence interval (CI) were pooled. Sixteen studies (13 cross‐sectional and 3 case–control studies) were included. The consumption of fast foods was significantly related to current asthma (aOR: 1.58; 95% CI: 1.17–2.13 for case–control study and aOR: 1.58; 95% CI: 1.10–2.26 for cross‐sectional studies), severe asthma (aOR: 1.34; 95% CI: 1.23–1.46), asthma ever (aOR: 1.36; 95% CI: 1.06–1.75), current wheeze (aOR: 1.21; 95% CI: 1.16–1.27), wheeze ever (aOR: 1.65; 95% CI: 1.07–2.52), physician‐diagnosed allergic rhinitis (odds ratio: 1.43; 95% CI: 1.05–1.95), severe eczema (aOR: 1.51; 95% CI: 1.16–1.96) and severe rhino‐conjunctivitis (aOR: 1.54; 95% CI: 1.18–2.00). The consumption of hamburgers was associated with current asthma (aOR: 1.59; 95% CI: 1.13–2.25), severe asthma (aOR: 1.34; 95% CI: 1.23–1.46), asthma ever (aOR: 1.47; 95% CI: 1.13–1.92), severe eczema (aOR: 1.51; 95% CI: 1.16–1.96), severe rhino‐conjunctivitis (aOR: 1.54; 95% CI: 1.18–2.00) and rhino‐conjunctivitis (aOR: 1.21; 95% CI: 1.15–1.27). The consumption of fast foods, especially hamburgers, ≥3 times/week, was more likely to be associated with severe asthma and current wheeze compared with the consumption of 1–2 times/week (both P < 0.001). In conclusion, the consumption of fast foods, particularly hamburgers, correlates to asthma in a dose–response pattern, which needs to be further validated in longitudinal and interventional studies.     

Is hyperfiltration associated with the future risk of developing diabetic nephropathy? A meta-analysis

Aims/hypothesis  Glomerular hyperfiltration is a well-established phenomenon occurring early in some patients with type 1 diabetes. However, there is no consistent answer regarding whether hyperfiltration predicts later development of nephropathy. We performed a systematic review and meta-analysis of observational studies that compared the risk of developing diabetic nephropathy in patients with and without glomerular hyperfiltration and also explored the impact of baseline GFR. Methods  A systematic review and meta-analysis was carried out. Cohort studies in type 1 diabetic participants were included if they contained data on the development of incipient or overt nephropathy with baseline measurement of GFR and presence or absence of hyperfiltration. Results  We included ten cohort studies following 780 patients. After a study median follow-up of 11.2 years, 130 patients had developed nephropathy. Using a random effects model, the pooled odds of progression to a minimum of microalbuminuria in patients with hyperfiltration was 2.71 (95% CI 1.20–6.11) times that of patients with normofiltration. There was moderate heterogeneity (heterogeneity test p = 0.05, measure of degree of inconsistency = 48%) and some evidence of funnel plot asymmetry, possibly due to publication bias. The pooled weighted mean difference in baseline GFR was 13.8 ml min⁻¹ 1.73 m⁻² (95% CI 5.0–22.7) greater in the group progressing to nephropathy than in those not progressing (heterogeneity test p < 0.01). Conclusions/interpretation  In published studies, individuals with glomerular hyperfiltration were at increased risk of progression to diabetic nephropathy using study level data. Further larger studies are required to explore this relationship and the role of potential confounding variables.     

Is ritonavir boosting associated with gout?

Asymptomatic hyperuricaemia is associated with ritonavir therapy, but gout has rarely been reported. We present a retrospective cohort study of 1825 HIV-positive patients seen at one inner London HIV clinic over a two-year period. In all, 18 patients had gout, of whom 15 were receiving antiretroviral therapy. Seven had predisposing risk factors for gout (e.g. pyrazinamide therapy, haematological malignancy). Of the remaining 11 patients, two were on no medication and eight (73%) were receiving ritonavir as a boosted protease inhibitor (PI). By comparison, 11% of HIV-positive patients without gout were receiving ritonavir (odds ratio = 22; confidence interval = 5-104). Seven of the 18 patients had documented features of lipodystrophy and dyslipidaemia. Gout was seen in patients with known risk factors for gout or who were receiving ritonavir as a boosted PI and who also had lipodystrophy.     

Is leptin associated with hypertensive retinopathy?

Previous studies have demonstrated that elevated plasma leptin concentrations are associated with essential hypertension. It has also recently been shown that leptin plays a promoting role in angiogenesis, and the vascular endothelium expresses the long form of leptin receptor. Those data led us to hypothesize that leptin might contribute to end-organ damage in hypertension. Thus, in the present study we evaluated the relationship between plasma leptin concentrations and hypertensive retinopathy (HR). One hundred and eleven patients newly diagnosed with essential hypertension [EHT; mean age, 43.5 +/-10.7 yr; body mass index (BMI), 28.1 +/- 4.4 kg/m2; male/female ratio, 71/40] and 79 healthy normotensive control subjects (NT; mean age, 43.6 +/- 9.2 yr; BMI, 28.2 +/- 3.3 kg/m2; male/female ratio, 50/29) were enrolled in the study. For the assessment of retinopathy according to the Keith-Wagener classification, direct and indirect ophthalmoscopy were performed in all subjects after dilatation of the pupils. Plasma leptin levels were significantly higher in EHT (11.8 +/- 11.1 ng/mL) than in NT (7.2 +/- 5.1 ng/mL) (P = 0.003). Plasma leptin concentrations were strongly correlated with BMI in both EHT (r = 0.45; P = 0.001) and NT (r = 0.38; P = 0.001) groups. Plasma leptin in patients with grade 2 HR (24.8 +/- 15.8 ng/mL; n = 22) was significantly higher than that in patients with grade 1 HR (16.1 +/- 4.9 ng/mL; n = 29; P = 0.001), grade 0 HR (5.1 +/- 3.1 ng/mL; n = 60; P = 0.001), and NT (P = 0.001). Plasma leptin in patients with grade 1 HR was also significantly higher than that in patients without retinopathy (P = 0.001) or in NT (P = 0.001). The estimated threshold of plasma leptin concentration for HR was 10.2 ng/mL. This critical leptin level served largely to separate patients with retinopathy from those without retinopathy. In summary, our results show that plasma leptin concentrations increase progressively with higher grades of hypertensive retinopathy even after correction for BMI, suggesting that a critical leptin level is needed for the development of retinopathy. Elevated concentrations of plasma leptin might be secondary to release of leptin by the vascular endothelium damaged by high blood pressure, as an epiphenomenon. However, a pathogenic role for leptin in hypertensive retinopathy cannot be excluded.     

Is chemotherapy associated with cognitive impairment?

Cancer survivors often report difficulties with memory and concentration—sometimes referred to by patients as "chemobrain" or "chemofog". The results from two recent studies suggest that, while chemotherapy itself may not be associated with cognitive impairment, some patients might already be experiencing cognitive difficulties before treatment is even started.     

Is social integration associated with the risk of falling in older community-dwelling women?

BACKGROUND: Social integration may lead to social support and influence that may in turn protect older community-dwelling adults from falls. METHODS: We examined incident falls over 3 years across quartiles of social integration scores in 6692 Caucasian women enrolled in the Study of Osteoporotic Fractures (mean age = 77 +/- 5 years). Social integration was assessed using family networks, friendship networks, and interdependence scores. Higher scores correspond to greater integration. Data were analyzed using Poisson regression with generalized estimating equations. Multivariate analyses were used to adjust for other risk factors and potential confounders. RESULTS: Women reported 11863 falls, averaging 0.60 falls per person annually, 95% confidence interval (CI) (0.57, 0.63), or 600 falls per 1000 women. In age-adjusted analysis, the average incidence rate of falls correlated inversely with family networks, interdependence, and composite integration scores (p <.05). In multivariate analysis, increasing family networks were inversely associated with fall risk, p(trend) =.02. Compared to the lowest quartile, the relative risk of falls (95% CI) associated with family network scores in the second, third, and fourth quartiles were 0.90 (0.79-1.03), 0.86 (0.74-1.00), and 0.84 (0.71-0.99), respectively. CONCLUSIONS: Strong family networks may protect against the risk of falls in older community-dwelling adults.