Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists

OBJECTIVES: To compare prescribing trends and appropriateness of use of traditional and cyclooxygenase-2 selective (COX-2) nonsteroidal anti-inflammatory drugs (NSAIDs) by primary care physicians (PCPs) and specialists. DESIGN: Retrospective cohort study. PATIENTS: One thousand five hundred and seventy-six adult patients continuously enrolled for at least 1 year with an independent practice association of a University-associated managed care plan who were started on a traditional NSAID or a COX-2 inhibitor from 1999 to 2002 and received at least 3 separate medication fills. MEASUREMENTS: Physician specialty was identified from office visits. Appropriateness of utilization was based on gastrointestinal risk characteristics. RESULTS: Primary care patients were younger and less likely to have comorbid conditions. Despite similar GI risk, COX-2 use among patients seen by PCPs was half that of patients seen by specialists (21% vs 44%, P<.001). While PCPs overused cyclooxygenase-2-specific inhibitors (COX-2s) less often than specialists (19% vs 41%, P<.001), they also tended to underuse COX-2s in patients who were at increased GI risk (46% vs 32%, P=.063). This represents a 3-fold and 8-fold difference in overuse versus underuse for PCPs and specialists, respectively. CONCLUSIONS: Using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication. This study demonstrates the tension between appropriate adoption of innovative therapies for those individuals who would benefit from their use and those individuals who would receive no added clinical benefit but would incur added cost and be placed at increased risk.     

Factors associated with the frequency of house calls by primary care physicians

Objective:To evaluate factors associated with the frequency of house calls by primary care physicians. Design:A cross-sectional design with a self-administered mailed survey. Setting/participants:751 primary care physicians who care for Medicaid patients in Virginia. Results:Among 389 physician respondents (52%), regular house callers (n=216) were compared with occasional house callers (n=162). Among physician characteristics, specialty and practice duration were associated with house call frequency. Regular house callers also more often cited chronic illness (67% vs. 20%, p<0.01) and terminal illness (67% vs. 40%, p<0.01) as indications for house calls, compared with occasional house callers. Use of visiting nurses to substitute for physician house calls was less often considered appropriate by frequent house callers (7% vs. 24%, p<0.01), and regular house callers were less likely to report being “too busy” to make house calls (71% vs. 29%, p<0.01). Multivariate analysis confirmed the association of these attitudes with house call frequency. Conclusion:These data suggest that specific attitudes among primary care physicians are associated with house call frequency. Presented in part at the annual meeting of the Society of General Internal Medicine, May 2–4, 1990, Arlington, Virginia. Supported in part by a grant from Virgina Commonwealth University.     

Frequency and impact of housestaff contact with primary care physicians

To determine how often housestaff notified primary care providers (PCPs) of admissions, whether notification prompted a visit, and whether PCP input impacted care, 210 medical inpatients were asked about their PCPs, and at discharge, housestaff completed a questionnaire on the patient’s PCP, and whether he or she was contacted, came to the hospital, and influenced care. Of 105 patients with a PCP, 74 were contacted and 26 visited their patients. The PCPs spoken with personally more often made hospital visits than those contacted only by message (p<0.0001). PCP input frequently contributed to patient care by providing continuity, clarifying history/diagnosis, managing chronic problems, and elucidating psychosocial/cultural factors. Having a PCP did not influence length of stay or readmission rates. Received from the Department of Medicine, University of Washington, Seattle, Washington.     

Primary care physician productivity

OBJECTIVES: To model physician productivity as a function of clinic (support system) characteristics and physician characteristics and to model the time a physician spends with the patient as a function of patient characteristics. DESIGN: Observational study. SETTING: A general medicine clinic of a university-affiliated Veterans Affairs medical center. PATIENTS: A cohort of 2,520 patients having 2,721 consecutive outpatient visits to 56 physicians. MAIN OUTCOME MEASURES: Physician productivity defined as patients seen/physician/hour and time (minutes) spent with the patient. RESULTS: Physicians saw a mean (±SD) of 1.62±0.68 patients/hour. Clinic characteristics explained 8.2% of the variability of session-specific physician productivity. Controlling for clinic characteristics, a factor representing the physician explained an additional 55.4%. A model for overall physician productivity, using physician characteristics, explained 84.9% of the variance, and time spent with the patient was an important predictor. Modeling physician time with patients, patient characteristics accounted for only 7% of the variability. Controlling for patient characteristics, the individual physician again provided the greatest explanatory power, an additional 22.8% of the variability. CONCLUSIONS: Physicians’ practice patterns, rather than clinic or patient characteristics, may account for most of the variation in physician productivity. Given the magnitude of the influence of individual practice patterns, interventions to increase productivity need to consider methods to affect physician behavior. Presented at the annual meeting of the Veterans Affairs Health Services Research and Development (HSR&D) Service, Washington, DC, April 26, 1994. Supported by grants from Great Lakes HSR&D Field Program, #41-058, the Department of Veterans Affairs HSR&D, IIR 88-063.1. and the Agency for Health Care Policy and Research, PHS R18 HS 61 73-01.     

The effects of two continuing medical education programs on communication skills of practicing primary care physicians

Purpose: To evaluate and compare the effects of two types of continuing medical education (CME) programs on the communication skills of practicing primary care physicians. Participants: Fifty-three community-based general internists and family practitioners practicing in the Portland, Oregon, metropolitan area and 473 of their patients. Method: For the short program (a 4 1/2-hour workshop), 31 physicians were randomized to either the intervention or the control group. In the long program (a 2 1/2-day course), 20 physicians participated with no randomization. A research assistant visited all physicians’ offices both one month before and one month after the CME program and audiotaped five sequential visits each time. Data were based on analysis of the content and the affect of the interviews, using the Roter Interactional Analysis Scheme. Results: Based on both t-test analysis and analysis of covariance, no effect on communication was evident from the short program. The physicians enrolled in the long program asked more open-ended questions, more frequently asked patients’ opinions, and gave more biomedical information than did the physicians in the short program. Patients of the physicians who attended the long program tended to disclose more biomedical and psychosocial information to their physicians. In addition, there was a decrease in negative affect for both patient and physician, and patients tended to demonstrate fewer signs of outward distress during the visit. Conclusion: This study demonstrates some potentially important changes in physicians’ and patients’ communication after a 2 1/2-day CME program. The changes demonstrated in both content and affect may have important influences on both biologic outcome and physician and patient satisfaction.     

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.     

Self-perception of theoretical knowledges and practical skills by primary health care physicians in life-threatening emergencies according to their gender: A cross-sectional study

To assess the training received in Emergency Medicine (EM) by the Primary Health Care physicians of Asturias, as well as their perception of their own theoretical knowledge and practical skills in a series of procedures employed in life-threatening emergencies, and also to analyze the differences according to gender. The degree of preparation of Primary Health Care physicians for handling emergencies, according to the gender of the professionals, has never been studied before.Cross-sectional study of a sample of 213 Primary Health Care physicians from the Primary Health Care Service of Asturias, Spain, from among the total of 851 physicians on the staff of the Primary Health Care Service of Asturias. The survey was design ad hoc using the Body of Doctrine of Emergency Medicine proposed by the Spanish Society of Emergency Medicine, which indicates the theoretical and practical procedures that must be mastered by the Primary Health Care physicians.There are nonsignificant differences in the mean of theoretical knowledge and practical skills in many procedures or techniques studied depending on the gender.Female and male Asturian Primary Health Care physicians are generally well prepared to handle life-threatening emergencies. The degree of self-perception and acquisition of general theoretical knowledge and general practical skills for handling life-threatening emergencies is heterogeneous, and differences according to gender are not statistically significant.     

Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians

OBJECTIVES: This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider. DESIGN: A randomized, prospective controlled trial involving 41 primary care sites. SETTING: Primary care practice sites. PARTICIPANTS: 49 older adults age 60 and older not previously screened for UI by their primary care doctor. MEASUREMENTS: Demographic data, self-reported bladder-control information using questionnaires, and health status. RESULTS: Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%). CONCLUSIONS: Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.     

Survey of primary care physicians and home care clinicians

CONTEXT: Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients. OBJECTIVE: To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network. DESIGN: Mail survey. SETTING: Boston. PARTICIPANTS: Sixty-seven PCPs from 1 academic medical center-affiliated primary care network and 820 HCCs from 8 regional home care agencies. MEASUREMENTS: Provider responses RESULTS: Ninety percent of PCPs and 63% of HCCs responded. The majority (54%) of PCPs reported that they only "rarely" or "occasionally" read carefully the home care order forms sent to them for signature. Further, when asked to rate their prospective involvement in the decision making about home care, only 24% of PCPs and 25% of HCCs rated this as "excellent" or "very good." Although more HCCs (79%) than PCPs (47%) reported overall satisfaction with communication and collaboration, 28% of HCCs felt they provided more services to patients than clinically necessary. CONCLUSIONS: PCPs from 1 provider network and the HCCs with whom they coordinate home care were both dissatisfied with many aspects of communication and collaboration regarding home care services. Moreover, neither group felt in control of home care decision making. These findings are of concern because poor coordination of home care may adversely affect quality and contribute to inappropriate utilization of these services.     

Shortcomings in the diagnosis of chronic rhinosinusitis: evaluating diagnosis by otolaryngologists and primary care physicians

Background

Chronic rhinosinusitis (CRS) is a prevalent illness in the United States that accounts for 18–22 million physician visits annually. The American Academy of Otolaryngology–Head and Neck Surgery (AAO‐HNS) has defined diagnostic criteria, but a recent study demonstrated that nearly all patients diagnosed by nonspecialists did not meet these criteria. In this study we aimed to evaluate the diagnostic rate of CRS by primary care physicians and otolaryngologists.

Methods

We retrospectively reviewed a random sample of adult patients diagnosed with CRS in 2016, based on ICD‐10 codes from primary care and otolaryngology departments. Patients with previous CRS diagnosis, previous sinus surgery, and related comorbidities were excluded.

Results

A total of 502 patients with a new CRS diagnosis were analyzed (308 from primary care, 194 from otolaryngology). The percentage of diagnoses meeting the criteria was significantly higher from otolaryngology (28.9% vs 0.97%, p < 0.0001), but was low in both cohorts. Symptom duration <12 weeks was higher in primary care (81.6% vs 53.6%, p < 0.0001), as was lack of evidence of inflammation (97.4% vs 50.0%, p < 0.0001). Having <2 of the required symptoms was significantly higher in otolaryngology (63.8% vs 50.8%, p = 0.013). The most commonly unevaluated symptom was decreased sense of smell (97.7% in primary care, 69.1% in otolaryngology encounters).

Conclusion

CRS diagnoses commonly do not meet the diagnostic criteria outlined by the AAO‐HNS in both primary care and otolaryngology. As a specialty, we should aim to improve our adherence to the guidelines and educate our primary care colleagues to better identify patients with CRS and initiate appropriate treatment.

     

鬼箭羽治疗糖尿病肾病药理机制的研究进展

糖尿病肾病作为糖尿病最常见的微血管并发症,是全球终末期肾功能衰竭的最主要原因,严重影响到患者的生活质量。糖尿病肾病发病机制是复杂的,目前主要有糖脂代谢紊乱、氧化应激、炎症反应等。通过古籍、文献查阅,结合吕仁和、赵进喜、黄文政等全国名老中医的用药经验,发现鬼箭羽在治疗消渴病上运用较多。现代药理研究发现鬼箭羽,通过降糖、降脂、调节糖脂代谢紊乱、调节氧化应激、抗炎、抗肾小球硬化等方面起到保护肾脏的作用,延缓糖尿病肾病的进展。     

Student loan debt does not predict choosing a primary care specialty for U.S. women physicians

OBJECTIVE: There has never been a conclusive test of whether there is a relation between ultimately choosing to be a primary care physician and one's amount of student loan debt at medical school graduation. DESIGN/SETTING/PARTICIPANTS: To test this question, we examined data from the Women Physicians' Health Study, a large, nationally representative, questionnaire-based study of 4,501 U.S. women physicians. MEASUREMENTS AND MAIN RESULTS: We found that the youngest physicians were more than five times as likely as the oldest to have had some student loan debt and far more likely to have had high debt levels (p <.0001). However, younger women physicians were also more likely to choose a primary care specialty (p <.002). There was no relation between being a primary care physician and amount of indebtedness (p =.77); this was true even when the results were adjusted for the physicians' decade of graduation and ethnicity (p =.79). CONCLUSIONS: Although there may be other reasons for reducing student loan debt, at least among U.S. women physicians, encouraging primary care as a specialty choice may not be a reason for doing so.     

An aid to the early detection and management of diabetic nephropathy: assessment of a new point of care microalbuminuria system in the diabetic clinic.

AIMS: To compare the performance of the DCA2000 microalbuminuria system for albumin and creatinine concentrations and the albumin:creatinine ratio (ACR) with laboratory measurements in the hospital diabetes clinic and to assess the ease of use and applicability by standard clinic personnel. METHODS: Urine albumin and creatinine concentration and ACR were measured in 154 diabetic patient samples and in 77 normal subjects. Both albumin assays are based on immunoturbidimetry. The DCA2000 system utilizes reagent cartridges processed automatically. RESULTS: Control material within-run precision (coefficient of variation (CV)) for albumin and creatinine ranged up to 7.1% and 3.3% respectively. Between-run CVs ranged from 2.1% to 4.3%. Method comparisons yielded correlation coefficients > 0.99 for albumin, creatinine and ACR, only a small negative bias of 3.2 mg/l for albumin and 0.10 mg/mmol for ACR, no concentration-related bias for ACR and no between-method difference for either albumin (P = 0.195) or ACR (P = 0.341). At a laboratory albumin concentration cut-off of 20 mg/l the sensitivity, specificity, negative and positive predictive values were 92.4% 100% 92.7% and 100%. Normal reference range mean albumin, creatinine and ACR values for the DCA2000 and the laboratory were 7.7 mg/l vs. 9.0 mg/l 13.0 mmol/l vs. 12.6 mmol/l and 0.66 mg/mmol vs. 0.81 mg/mmol respectively. Clinic personnel found that the DCA2000 system was easy to use suited the clinic environment and generated confidence in the results. CONCLUSIONS: This point of care system safely substitutes laboratory-based measurements. Ease of use and low cost make it suitable for screening and monitoring diabetes treatment. It facilitates the use of random urines, and may obviate the need for timed samples. This approach has a clear place in the battle to reduce the diabetic vascular disease burden.     

Prevalence of basic information technology use by U.S. physicians

BACKGROUND: Information technology (IT) has been advocated as an important means to improve the practice of clinical medicine. OBJECTIVES: To determine current prevalence of non-electronic health record (EHR) IT use by a national sample of U.S. physicians, and to identify associated physician, practice, and patient panel characteristics. DESIGN, SETTING, AND PARTICIPANTS: Survey conducted in early 2004 of 1,662 U.S. physicians engaged in direct patient care selected from 3 primary care specialties (family practice, internal medicine, pediatrics) and 3 nonprimary care specialties (anesthesiology, general surgery, cardiology). MEASUREMENTS: Self-reported frequency of e-mail communication with patients or other clinicians, online access to continuing medical education or professional journals, and use of any computerized decision support (CDS) during clinical care. Survey results were weighted by specialty and linked via practice zip codes to measures of area income and urbanization. RESULTS: Response rate was 52.5%. Respondents spent 49 (+/-19) (mean [+/-standard deviation]) hours per week in direct patient care and graduated from medical school 23 (+/-11) years earlier. "Frequent" use was highest for CDS (40.8%) and online professional journal access (39.0%), and lowest for e-mail communication with patients (3.4%). Ten percent of physicians never used any of the 5 IT tools. In separate logistic regression analyses predicting usage of each of the 5 IT tools, the strongest associations with IT use were primary care practice (adjusted odds ratios [aORs] ranging from 1.34 to 2.26) and academic practice setting (aORs 2.17 to 5.41). Years since medical school graduation (aOR 0.85 to 0.87 for every 5 years after graduation) and solo/2-person practice setting (aORs 0.21 to 0.55) were negatively associated with IT use. Practice location and patient panel characteristics were not independently associated with IT use. CONCLUSIONS: In early 2004, the majority of physicians did not regularly use basic, inexpensive, and widely available IT tools in clinical practice. Efforts to increase the use of IT in medicine should focus on practice-level barriers to adoption.     

Emerging role of thiamine therapy for prevention and treatment of early-stage diabetic nephropathy

Thiamine supplementation may prevent and reverse early-stage diabetic nephropathy. This probably occurs by correcting diabetes-linked increased clearance of thiamine, maintaining activity and expression of thiamine pyrophosphate-dependent enzymes that help counter the adverse effects of high glucose concentrations-particularly transketolase. Evidence from experimental and clinical studies suggests that metabolism and clearance of thiamine is disturbed in diabetes leading to tissue-specific thiamine deficiency in the kidney and other sites of development of vascular complications. Thiamine supplementation prevented the development of early-stage nephropathy in diabetic rats and reversed increased urinary albumin excretion in patients with type 2 diabetes and microalbuminuria in two recent clinical trials. The thiamine monophosphate prodrug, Benfotiamine, whilst preventing early-stage development of diabetic nephropathy experimentally, has failed to produce similar clinical effect. The probable explanations for this are discussed. Further definitive trials for prevention of progression of early-stage diabetic nephropathy by thiamine are now required.     

Hypertension,knowledge, attitudes,and practices of primary care physicians in Ulaanbaatar,Mongolia

We examined the knowledge, attitudes, and practices of primary care doctors in Ulaanbaatar, Mongolia using a recently developed World Hypertension League survey. The survey was administered as part of a quality assurance initiative to enhance hypertension control. A total of 577 surveys were distributed and 467 were completed (81% response rate). The respondents had an average age of 35 years and 90.1% were female. Knowledge of hypertension epidemiology was low (13.5% of questions answered correctly); 31% of clinical practice questions had correct answers and confidence in performing specific tasks to improve hypertension control had 63.2% “desirable/correct” answers. Primary care doctors mostly had a positive attitude toward hypertension management (76.5% desirable/correct answers) and highly prioritized hypertension management activities (85.7% desirable/correct answers). Some important highlights included the majority (> 80%) overestimating hypertension awareness, treatment, and control rates; 78.2% used aneroid blood pressure manometers; 15% systematically screened adults for hypertension in their clinics; 21.8% reported 2 or more drugs were required to control hypertension in most people; and 16.1% reported most people could be controlled by lifestyle changes alone. 55% of respondents were not comfortable prescribing more than 1 or 2 antihypertensive drugs in a patient and the percentage of desirable/correct responses to treating various high‐risk patients was low. Most (53%‐74%) supported task shifting to nonphysician health care providers except for drug prescribing, which only 13.9% supported. A hypertension clinical education program is currently being designed based on the specific needs identified in the survey.     

Attitudes of physicians toward objective measures of airway function in asthma

BACKGROUND: The National Asthma Education and Prevention Program (NAEPP) recommends pulmonary function testing as part of asthma evaluation. The objectives of this study were to determine the use of spirometry in patients with asthma by primary care physicians and asthma specialists, and to identify barriers to use of spirometry. METHODS: We developed, validated, and administered a mailed survey to primary care physicians and asthma specialists in the general community. We asked about the use of spirometry, access to spirometry, and barriers to spirometry use. RESULTS: Of 975 eligible subjects, 672 (69%) completed the survey. Asthma specialists were more likely to have an office spirometer (78% [216/277] vs. 43% [169/395], P <0.001) than were primary care physicians, and more likely to report measuring pulmonary function in at least 75% of their patients with asthma (83% [223/270] vs. 34% [131/388], P <0.001). In logistic regression analysis, factors most strongly associated with reported spirometry use (in at least 75% of patients) among asthma specialists were owning a spirometer, disagreeing with the statement that the test requires excessive use of office resources, and agreeing that spirometry is a necessary part of the asthma evaluation. Among primary care physicians, owning a spirometer, agreeing that the data are necessary for accurate diagnosis, and believing that they were trained to perform and interpret the test were most strongly associated with reported spirometry use. CONCLUSION: Pulmonary function testing is underutilized by physicians, with rates of utilization lowest among primary care physicians. Providing primary care physicians with better access to spirometry, through provision of a machine and appropriate training in its use and interpretation, may improve compliance with the NAEPP recommendations.     

Hypertension knowledge,attitudes, and practices of nurses and physicians in primary care in Ulaanbaatar Mongolia

Increased blood pressure is a leading risk for death globally, and interventions to enhance hypertension control have become a high priority. An important aspect of clinical interventions is understanding the knowledge, attitudes, and practices (KAP) of differing primary healthcare practitioners. We examined KAP surveys from 803 primary care practitioners in Ulaanbaatar, Mongolia (response rate 80%), using a comprehensive KAP survey developed by the World Hypertension League (WHL). The WHL KAP survey uniquely includes an assessment of key World Health Organization recommended interventions to enhance hypertension control. There were few substantive differences between healthcare professional disciplines. Primary care practitioners mostly had a positive attitude toward hypertension management. However, confidence and practice in performing specific tasks to control hypertension were suboptimal. A low proportion indicated they systematically screened adults for hypertension and many were not aware of the need to or were confident in prescribing more than two antihypertensive medications. It was the practice of a high proportion of doctors to not pharmacologically treat most people with hypertension who were at high cardiovascular risk. There was a reluctance by physicians to task share hypertension diagnosis, drug prescribing and assessing cardiovascular risk to nurses. The minority of health care professions use a hypertension management algorithm, and few have patient registries with performance reporting functions. There were few substantive differences based on the age, gender, and years of clinical practice of the practitioners. The study findings support the need for standardized education and training of primary care practitioners in Ulaanbaatar to enhance hypertension control.