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1.
Adeyinka O. Laiyemo Chyke Doubeni Paul F. Pinsky V. Paul Doria-Rose Robert Bresalier Thomas Hickey Thomas Riley Tim R. Church Joel Weissfeld Robert E. Schoen Pamela M. Marcus Philip C. Prorok 《Journal of general internal medicine》2015,30(10):1447-1453
BACKGROUND
It is unclear whether the higher rate of colorectal cancer (CRC) among non-Hispanic blacks (blacks) is due to lower rates of CRC screening or greater biologic risk.OBJECTIVE
We aimed to evaluate whether blacks are more likely than non-Hispanic whites (whites) to develop distal colon neoplasia (adenoma and/or cancer) after negative flexible sigmoidoscopy (FSG).DESIGN
We analyzed data of participants with negative FSGs at baseline in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial who underwent repeat FSGs 3 or 5 years later. Subjects with polyps or masses were referred to their physicians for diagnostic colonoscopy. We collected and reviewed the records of diagnostic evaluations.PARTICIPANTS
Our analytic cohort consisted of 21,550 whites and 975 blacks.MAIN MEASURES
We did a comparison by race (whites vs. blacks) in the findings of polyps or masses at repeat FSG, the follow-up of abnormal test results and the detection of colorectal neoplasia at diagnostic colonoscopy.KEY RESULTS
At the follow-up FSG examination, 304 blacks (31.2 %) and 4183 whites (19.4 %) had abnormal FSG, [adjusted relative risk (RR) = 1.00; 95 % confidence interval (CI), 0.90–1.10]. However, blacks were less likely to undergo diagnostic colonoscopy (76.6 % vs. 83.1 %; RR = 0.90; 95 % CI, 0.84–0.96). Among all included patients, blacks had similar risk of any distal adenoma (RR = 0.86; 95 % CI, 0.65–1.14) and distal advanced adenoma (RR = 1.01; 95 % CI, 0.60–1.68). Similar results were obtained when we restricted our analysis to compliant subjects who underwent diagnostic colonoscopy (RR = 1.01; 95 % CI, 0.80–1.29) for any distal adenoma and (RR = 1.18; 95 % CI, 0.73–1.92) for distal advanced adenoma.CONCLUSIONS
We did not find any differences between blacks and whites in the risk of distal colorectal adenoma 3–5 years after negative FSG. However, follow-up evaluations were lower among blacks.KEY WORDS: PLCO, colorectal cancer disparities, adenomatous polyps, flexible sigmoidoscopy, screening 相似文献2.
Rosette J. Chakkalakal MD MHS Stacy M. Higgins MD Lisa B. Bernstein MD Kristina L. Lundberg MD Victor Wu MD MPH Jacqueline Green MD MPH Qi Long PhD Joyce P. Doyle MD 《Journal of general internal medicine》2013,28(4):561-566
Background
Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam.Objective
To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain.Design
Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents’ performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse.Participants
One hundred forty-nine incoming residents.Main Measures
Residents’ performance for each skill was classified as correct, incorrect, or unknown.Key Results
One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46–0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41–0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16–0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01).Conclusions
We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.KEY WORDS: cardiovascular disease, clinical skills assessment, disparities, women’s health, medical student and residency education 相似文献3.
Erica S. Spatz MD MHS Sameer D. Sheth MD Kensey L. Gosch MS Mayur M. Desai PhD MPH John A. Spertus MD MPH Harlan M. Krumholz MD SM Joseph S. Ross MD MHS 《Journal of general internal medicine》2014,29(6):862-869
Background
The quality of the relationship between a patient and their usual source of care may impact outcomes, especially after an acute clinical event requiring regular follow-up.Objective
To examine the association between the presence and strength of a usual source of care with mortality and readmission after hospitalization for acute myocardial infarction (AMI).Design
Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, 19-center study.Patients
AMI patients discharged between January 2003 and June 2004.Main Measures
The strength of the usual source of care was categorized as none, weak, or strong based upon the duration and familiarity of the relationship. Main outcome measures were readmissions and mortality at 6 months and 12 months post-AMI, examined in multivariable analysis adjusting for socio-demographic characteristics, access and barriers to care, financial status, baseline risk factors, and AMI severity.Key Results
Among 2,454 AMI patients, 441 (18.0 %) reported no usual source of care, whereas 247 (10.0 %) and 1,766 (72.0 %) reported weak and strong usual sources of care, respectively. When compared with a strong usual source of care, adults with no usual source of care had higher 6-month mortality rates [adjusted hazard ratio (aHR) = 3.15, 95 % CI, 1.79–5.52; p < 0.001] and 12-month mortality rates (aHR = 1.92, 95 % CI, 1.19–3.12; p = 0.01); adults with a weak usual source of care trended toward higher mortality at 6 months (aHR = 1.95, 95 % CI, 0.98–3.88; p = 0.06), but not 12 months (p = 0.23). We found no association between the usual source of care and readmissions.Conclusions
Adults with no or weak usual sources of care have an increased risk for mortality following AMI, but not for readmission.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2794-0) contains supplementary material, which is available to authorized users.KEY WORDS: doctor and patient relationship, usual source of care, myocardial infarction 相似文献4.
Alison Brenner PhD MPH Kirsten Howard PhD Carmen Lewis MD MPH Stacey Sheridan MD MPH Trisha Crutchfield MHA MSIS Sarah Hawley PhD Dan Reuland MD MPH Christine Kistler MD MPH Michael Pignone MD MPH 《Journal of general internal medicine》2014,29(3):507-513
Purpose
To compare the effects of three methods of values clarification (VCM): balance sheet; rating and ranking; and a discrete choice experiment (DCE) on decision-making about colorectal cancer (CRC) screening among adults in the US and Australia.Methods
Using online panels managed by a survey research organization in the US and Australia, we recruited adults ages 50–75 at average risk for CRC for an online survey. Those eligible were randomized to one of the three VCM tasks. CRC screening options were described in terms of five key attributes: reduction in risk of CRC incidence and mortality; nature of the screening test; screening frequency; complications from screening; and chance of requiring a colonoscopy (as initial or follow-up testing). Main outcomes included self-reported most important attribute and unlabeled screening test preference by VCM and by country, assessed after the VCM.Results
A total of 920 participants were enrolled; 51 % were Australian; mean age was 59.0; 87.0 % were white; 34.2 % had a 4-year college degree; 42.8 % had household incomes less than $45,000 USD per year; 44.9 % were up to date with CRC screening. Most important attribute differed across VCM groups: the rating and ranking group was more likely to choose risk reduction as most important attribute (69.8 %) than the balance sheet group (54.7 %) or DCE (49.3 %), p < 0.0001; most important attribute did not vary by country (p = 0.236). The fecal occult blood test (FOBT)-like test was the most frequently preferred test overall (55.9 %). Unlabeled test choice did not differ meaningfully by VCM. Australians were more likely to prefer the FOBT (AU 66.2 % vs. US 45.1 %, OR 2.4, 95 % CI 1.8, 3.1). Few participants favored no screening (US: 9.2 %, AU: 6.2 %).Conclusions
Screening test attribute importance varied by VCM, but not by country. FOBT was more commonly preferred by Australians than by Americans, but test preferences were heterogeneous in both countries.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2701-0) contains supplementary material, which is available to authorized users.KEY WORDS: values clarification, colorectal cancer screening, patient decision support 相似文献5.
Vashitz G Pliskin JS Parmet Y Kosashvili Y Ifergane G Wientroub S Davidovitch N 《Journal of general internal medicine》2012,27(10):1265-1271
Background
Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians.Objective
To evaluate whether physicians’ judgment is affected by another medical opinion given to a patient.Design
Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician’s opinion was (study group), and the other group was not told what it was (control group).Participants
A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population).Measurements
Scoring was by choice of less or more interventional treatment in the scenarios. We used χ2 tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician’s responses.Results
Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) = 4.6, p = 0.03; OR = 1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p = 0.039; scenario 2, p < 0.001; scenario 3, p = 0.033; scenario 6, p < 0.001). These effects were insignificant among the neurologists [F (1,158) = 0.44, p = 0.51; OR = 1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) = 0.752, p = 0.473; neurologists: F (2,154) = 1.951, p = 0.146].Conclusions
The exploratory survey showed that in some cases physicians’ judgments may be affected by other physicians’ opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2056-y) contains supplementary material, which is available to authorized users.KEY WORDS: second-opinion, differential diagnosis, diagnostic reasoning, medical decision-making, health policy, surgery, orthopedics, neurology, surveys, consultation 相似文献6.
Nancy C. Dolan Vanessa Ramirez-Zohfeld Alfred W. Rademaker M. Rosario Ferreira William L. Galanter Jonathan Radosta Milton “Mickey” Eder Kenzie A. Cameron 《Journal of general internal medicine》2015,30(12):1780-1787
BACKGROUND
Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.OBJECTIVE
Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.DESIGN
This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.PARTICIPANTS
Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.INTERVENTION
Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.MAIN MEASURES
Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.KEY RESULTS
The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.CONCLUSIONS
Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care 相似文献7.
David Goldberg MD Kathleen M. Weber BSN Jennifer Orsi MPH Nancy A. Hessol MSPH Gypsyamber D’Souza PhD D. Heather Watts MD Rebecca Schwartz PhD Chenglong Liu MD Marshall Glesby MD Pamela Burian PA-C Mardge H. Cohen MD 《Journal of general internal medicine》2010,25(1):39-44
BACKGROUND
Cigarette smoking is an important risk factor for adverse health events in HIV-infected populations. While recent US population-wide surveys report annual sustained smoking cessation rates of 3.4–8.5%, prospective data are lacking on cessation rates for HIV-infected smokers.OBJECTIVE
To determine the sustained tobacco cessation rate and predictors of cessation among women with or at risk for HIV infection.DESIGN
Prospective cohort study.PARTICIPANTS
A total of 747 women (537 HIV-infected and 210 HIV-uninfected) who reported smoking at enrollment (1994–1995) in the Women’s Interagency HIV Study (WIHS) and remained in follow-up after 10 years. The participants were mostly minority (61% non-Hispanic Blacks and 22% Hispanics) and low income (68% with reported annual incomes of less than or equal to $12,000).MEASUREMENTS AND MAIN RESULTS
The primary outcome was defined as greater than 12 months continuous cessation at year 10. Multivariate logistic regression was used to identify independent baseline predictors of subsequent tobacco cessation. A total of 121 (16%) women reported tobacco cessation at year 10 (annual sustained cessation rate of 1.8%, 95% CI 1.6–2.1%). Annual sustained cessation rates were 1.8% among both HIV-positive and HIV-negative women (p = 0.82). In multivariate analysis, the odds of tobacco cessation were significantly higher in women with more years of education (p trend = 0.02) and of Hispanic origin (OR = 1.87, 95% CI = 1.4–2.9) compared to Black women. Cessation was significantly lower in current or former illicit drug users (OR = 0.42 95% CI = 0.24–0.74 and OR = 0.65, 95% CI = 0.49–0.86, respectively, p trend = 0.03) and women reporting a higher number of cigarettes per day at baseline (p trend < 0.001).CONCLUSIONS
HIV-infected and at-risk women in this cohort have lower smoking cessation rates than the general population. Given the high prevalence of smoking, the high risk of adverse health events from smoking, and low rates of cessation, it is imperative that we increase efforts and overcome barriers to help these women quit smoking.KEY WORDS: smoking cessation, HIV/AIDS, clinical epidemiology, vulnerable populations 相似文献8.
Michael S. Wolf PhD MPH Jennifer King MPH Elizabeth A. H. Wilson PhD Laura M. Curtis MS Stacy Cooper Bailey PhD MPH James Duhig PhD Allison Russell BA Ashley Bergeron MPH Amanda Daly BA Ruth M. Parker MD Terry C. Davis PhD William H. Shrank MD MSHS Bruce Lambert PhD 《Journal of general internal medicine》2012,27(12):1714-1720
9.
Bella Patel Keiren E. Kirkland Richard Szydlo Rachel M. Pearce Richard E. Clark Charles Craddock Effie Liakopoulou Adele K. Fielding Stephen Mackinnon Eduardo Olavarria Mike N. Potter Nigel H. Russell Bronwen E. Shaw Gordon Cook Anthony H. Goldstone David I. Marks 《Haematologica》2009,94(10):1399-1406
Background
Approximately 40% of adults with Philadelphia chromosome-negative acute lymphoblastic leukemia achieve long-term survival following unrelated donor hematopoietic stem cell transplantation in first complete remission but severe graft-versus-host disease remains a problem affecting survival. Although T-cell depletion abrogates graft-versus-host disease, the impact on disease-free survival in acute lymphoblastic leukemia is not known.Design and Methods
We analyzed the outcome of 48 adults (median age 26 years) with high-risk, Philadelphia-chromosome-negative acute lymphoblastic leukemia undergoing T-cell depleted unrelated donor-hematopoietic stem cell transplantation (67% 10 of 10 loci matched) in first complete remission reported to the British Society of Blood and Marrow Transplantation Registry from 1993 to 2005.Results
T-cell depletion was carried out by in vivo alemtuzumab administration. Additional, ex vivo T-cell depletion was performed in 21% of patients. Overall survival, disease-free survival and non-relapse mortality rates at 5 years were 61% (95% CI 46–75), 59% (95% CI 45–74) and 13% (95% CI 3–25), respectively. The incidences of grades II–IV and III–IV acute graft-versus-host disease were 27% (95% CI 16–44) and 10% (95% CI 4–25), respectively. The actuarial estimate of extensive chronic graft-versus-host disease at 5 years was 22% (95%CI 13–38). High-risk cytogenetics at diagnosis was associated with a lower 5-year overall survival (47% (95% CI 27–71) vs. 68% (95% CI 44–84), p=0.045).Conclusions
T-cell depleted hematopoietic stem cell transplantation from unrelated donors can result in good overall survival and low non-relapse mortality for adults with high-risk acute lymphoblastic leukemia in first complete remission and merits prospective evaluation. 相似文献10.
David Edelman Rowena J. Dolor Cynthia J. Coffman Katherine C. Pereira Bradi B. Granger Jennifer H. Lindquist Alice M. Neary Amy J. Harris Hayden B. Bosworth 《Journal of general internal medicine》2015,30(5):626-633
Background
Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.Objective
To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.Design
The study was designed as a patient-level randomized controlled trial.Participants
Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5 %) but could have well-controlled HTN.Interventions
All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).Main Outcomes and Measures
Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.Results
Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD = 1 %) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention – control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (−0.3, 0.5), p = 0.51] and SBP [diff = −0.9 mmH g, 95% CI (−5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.Conclusions
In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.KEY WORDS: Diabetes, Hypertension, Implementation 相似文献11.
12.
Turner BJ Hollenbeak CS Liang Y Pandit K Joseph S Weiner MG 《Journal of general internal medicine》2012,27(10):1258-1264
OBJECTIVE
Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure.DESIGN AND SUBJECTS
A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension.INTERVENTION
Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease.MAIN MEASURES
Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months.KEY RESULTS
At baseline, the 136 intervention and 144 control subjects’ mean 4-year coronary heart disease risk did not differ (intervention = 5.8 % and control = 6.4 %, P = 0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p = 0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference −0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p = 0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a >5 mmHg reduction (61 % versus 45 %, respectively, p = 0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference −6.47 mmHg, 95 % confidence interval: −10.69 to −2.25, P = 0.003). One patient died in each study arm.CONCLUSIONS
Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure.KEY WORDS: coronary heart disease, hypertension, African American, peer support 相似文献13.
Sonja R. Solomon Holly C. Gooding Harry Reyes Nieva Jeffrey A. Linder 《Journal of general internal medicine》2015,30(11):1611-1617
BACKGROUND
The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes.OBJECTIVE
Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents’ primary care patients.DESIGN AND PARTICIPANTS
This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012.MAIN MEASURES
We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating.KEY RESULTS
Our study population comprised 90 residents, 4018 unique patients, and 5988 resident–patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, −2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31).CONCLUSIONS
Acute care utilization by residents’ patients did not increase or decrease after graduation. Acute care utilization was high before and after graduation. Interventions to decrease the need for acute care should be employed throughout the year.KEY WORDS: continuity of care, care transitions, medical education-systems based practice, medical education-graduate, ambulatory care, utilization 相似文献14.
Ishani Ganguli Yuchiao Chang Arlene Weissman Katrina Armstrong Joshua P. Metlay 《Journal of general internal medicine》2016,31(3):276-281
Background
The 2014–2015 Ebola virus disease (Ebola) epidemic centered in West Africa highlighted recurring challenges in the United States regarding risk communication and preparedness during global epidemics.Objective
To investigate perceptions, preparedness, and knowledge among U.S. internists with regard to Ebola risk.Design
Cross-sectional Web-based national survey distributed by e-mail between December 2014 and January 2015.Participants
Practicing U.S. internists participating in a research panel representative of American College of Physicians (ACP) membership.Main Measures
Respondents’ perceptions of Ebola, reported sources of information, and reported management of possible Ebola cases. The primary predictor was the possibility of encountering Ebola (based on respondents’ geographic proximity to designated airports or confirmed Ebola cases, or on their patients’ travel histories). Pre-specified outcomes included reported management intensity in clinical vignettes involving patients at low risk of symptomatic Ebola as well as reported Ebola preparedness.Key Results
The survey response rate was 46.1 %. Among the 202 respondents, 9.9 % (95 % CI 6.2–14.9 %) reported that they had recently evaluated a patient who had traveled to West Africa. Seventy percent (95 % CI 63.0–76.0 %) reported a practice-level protocol. The Centers for Disease Control and Prevention (CDC) was the most popular source for Ebola information (75.2 %, 95 % CI 68.7–81.0 %). Most respondents felt very (45.0 %) or somewhat prepared (52.0 %) to communicate information about or diagnose Ebola, especially those with the possibility of encountering Ebola and those who reported medical journals, professional groups, or government as information sources. One-fifth of respondents (19.8 %, 95 % CI 14.5–26.0 %) reported overly intensive management for low-risk patients. Those with the possibility of encountering Ebola were less likely to report overly intensive management (3.1 vs. 22.9 %, p = 0.011).Conclusions
Internists had wide-ranging views and understanding of Ebola risk; those least likely to encounter Ebola were most likely to be overly aggressive in managing patients at low risk. Our findings underscore the need for better risk communication through various information channels to empower frontline providers in infectious disease outbreaks.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-015-3493-1) contains supplementary material, which is available to authorized users.KEYWORDS: Ebola, risk communication, physician behavior, medical decision making, evidence based medicine 相似文献15.
16.
Working with Patients with Alcohol Problems: A Controlled Trial of the Impact of a Rich Media Web Module on Medical Student Performance
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Lee JD Triola M Gillespie C Gourevitch MN Hanley K Truncali A Zabar S Kalet A 《Journal of general internal medicine》2008,23(7):1006-1009
INTRODUCTION/AIMS
We designed an interactive web module to improve medical student competence in screening and interventions for hazardous drinking. We assessed its impact on performance with a standardized patient (SP) vs. traditional lecture.SETTING
First year medical school curriculum.PROGRAM DESCRIPTION
The web module included pre/posttests, Flash©, and text didactics. It centered on videos of two alcohol cases, each contrasting a novice with an experienced physician interviewer. The learner free-text critiqued each clip then reviewed expert analysis.PROGRAM EVALUATION
First year medical students conveniently assigned to voluntarily complete a web module (N = 82) or lecture (N = 81) were rated by a SP in a later alcohol case. Participation trended higher (82% vs. 72%, p < .07) among web students, with an additional 4 lecture-assigned students crossing to the web module. The web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score (1–13 pt.; 9 vs. 7.8, p < .02) and self-reported as better prepared for the SP case.CONCLUSIONS
A web module for alcohol use interview skills reached a greater proportion of voluntary learners and was associated with equivalent overall performance scores and higher brief intervention skills scores on a standardized patient encounter.KEY WORDS: health education, alcohol use disorders/alcoholism, Internet, multimedia learning 相似文献17.
Kong MC Nahata MC Lacombe VA Seiber EE Balkrishnan R 《Journal of general internal medicine》2012,27(9):1159-1164
Background
Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist.Objective
To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients.Design
Retrospective cohort study.Setting
Multi-state Medicaid database (Thomson Reuters MarketScan®).Participants
Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed.Main Measures
Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables.Key Results
In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63–0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12–3.29).Conclusions
Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.KEY WORDS: HIV, adherence, depression, race, Medicaid 相似文献18.
19.
Sunil Kripalani MD MSc Brian Schmotzer MS Terry A. Jacobson MD 《Journal of general internal medicine》2012,27(12):1609-1617
Background
Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most.Objective
To test the effect of two low-literacy interventions on medication adherence.Design
Randomized controlled trial, 2 × 2 factorial design.Participants
Adults with coronary heart disease in an inner-city primary care clinic.Interventions
For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions.Main Measures
The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG < 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest.Key Results
Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG < 0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR = 2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR = 2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR = 1.89; 95 % CI, 0.99 to 3.60).Conclusions
The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.KEY WORDS: coronary heart disease, medical adherence, medication management 相似文献20.