The relative risk of myocardial infarction in patients who have high blood pressure and non-cardiac pain

The authors conducted a population-based case-control study to determine the risk of myocardial infarction in patients who reported angina-like symptoms. The cases studied were those of patients who had high blood pressure and had sought treatment in 1984 with myocardial infarction as the first manifestation of coronary artery disease. Controls, a random sample of patients who had hypertension, were frequency-matched to cases by age and gender. Blind to case-control status, the authors reviewed the medical records of the 32 cases and 64 controls for reports of angina-like symptoms. While controls reported such symptoms at a constant rate, the events for the cases clustered near their infarctions. When a patient with hypertension sought medical advice for angina-like symptoms, the risk of infarction within 30 days was 14.2 (95% confidence interval, 2.8 to 71), and after 30 days it fell to 1.03. Among patients who have high blood pressure but no history of angina, presentations with prodromal symptoms in the primary care setting are so common that only about one in 100 such visits actually heralds myocardial infarction. Presented at the National Meeting of the Robert Wood Johnson Clinical Scholars Program, Scottsdale, AZ (October 1986) and the National Meeting of the American Federation for Clinical Research, San Diego, CA (May 1987). Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, NJ, and by the Health Services Research and Development Program, Veterans Administration Medical Center, Seattle, WA. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the VA Medical Center.     

A survival guide for generalist physicians in academic fellowships

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

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

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

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

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

A controlled trial to increase office visits and reduce hospitalizations of diabetic patients

An intervention package was examined to determine its effectiveness in increasing office visits and in reducing the incidence of nonelective hospitalizations (those for urgent or emergent reasons). The intervention included mailings of information, appointment reminders, and intense follow-up by telephone of visit failures for rescheduling. Eight hundred fifty-four patients receiving drug therapy for diabetes mellitus were stratified by risk of nonelective hospitalization and randomly assigned to the control group or the intervention group. After two years, the intervention group averaged 9.1 per cent more kept scheduled visits per month than the control group (0.371 vs. 0.340, p=0.02). However, the mean incidence of nonelective hospitalizations per month was not significantly different between intervention and control groups (0.040 vs. 0.041, p=0.9), nor was there a difference in nonelective hospital days per month (0.443 vs. 0.425, p=0.7). The authors conclude that while mailings and telephone calls can increase office visits, the intervention is not sufficient to reduce morbidity necessitating nonelective hospitalizations of diabetic patients. Received from the Regenstrief Institute for Health Care, the Divisions of General Medicine and Biostatistics of the Department of Medicine, Indiana University School of Medicine, and the Veterans Administration Medical Center, Indianapolis, Indiana. Supported in part by Public Health Services Research Grant P60 20542 from the National Institutes of Health and by a grant from the Robert Wood Johnson Foundation.     

Can a specialty society educate its members to think differently about clinical decisions?

OBJECTIVE: Measure the effect of specialty society-developed continuing medical education (CME) on clinical decision making. DESIGN: Randomized controlled trial. SETTING: National sample of neurologists. PARTICIPANTS: Of 492 neurologists randomly selected from an ongoing American Academy of Neurology CME program, 248 were randomized to receive a mailed CME course, and 244 did not receive it. INTERVENTION: A mailed educational course on movement disorders, developed by the specialty society, containing information on diseases and practice recommendations with illustrative case presentations. MEASUREMENTS AND MAIN RESULTS: We assessed adherence to 16 practice recommendations on disease detection, diagnostic test use, and treatments by mailed survey sent to all subjects 4.5 months after the intervention group received the course (73% response rate). The survey contained detailed clinical scenarios to measure self-reported clinical decision making and short open-ended questions to measure factual knowledge. More intervention participants (up to 2.6 times more) than control subjects reported clinical decision making adherent to 9 of the 16 recommendations (p<.05). For 4 of the other 7 recommendations, adherence exceeded 85% in both groups. Within the intervention group, neurologists who read the educational course were 2 to 6 times more likely to be adherent than neurologists who did not. The intervention group had better factual knowledge than control subjects in six of seven areas (p<.01). CONCLUSIONS: This educational course improved neurologists’ reported decision making. Specialty society-developed CME that utilizes a similar format may enhance the effectiveness of mailed CME information to improve physicians’ approach to clinical decisions. Presented at the Robert Wood Johnson Clinical Scholars annual meeting, November 1995, and VA Health Services Research and Development annual meeting, February 1996. Supported by an unrestricted grant from the American Academy of Neurology and by the Office of Research and Development, Health Services Research & Development Program, Center for the Study of Healthcare Provider Behavior. Dr. Gifford received additional support from the Robert Wood Johnson Clinical Scholars Program and from the Bureau of Health Professions, Mid-Career Faculty Training Program in Geriatric Medicine and Dentistry, grant 5D31AH99000-08. Dr. Vickrey received additional support from a Clinical Investigator Development Award from NINDS (K08NS0 1669-02). Opinions are those of the authors and do not necessarily reflect the views of the sponsoring institutions, the Department of Veterans Affairs, the University of California, Los Angeles, or RAND.     

Proficiency of internal medicine residents in outpatient care of patients with HIV infection

To determine internal medicine residents’ knowledge of HIV care, the authors conducted a survey of residents from four internal medicine programs in the San Francisco Bay area. On a knowledge test, the mean score was 42.4/55, 77% correct. The residents performed relatively worse on questions regarding didanosine and zalcitabine, tuberculosis prophylaxis, and risk of cervical neoplasia in HIV-infected women. Predictors of greater knowledge were specific residency program, higher postgraduate year, primary care residency track, and more extensive HIV experience. Primary care internal medicine residencies and programs with more exposure to HIV patients are most effective in producing knowledgeable residents. Supported by the AIDS Clinical Research Center, University of California San Francisco, VA Medical Center (141A), 4150 Clement Street, San Francisco, CA 94121; and National Institute of Mental Health Grant: MH44045 (Dr. Cooke). Dr. Bindman is a Robert Wood Johnson Generalist Physician Faculty Scholar. This research was conducted, in part, while Dr. Schultz was a fellow in general internal medicine and clinical epidemiology in the Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California.     

Health of homeless women with recent experience of rape

There is limited understanding of the physical health, mental health, and substance use or abuse correlates of sexual violence against homeless women. This study documents the association of rape with health and substance use or abuse characteristics reported by a probability sample of 974 homeless women in Los Angeles. Controlling for potential confounders, women who reported rape fared worse than those who did not on every physical and mental health measure and were also more likely to have used and abused drugs other than alcohol. Results should serve to alert clinicians about groups of homeless women who may benefit from rape screening and treatment interventions. Presented, in part, at the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) Second National Conference on Women in Los Angeles, Calif, June 1999. The research presented here was supported by a grant to Suzanne Wenzel from The Commonwealth Fund, and by a grant to Lillian Gelberg from the Agency for Health Care Policy and Research. Dr. Gelberg is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar.     

Transforming Clinical Practice to Eliminate Racial–Ethnic Disparities in Healthcare

Racial–ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial–ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial–ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial–ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. Funding: Drs. Washington (#RCD-00-017), Saha (#RCD-00-028), and Moody (#RCD-03-183) are supported by grants from the Department of Veterans Affairs, Health Services Research and Development Service. Dr. Saha is supported by a Generalist Physician Faculty Scholar award from the Robert Wood Johnson Foundation. Drs. Horowitz (#P60 MD00270) and Brown (#P20MD00148) are supported by grants from the National Center on Minority Health and Health Disparities. Dr. Brown also received support from the University of California, Los Angeles, Resource Center in Minority Aging Research (#AG02004) and the Beeson Career Development Award (#AG26748). Dr. Cooper is supported by a grant from the National Heart, Lung, and Blood Institute (K24HL083113).     

The prediction of streptococcal pharyngitis in adults

The usefulness of clinical and laboratory findings for prediction of the presence of Group A streptococci on throat culture and of an increase in antistreptococcal antibodies was investigated in 693 adult patients. Several findings were shown to increase the likelihood of streptococcal isolation, alone and in combination: tonsillar exudate, tonsillar enlargement, tender anterior cervical adenopathy, myalgias, and a positive throat culture in the preceding year. Compared with a frequency of 9.7% in all patients, the probabilities of a positive culture were quite different (ranging from 2 to 53%) in subgroups of patients with different combinations of these clinical findings. The results of a leukocyte count and measurement of C-reactive protein added little additional predictive information. While clinical findings can never predict perfectly the results of a throat culture, they nevertheless can provide useful information — particularly in tending to “rule out” streptococcal infection — in adult patients with pharyngitis. Received from the Divisions of General Medicine and Primary Care, Joint Department of Medicine, Brigham and Women’s Hospital and Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts: the Charles A. Dana Research Center and the Harvard-Thorndike Laboratory: the Institute for Health Research, Harvard School of Public Health: the Harvard Community Health Plan (Kenmore Branch), Boston, Massachusetts; and the Rhode Island Group Health Association, Providence, Rhode Island. Supported by grants from the National Center for Health Services Research (HS 02063 and HS 04066) and grants from the Commonwealth Fund, and the Robert Wood Johnson Foundation.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

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

Predicting the outcomes of electrophysiologic studies of patients with unexplained syncope

Purpose:To develop and validate a predictive model that would allow clinicians to determine whether an electrophysiologic (EP) study is likely to result in useful diagnostic information for a patient who has unexplained syncope. Patients:One hundred seventy-nine consecutive patients with unexplained syncope who underwent EP studies at two university medical centers comprised the training sample. A test sample to validate the model was made up of 138 patients from the clinical literature who had undergone EP studies for syncope. Design:Retrospective analysis of patients undergoing EP studies for syncope. The data collector was blinded to the study hypothesis; the electrophysiologist assessing outcomes was blinded to clinical and historical data. Clinical predictor variables available from the history, the physical examination, electrocardiography (ECG), and Holter monitoring were analyzed via two multivariable predictive modeling strategies (ordinal logistic regression and recursive partitioning) for their abilities to predict the results of EP studies, namely tachyarrhythmic and bradyarrhythmic outcomes. These categories were further divided into full arrhythmia and borderline arrhythmia groups. Results:Important outcomes were 1) sustained monomorphic ventricular tachycardia (VT) and 2) bradyarrhythmias, including sinus node and atrioventricular (AV) conducting disease. The results of the logistic regression (in this study, the superior strategy) showed that the presence of organic heart disease [odds ratio (OR)=3.0, p<0.001] and frequent premature ventricular contractions on ECG (OR=6.7, p<0.004) were associated with VT, while the following abnormal ECG findings were associated with bradyarrhythmias: first-degree heart block (OR=7.9, p<0.001), bundle-branch block (OR=3.0, p<0.02), and sinus bradycardia (OR=3.5, p<0.03). Eighty-seven percent of the 31 patients with important outcomes at EP study had at least one of these clinical risk factors, while 95% of the patients with none of these risk factors had normal or nondiagnostic EP studies. In the validation sample, the presence of one or more risk factors would have correctly identified 88% of the test VT patients and 65% of the test bradyarrhythmia patients as needing EP study. Conclusion:These five identified predictive factors, available from the history, the physical examination, and the initial ECG, could be useful to clinicians in selecting those patients with unexplained syncope who will have a serious arrhythmia identified by EP studies. Received from the Divisions of General Internal Medicine and Cardiology, Department of Medicine, the Division of Biometry, Department of Community and Family Medicine, and the Center for Health Policy Research and Education, Duke University Medical Center, and the Health Services Research Field Program, Veterans Affairs Medical Center, Durham, North Carolina. Presented at the annual meeting of the Society of General Internal Medicine, Arlington, VA, April 26–28, 1989. Supported by an Andrew Mellon Foundation Clinical Epidemiology Grant and a grant from the Robert Wood Johnson Foundation.     

The effects of a cost-education program on hospital charges

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

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking

OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared. DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months. PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients (N=47) and providers (N=17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus. INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit. MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P=.026). CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted. This research was supported by grants from the University of Washington Royalty Research Fund, and the Department of Veterans Affairs, Health Services Research and Development Service (SDR 96-002). Dr. Bradley is an investigator at the VA Puget Sound Health Care System, and is currently supported by National Institute of Alcohol Abuse and Alcoholism grant no. K23AA00313) and is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, the National Institute of Alcohol Abuse and Alcoholism, or the Robert Wood Johnson Foundation.     

Does the mean corpuscular volume help physicians evaluate hospitalized patients with anemia?

The authors analyzed the value of using mean corpuscular volume (MCV) as a guide for selecting tests for further evaluation of anemia in hospitalized patients. Of the 2,082 patients with anemia admitted to the medical service of a teaching hospital over one year, 655 (31%) had further diagnostic tests to evaluate the cause of the anemia. Within this group of 655 patients, 399 (61%) had normal MCVs. Over half the patients with abnormal serum vitamin B₁₂, folate, or ferritin levels, or with low serum iron (Fe) levels with elevated total iron-binding capacity (TIBC), did not have the MCVs expected according to the classification of anemia proposed by Wintrobe. Furthermore, 5% of patients with evidence of iron deficiency had high MCVs, and about 12% of patients with decreased vitamin B₁₂ levels had low MCVs. The MCV was quite specific in identifying patients who had low ferritin levels: specificity was 83%; however, sensitivity was only 48%. The MCV was also specific (88%) for identifying patients who had low Fe with elevated TIBC; however, sensitivity was only 43%. The MCV was poor in identifying patients with abnormalities of serum vitamin B₁₂ and folate levels. In this study the MCV did not provide sufficient diagnostic accuracy to be a useful criterion for the selection of more definitive tests in the evaluation of anemia in hospitalized patients. Supported in part by Grant LM 04260 from the National Library of Medicine and Grant HS04928 from the National Center for Health Services Research.     

Visual impairment and cognitive dysfunction in Alzheimer’s disease

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

The impact of leaving against medical advice on hospital resource utilization

OBJECTIVE: To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism. DESIGN: Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges. SETTING: Acute care hospitals. PATIENTS: We studied 23,198 pneumonia hospitalizations in a statewide administrative database. MEASUREMENTS AND MAIN RESULTS: Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD (p=.012). ARD-attributable increases of $1,659 (p=.002) and $1,664 (p=.002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD (p=.188). An increase of 1 day was seen using both strategies 2 and 3 (p=.044 and p=.027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1. CONCLUSIONS: Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization. Prelininary data were presented at the Association for Health Services Research national meeting in Atlanta, Ga, on June 11, 1997, and appear in abstract form on the National Library of Medicine’s MEDLARS database HealthSTAR. Dr. Saitz is a Generalist Physician Faculty Scholar of the Robert Wood Johnson Foundation and was also supported in this work by the Center for Substance Abuse Prevention Faculty Development Program, grant number 1 T15 SP07773-01, Substance Abuse Mental Health Services Administration, Department of Health and Human Services. This work was supported by the Massachusetts Health Data Consortium, which provided the data used in the analyses. Dr. Ghali is supported by a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research and is now at the Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.     

Screening elderly veterans for alcoholism

Objective:To determine the sensitivity and specificity of an alcoholism screening test not previously tested in the elderly. Design:Cross-sectional study, face-to-face interviews. Setting:Veterans Administration (VA) outpatient facility. Patients/participants:Men ≥70 years old seeking care in a newly established VA outpatient facility were invited to participate in a health assessment program. Of 109 participants who enrolled, 96 completed both interviews. Interventions:The screening test was administered by an internist as part of a medical history. The Michigan Alcobolism Screening Test (MAST), used as the “gold standard,” was administered by a trained interviewer as part of a longer structured interview. Measurements and main results:The screening test had a sensitivity of 0.52 and a specificity of 0.76 in this sample. Conclusions:The sensitivity and specificity of the screening test were lower in this sample in comparison with previously reported results in a younger population. Differences in the test performance may be related to differences in attitudes and drinking behaviors of elderly veterans when compared with those of younger men and women. Received from the Veterans Administration Lakeside Medical Center and the Northwestern University School of Medicine, Chicago, Illinois, and the Center for Health Services and Policy Research, Northwestern University, Evanston, Illinois. Supported by a grant from Medical District 17 Health Services Research and Development Field Program, Hines Veterans Administration Medical Center, Hines, Illinois.     

A controlled trial to decrease the unnecessary use of diagnostic tests

A controlled trial evaluated a program to decrease the unnecessary use of inpatient testing by medical residents in a university medical center. The program included education, concurrent feedback, and resident participation in program planning. Using specific criteria for 7,891 chart audits of patients who had repeat tests within seven days, the authors measured change in testing among 44 residents in the first year and 43 in the second year. There were no significant differences related to the program. They conclude that substantial overuse of diagnostic tests did occur, that it varied from hospital to hospital, and that the program could not overcome powerful counteracting influences. Future studies, using control groups and chart audits, should evaluate interventions other than education. Received from the Section of General Medicine, Department of Medicine, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Williams is a Henry J. Kaiser Family Foundation Faculty Scholar and Associate Professor of General Medicine. Dr. Eisenberg is Sol Katz Associate Professor of General Medicine and Chief of the Section of General Medicine. Supported primarily by a grant from Blue Cross of Greater Philadelphia. Additional support came from the National Fund for Medical Education (sponsored by the Prudential Insurance Corporation of America) and the National Health Care Management Center at the Leonard Davis Institute of Health Economics (Grant No. HS 02557, National Center for Health Services Research).     

Long-term care preferences of hospitalized persons with AIDS

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