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.     

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.     

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.     

Predictors of recovery in activities of daily living among disabled older persons living in the community

Objective  To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community. Design  Prospective cohort study with 2-year follow-up. Setting  General community. Participants  213 men and women 72 years or older, who reported dependence in one or more ADLs. Measurements and Main Results  All participants underwent a comprehensive home assessment and were followed for recovery of ADL function, defined as requiring no personal assistance in any of the ADLs within 2 years. Fifty-nine participants (28%) recovered independent ADL function. Compared with those older than 85 years, participants aged 85 years or younger were more than 8 times as likely to recover their ADL function (relative risk [RR] 8.4; 95% confidence interval [CI] 2.7. 26). Several factors besides age were associated with ADL recovery in bivariate analysis, including disability in only one ADL, self-efficacy score greater than 75, Folstein Mini-Mental State Examination (MMSE) score of 28 or better, high mobility, score in the best third of timed physical performance, fewer than five medications, and good nutritional status. In multivariable analysis, four factors were independently associated with ADL recovery—age 85 years or younger (adjusted RR 4.1; 95% CI 1.3, 13), MMSE score of 28 or better (RR 1.7; 95% CI 1.2, 2.3), high mobility (RR 1.7; 95% CI 1.0, 2.9), and good nutritional status (RR 1.6; 95% CI 1.0, 2.5). Conclusions  Once disabled, few persons older than 85 years recover independent ADL function. Intact cognitive function, high mobility, and good nutritional status each improve the likelihood of ADL recovery and may serve as markers of resilliency in this population. Presented at the annual meeting of the American Geriatric Society, Chicago, Ill., May 4, 1996. Funded in part by the Claude D. Pepper Older Americans Independence Center (P60-AG10469) and by grant R01-AG07449 from the National Institute on Aging, Bethesda, Md., and was conducted while Dr. Gill was a Pfizer/AGS Postdoctoral Fellow. Dr. Gill is currently supported as a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar and as a Paul Beeson Physician Faculty Scholar in Aging Research. Dr. Robison was supported by a Research Training Award in the Epidemiology of Aging from the National Institute on Aging (5T32-AG00153).     

Decreased alcohol consumption in outpatient drinkers is associated with improved quality of life and fewer alcohol-related consequences

This study’s objective was to determine whether changes in alcohol consumption are associated with changes in quality of life and alcohol-related consequences in an outpatient sample of drinkers. Two hundred thirteen subjects completed the Short Form 36-item (SF-36) Health Survey and the Short Inventory of Problems at baseline, 6 months, and 12 months. Subjects who sustained a 30% or greater decrease in drinks per month reported improvement in SF-36 Physical Component Summary (P=.058) and Mental Component Summary (P=.037) scores and had fewer alcohol-related consequences (P<.001) when compared to those with a <30% decrease. These findings suggest another benefit of alcohol screening and intervention in the primary care setting. This research was supported by grant AA1029 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Dr. Kraemer is supported by a Mentored Career Development Award from NIAAA (K23 AA00235). Dr. Conigliaro is supported by an Advanced Career Development Award from the Department of Veterans Affairs HSR&D Service (CD-97324-A) and a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award (no. 031500).     

Medication management of depression in the United States and Ontario

OBJECTIVE: To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in the general population with major depression in the United States and Ontario, Canada. DESIGN: Survey using the U.S. National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Survey. PARTICIPANTS: All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States (n=574) and Ontario (n=250) in 1990. MEASUREMENTS AND MAIN RESULTS: Self-reported contact with general medical or mental health specialty providers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any provider within the previous 12 months, were the main outcome measures. The proportion of depressed persons receiving appropriate management was lower in the United States than in Ontario (7.3% vs 14.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of fewer Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AOR 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). These between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making contact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-income persons. The proportions of depressed recipients of any mental health care who received appropriate management were similar between countries (23.9% in the United States vs 27.7% in Ontario; AOR 0.8; 95% CI 0.3, 1.7). CONCLUSIONS: Most persons with depression in the United States and Ontario do not receive appropriate medication management. The rate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with general medical physicians for mental problems, especially for the poor. Economic barriers, rather than knowledge and attitudinal factors, appear to explain this difference. Preparation of this report was supported by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Award to Dr. Katz and a research scientist award to Dr. Kessler (grant MH00507) and Dr. Wells. The National Comorbidity Study is supported by the National Institute of Mental Health (grants MH46376 and MH49098) with supplemental support from the National Institute of Drug Abuse (through a supplement to MH46376) and the W. T. Grand Foundation (grant 90135190). Ronald C. Kessler is the principal investigator. The Mental Health Supplement to the Ontario Health Surveyor is supported by the Ontario Ministries of Health and Community and Social Services through the Ontario Mental Health Foundation. David R. Offord is the principal investigator. Collaborating National Comorbidity Study sites and investigatiors are The Addiction Research Foundation (Robin Room), Duke University Medical Center (Dan Blazer, Marvin Swartz), Harvard University (Richard Frank), Johns Hopkins University (James Anthony, William Eaton, Philip Leaf), the Max Planck Institute of Psychiatry—Clinical Institute (Hans-Ulrich Wittchen), the Medical College of Virginia (Kenneth Kendler), the University of Michigan (Lloyd Johnston, Ronald Kessler, Roderick Little), New York University (Patrick Shrout), SUNY Stony Brook (Evelyn Bromet), The University of Toronto (R. Jay Turner), and Washington University School of Medicine (Linda Cottler, Andrew Heath). Collaborating Mental Health Supplement to the Ontario Health Survey agencies and investigators are The Ontario Mental Health Foundation (Dugal Campbell), The Clarke Institute of Psychiatry (Paula Goering, Elizabeth Lin), McMaster University (Michael Boyle, David Offord), and the Ontario Ministry of Health (Gary Catlin).     

Physicians’ reports of focused expertise in clinical practice

Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians, yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute to decisions about physician training and staffing of medical groups. Dr. Keating was the recipient of a National Research Service Award from the Agency for Healthcare Research and Quality, Rockville, MD, Dr. Ayanian was a Generalist Physician Faculty Scholar of the Robert Wood Johnson Foundation, Princeton, NJ. This study was supported by the Primary Care Research and Education Fund of Brigham and Women’s Hospital.     

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.     

Alcohol Counseling Reflects Higher Quality of Primary Care

Background  Some primary care physicians do not conduct alcohol screening because they assume their patients do not want to discuss alcohol use. Objectives  To assess whether (1) alcohol counseling can improve patient-perceived quality of primary care, and (2) higher quality of primary care is associated with subsequent decreased alcohol consumption. Design  A prospective cohort study. Subjects  Two hundred eighty-eight patients in an academic primary care practice who had unhealthy alcohol use. Measurements  The primary outcome was quality of care received [measured with the communication, whole-person knowledge, and trust scales of the Primary Care Assessment Survey (PCAS)]. The secondary outcome was drinking risky amounts in the past 30 days (measured with the Timeline Followback method). Results  Alcohol counseling was significantly associated with higher quality of primary care in the areas of communication (adjusted mean PCAS scale scores: 85 vs. 76) and whole-person knowledge (67 vs. 59). The quality of primary care was not associated with drinking risky amounts 6 months later. Conclusions  Although quality of primary care may not necessarily affect drinking, brief counseling for unhealthy alcohol use may enhance the quality of primary care. Results of this study were presented at the following meetings: the annual national meeting of the Society of General Internal Medicine, Chicago, May 2004 and the annual national meeting of the Research Society on Alcoholism, Vancouver, Canada, June 2004. This study was funded by a grant from the Robert Wood Johnson Foundation (grant 031489). Dr. Samet received support from the National Institute on Alcohol Abuse and Alcoholism (K24-AA015674).     

Effect of residency duty-hour limits: views of key clinical faculty

BACKGROUND: To determine the effect of duty-hour limitations, it is important to consider the views of faculty who have the most contact with residents. METHOD: We conducted a national survey of key clinical faculty (KCF) at 39 internal medicine residency programs affiliated with US medical schools selected by random sample stratified by federal research funding and program size to elicit their views on the effect of duty-hour limitations on residents' patient care, education, professionalism, and well-being and on faculty workload and satisfaction. RESULTS: Of 154 KCF surveyed, 111 (72%) responded. The KCF reported worsening in residents' continuity of care (87%) and the physician-patient relationship (75%). Faculty believed that residents' education (66%) and professionalism, including accountability to patients (73%) and ability to place patient needs above self-interests (57%), worsened, yet 50% thought residents' well-being improved. The KCF reported spending more time providing inpatient services (47%). Faculty noted decreased satisfaction with teaching (56%), ability to develop relationships with residents (40%), and overall career satisfaction (31%). In multivariate analysis, KCF with 5 years of teaching experience or more were more likely to perceive a negative effect of duty hours on residents' education (odds ratio, 2.84; 95% confidence interval, 1.15-7.00). CONCLUSIONS: Key clinical faculty believe that duty-hour limitations have adversely affected important aspects of residents' patient care, education, and professionalism, as well as faculty workload and satisfaction. Residency programs should continue to look for ways to optimize experiences for residents and faculty within the confines of the duty-hour requirements.     

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.     

Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey

OBJECTIVE: To assess attitudes about career progress, resources for career development, and commitment to academic medicine in physician faculty at an academic medical center who spend more than 50% of their time in clinical care. DESIGN: Faculty survey. SETTING: Academic medical center and associated Veterans Affairs medical center. RESULTS: A total of 310 physician faculty responded to the survey. Half of the faculty reported spending 50% or less of their time in clinical care (mean, 31% of time) (group 1) and half reported spending more than 50% of their time in clinical care (mean, 72% of time) (group 2). Group 2 faculty had one third of the time for scholarly activities, reported slower career progress, and were less likely to be at the rank of professor (40% and 16% for groups 1 and 2, respectively; P<.001) or to be tenured (52% and 26%, respectively; P<.001) despite similar age and years on faculty. Group 2 faculty were 50% more likely to report that tenure and promotion criteria were not reviewed at their annual progress report (P =.003) and that they did not understand the criteria (P<.001). Group 2 faculty valued excellence in patient care over scholarship and national visibility. Group 2 faculty reported greater dissatisfaction with academic medicine and less commitment to a career in academic medicine. CONCLUSIONS: Physician faculty who spend more than 50% of their time in clinical care have less time, mentoring, and resources needed for development of an academic career. These obstacles plus differences in their attitudes about career success and recognition contribute to significant differences in promotion. These factors are associated with greater dissatisfaction with academic medicine and lower commitment to academic careers.     

Skin cancer control practices among physicians in a university general medicine practice

Physician counseling about sun protection and routine screening for skin cancer in high-risk individuals have been widely recommended. The purpose of this study was to assess the skin cancer control practices and knowledge among physicians in a university-based general medicine practice. Fifty-two physicians completed a survey on attitudes toward, behaviors in, and knowledge of skin cancer control. In addition, the ability of general medicine residents and attending physicians to correctly identify and make biopsy recommendations for ten photographed skin lesions was compared with that of third-year medical students and dermatology residents and attendings. The results of the survey illustrate a need for improving primary care physicians’ knowledge and identification of skin cancer risk factors, and increasing the frequency and consistency with which they perform skin cancer prevention counseling and complete skin examination in high-risk patient groups. Presented at the annual meeting of the Society of General Internal Medicine, April 29, 1994, Washington, DC. Dr. Dolan is supported by an American Cancer Society Cancer Control Career Development Award for Primary Care Physicians.     

Hidden from plain sight: Residents’ domestic violence screening attitudes and reported practices

BACKGROUND: Domestic violence (DV) is prevalent across all racial and socioeconomic classes in the United States. Little is known about whether physicians differentially screen based on a patient’s race or socioeconomic status (SES) or about resident physician screening attitudes and practices. OBJECTIVE: To assess the importance of patient race and SES and resident and clinical characteristics in resident physician DV screening practices. DESIGN, PARTICIPANTS: One-hundred and sixty-seven of 309 (response rate: 54%) residents from 6 specialties at a large academic medical center responded to a randomly assigned online survey that included 1 of 4 clinical vignettes and questions on attitudes and practices regarding DV screening. MEASUREMENTS: We measured patient, resident, and clinical practice characteristics and used bivariate and multivariate methods to assess their association with the importance residents place on DV screening and if they would definitely screen for DV in the clinical vignette. RESULTS: Residents screened the African-American and the Caucasian woman (51% vs 57%,P=.40) and the woman of low SES and high SES (49% vs 58%.P=.26) at similar rates. Thirty-seven percent of residents incorrectly reported rates of DV are higher among African Americans than Caucasians, and 66% incorrectly reported rates are higher among women of lower than of higher SES. In multivariate analyses, residents who knew where to refer DV victims (adjusted odds ratio [AOR]=3.54, 95% confidence interval [CI]: 1.43 to 8.73) and whose mentors advised them to screen (AOR=3.46, 95% CI: 1.42 to 8.42) were more likely to screen for DV. CONCLUSION: Although residents have incorrect knowledge about the epidemiology of DV. they showed no racial or SES preferences in screening for DV. Improvement of mentoring and educating residents about referral resources may be promising strategies to increase resident DV screening. This work was supported by the Department of Internal Medicine residency program at the University of Michigan Health System, the Robert Wood Johnson Foundation’s Clinical Scholar Program, and the Department of Veterans Affairs (VA) Health Services Research & Development (HSR&D) Service. Dr. Heisler is a VA Research Career Development awardee.     

How well do faculty evaluate the interviewing skills of medical students?

Objective:To study the reliability and validity of using medical school faculty in the evaluation of the interviewing skills of medical students. Design:All second-year University of North Carolina medical students (n=159) were observed interviewing standardized patients for 5 minutes by one of eight experienced clinical faculty. Interview quality was assessed by a faculty checklist covering questioning style, facilitative behaviors, and specific content. Twenty-one randomly chosen students were videotaped and rated: by the original rater as well as four other raters; by two nationally recognized experts; and according to Roter’s coding dimensions, which have been found to correlate strongly with patient compliance and satisfaction. Setting:Medical school at a state university in the southeastern United States. Participants:Faculty members who volunteered to evaluate second-year medical students during an annual Objective Structured Clinical Exam. Interventions:Interrater reliability and intrarater reliability were tested using videotapes of medical students interviewing a standardized patient. Validity was tested by comparing the faculty judgment with both an analysis using the Roter Interactional Analysis System and an assessment made by expert interviewers. Measurements and main results:Faculty mean checklist score was 80% (range 41–100%). Intrarater reliability was poor for assessment of skills and behaviors as compared with that for content obtained. Interrater reliability was also poor as measured by intraclass correlation coefficients ranging from 0.11 to 0.37. When compared with the experts, faculty raters had a sensitivity of 80% but a specificity of 45% in identifying students with adequate skills. The predictive value of faculty assessment was 12%. Analysis using Roter’s coding scheme suggests that faculty scored students on the basis of likability rather than specific behavioral skills, limiting their ability to provide behaviorally specific feedback. Conclusions:To accurately evaluate clinical interviewing skills we must enhance rater consistency, particularly in assessing those skills that both satisfy patients and yield crucial data. Received from the Robert Wood Johnson Clinical Scholars Program, Division of General Medicine, Department of Medicine, Department of Health Behavior and Health Education, School of Public Health, Office of Academic Affairs, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Presented at the Southern regional meeting of the Society of General Internal Medicine, January 1990, New Orleans, Louisiana; the annual meeting of the Society for Behavioral Medicine, April 1990, Chicago, Illinois; and the annual meeting of the Clinical Scholars, November 1990, Ft. Lauderdale, Florida.     

Potentially modifiable resident characteristics that are associated with physical or verbal aggression among nursing home residents with dementia

BACKGROUND: Physical aggression by nursing home residents is a burden to residents and staff. The identification of modifiable correlates would facilitate developing preventive strategies. The objectives of the study were to determine potentially modifiable resident characteristics that are associated with physical aggression and to correlate these characteristics with verbal aggression. METHODS: This was a cross-sectional study of nursing home residents in 5 states who had at least 1 annual Minimum Data Set assessment completed during 2002. Case subjects were defined as nursing home residents 60 years and older with dementia who were reported to have been physically aggressive in the week before their assessment. Control subjects were all other residents 60 years and older with dementia. The main outcome measure was being physically aggressive during the past week. RESULTS: A total of 103 344 residents met study criteria, of whom 7120 (6.9%) had been physically aggressive in the week before their annual Minimum Data Set assessment. After adjustment for potential confounders, including age, sex, severity of cognitive impairment, and dependence in activities of daily living, physical aggression was associated with depressive symptoms (adjusted odds ratio [AOR], 3.3; 99% confidence interval [CI], 3.0-3.6), delusions (AOR, 2.0; 99% CI, 1.7-2.4), hallucinations (AOR, 1.4; 99% CI, 1.1-1.8), and constipation (AOR, 1.3; 99% CI, 1.2-1.5). Urinary tract infections, respiratory tract infections, fevers, reported pain, and participation in recreational activities were not significantly associated with physical aggression in multivariate analyses (P >.01 for all). Except for constipation, the correlates of verbal aggression were similar to those of physical aggression. CONCLUSION: If the associations we have estimated are causal, then treatment of depression, delusions, hallucinations, and constipation may reduce physical aggression among nursing home residents.     

Is physician self-disclosure related to patient evaluation of office visits?

CONTEXT: Physician self-disclosure has been viewed either positively or negatively, but little is known about how patients respond to physician self-disclosure. OBJECTIVE: To explore the possible relationship of physician self-disclosure to patient satisfaction. DESIGN: Routine office visits were audiotaped and coded for physician self-disclosure using the Roter Interaction Analysis System (RIAS). Physician self-disclosure was defined as a statement describing the physician's personal experience that has medical and/or emotional relevance for the patient. We stratified our analysis by physician specialty and compared patient satisfaction following visits in which physician self-disclosure did or did not occur. PARTICIPANTS: Patients (N= 1,265) who visited 59 primary care physicians and 65 surgeons. MAIN OUTCOME MEASURE: Patient satisfaction following the visit. RESULTS: Physician self-disclosure occurred in 17% (102/589) of primary care visits and 14% (93/676) of surgical visits. Following visits in which a primary care physician self-disclosed, fewer patients reported feelings of warmth/friendliness (37% vs 52%; P =.008) and reassurance/comfort (42% vs 55%; P =.027), and fewer reported being very satisfied with the visit (74% vs 83%; P =.031). Following visits in which a surgeon self-disclosed, more patients reported feelings of warmth/friendliness (60% vs 45%; P =.009) and reassurance/comfort (59% vs 47%; P=.044), and more reported being very satisfied with the visit (88% vs 75%; P =.007). After adjustment for patient characteristics, length of the visit, and other physician communication behaviors, primary care patients remained less satisfied (adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.24 to 0.81) and surgical patients more satisfied (AOR, 2.22; 95% CI, 1.12 to 4.50) after visits in which the physician self-disclosed. CONCLUSIONS: Physician self-disclosure is significantly associated with higher patient satisfaction ratings for surgical visits and lower patient satisfaction ratings for primary care visits. Further study is needed to explore these intriguing findings and to define the circumstances under which physician self-disclosure is either well or poorly received.     

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).     

Primary care and receipt of preventive services

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services. DESIGN: A cross-sectional telephone survey. SETTING: Population based. PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California. INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication. MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services. CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care. Supported by Robert Wood Johnson Foundation grant 22907 and Agency for Health Care Policy Research (AHCPR) grant HSO7373. Dr. Bindman and Dr. Grumbach are Robert Wood Johnson Foundation Generalist Physician Faculty Scholars.