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Tyler N. A. Winkelman Lisa Soleymani Lehmann Navjyot K. Vidwan Meredith Niess Cynthia S. Davey Derek Donovan Joseph Cofrancesco Jr. Mia Mallory Sandi Moutsios Ryan M. Antiel John Y. Song 《Journal of general internal medicine》2015,30(7):1018-1024
BACKGROUND
It is not known whether medical students support the Affordable Care Act (ACA) or possess the knowledge or will to engage in its implementation as part of their professional obligations.OBJECTIVE
To characterize medical students’ views and knowledge of the ACA and to assess correlates of these views.DESIGN
Cross-sectional email survey.PARTICIPANTS
All 5,340 medical students enrolled at eight geographically diverse U.S. medical schools (overall response rate 52 % [2,761/5,340]).MAIN MEASURES
Level of agreement with four questions regarding views of the ACA and responses to nine knowledge-based questions.KEY RESULTS
The majority of respondents indicated an understanding of (75.3 %) and support for (62.8 %) the ACA and a professional obligation to assist with its implementation (56.1 %). The mean knowledge score from nine knowledge-based questions was 6.9 ± 1.3. Students anticipating a surgical specialty or procedural specialty compared to those anticipating a medical specialty were less likely to support the legislation (OR = 0.6 [0.4–0.7], OR = 0.4 [0.3–0.6], respectively), less likely to indicate a professional obligation to implement the ACA (OR = 0.7 [0.6–0.9], OR = 0.7 [0.5–0.96], respectively), and more likely to have negative expectations (OR = 1.9 [1.5–2.6], OR = 2.3 [1.6–3.5], respectively). Moderates, liberals, and those with an above-average knowledge score were more likely to indicate support for the ACA (OR = 5.7 [4.1–7.9], OR = 35.1 [25.4–48.5], OR = 1.7 [1.4–2.1], respectively) and a professional obligation toward its implementation (OR = 1.9 [1.4–2.5], OR = 4.7 [3.6–6.0], OR = 1.2 [1.02–1.5], respectively).CONCLUSIONS
The majority of students in our sample support the ACA. Support was highest among students who anticipate a medical specialty, self-identify as political moderates or liberals, and have an above-average knowledge score. Support of the ACA by future physicians suggests that they are willing to engage with health care reform measures that increase access to care.KEY WORDS: Medical students, Health care reform, Affordable Care Act, Survey 相似文献3.
Prabhu P. Gounder Tiffany G. Harris Holly Anger Lisa Trieu Jeanne Sullivan Meissner Betsy L. Cadwell Elena Shashkina Shama D. Ahuja 《Journal of general internal medicine》2015,30(6):742-748
Background
Patients with prior positive tuberculin skin test (TST) results may benefit from prophylaxis after repeat exposure to infectious tuberculosis (TB).Objective
To evaluate factors associated with active TB disease among persons with prior positive TST results named as contacts of persons with infectious TB.Design
Population-based retrospective cohort study.Participants
A total of 2,933 contacts with prior positive TST results recently exposed to infectious TB identified in New York City’s TB registry during the period from January 1, 1997 through December 31, 2003.Main Measurements
Contacts developing active TB disease ≤ 4 years after exposure were identified and compared with those who did not, using Poisson regression analysis. Genotyping was performed on selected Mycobacterium tuberculosis-positive isolates.Key Results
Among contacts with prior positive TST results, 39 (1.3 %) developed active TB disease ≤ 4 years after exposure (≤2 years: 34). Risk factors for contacts that were independently associated with TB were age < 5 years (adjusted prevalence ratio [aPR] = 19.48; 95 % confidence interval [CI] = 7.15–53.09), household exposure (aPR = 2.60;CI = 1.30–5.21), exposure to infectious patients (i.e., cavities on chest radiograph, acid-fast bacilli on sputum smear; aPR = 1.9 3;CI = 1.01–3.71), and exposure to a U.S.-born index patient (aPR = 4.04; CI = 1.95–8.38). Receipt of more than1 month of treatment for latent TB infection following the current contact investigation was found to be protective (aPR = 0.27; CI = 0.08–0.93). Genotype results were concordant with the index patients among 14 of 15 contacts who developed active TB disease and had genotyping results available.Conclusions
Concordant genotype results and a high proportion of contacts developing active TB disease within 2 years of exposure indicate that those with prior positive TST results likely developed active TB disease from recent rather than remote infection. Healthcare providers should consider prophylaxis for contacts with prior TB infection, especially young children and close contacts of TB patients (e.g., those with household exposure).KEY WORDS: contact tracing, tuberculosis infection, prevention and control, epidemiology 相似文献4.
Audrey L. Jones Susan D. Cochran Arleen Leibowitz Kenneth B. Wells Gerald Kominski Vickie M. Mays 《Journal of general internal medicine》2015,30(12):1828-1836
BACKGROUND
The benefits of the patient-centered medical home (PCMH) over and above that of a usual source of medical care have yet to be determined, particularly for adults with mental health disorders.OBJECTIVE
To examine qualities of a usual provider that align with PCMH goals of access, comprehensiveness, and patient-centered care, and to determine whether PCMH qualities in a usual provider are associated with the use of mental health services (MHS).DESIGN
Using national data from the Medical Expenditure Panel Survey, we conducted a lagged cross-sectional study of MHS use subsequent to participant reports of psychological distress and usual provider and practice characteristics.PARTICIPANTS
A total of 2,358 adults, aged 18–64 years, met the criteria for serious psychological distress and reported on their usual provider and practice characteristics.MAIN MEASURES
We defined “usual provider” as a primary care provider/practice, and “PCMH provider” as a usual provider that delivered accessible, comprehensive, patient-centered care as determined by patient self-reporting. The dependent variable, MHS, included self-reported mental health visits to a primary care provider or mental health specialist, counseling, and psychiatric medication treatment over a period of 1 year.RESULTS
Participants with a usual provider were significantly more likely than those with no usual provider to have experienced a primary care mental health visit (marginal effect [ME] = 8.5, 95 % CI = 3.2–13.8) and to have received psychiatric medication (ME = 15.5, 95 % CI = 9.4–21.5). Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist (ME = 7.6, 95 % CI = 0.7–14.4) and receive mental health counseling (ME = 8.5, 95 % CI = 1.5–15.6). Among those who reported having had any type of mental health visit, participants with a PCMH were more likely to have received mental health counseling than those with only a usual provider (ME = 10.0, 95 % CI = 1.0–19.0).CONCLUSIONS
Access to a usual provider is associated with increased receipt of needed MHS. Patients who have a usual provider with PCMH qualities are more likely to receive mental health counseling.KEY WORDS: patient-centered medical home, primary care, mental health services, Affordable Care Act, race 相似文献5.
Lindsay C. Kobayashi Jane Wardle Michael S. Wolf Christian von Wagner 《Journal of general internal medicine》2015,30(7):958-964
BACKGROUND
Low health literacy is common among aging patients and is a risk factor for morbidity and mortality. We aimed to describe health literacy decline during aging and to investigate the roles of cognitive function and decline in determining health literacy decline.METHODS
Data were from 5,256 non-cognitively impaired adults aged ≥ 52 years in the English Longitudinal Study of Ageing. Health literacy was assessed using a four-item reading comprehension assessment of a fictitious medicine label, and cognitive function was assessed in a battery administered in-person at baseline (2004–2005) and at follow-up (2010–2011).RESULTS
Overall, 19.6 % (1,032/5,256) of participants declined in health literacy score over the follow-up. Among adults aged ≥ 80 years at baseline, this proportion was 38.2 % (102/267), compared to 14.8 % (78/526) among adults aged 52–54 years (OR = 3.21; 95 % CI: 2.26–4.57). Other sociodemographic predictors of health literacy decline were: male sex (OR = 1.20; 95 % CI: 1.04–1.38), non-white ethnicity (OR = 2.42; 95 % CI: 1.51–3.89), low educational attainment (OR = 1.58; 95 % CI: 1.29–1.95 for no qualifications vs. degree education), and low occupational class (OR = 1.67; 95 % CI: 1.39–2.01 for routine vs. managerial occupations). Higher baseline cognitive function scores protected against health literacy decline, while cognitive decline (yes vs. no) predicted decline in health literacy score (OR = 1.59; 95 % CI: 1.35–1.87 for memory decline and OR = 1.56; 95 % CI: 1.32–1.85 for executive function decline).CONCLUSIONS
Health literacy decline appeared to increase with age, and was associated with even subtle cognitive decline in older non-impaired adults. Striking social inequalities were evident, whereby men and those from minority and deprived backgrounds were particularly vulnerable to literacy decline. Health practitioners must be able to recognize limited health literacy to ensure that clinical demands match the literacy skills of diverse patients.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-015-3206-9) contains supplementary material, which is available to authorized users.KEY WORDS: health literacy, cognition, aging, epidemiology 相似文献6.
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Christos Skouras Alastair J Hayes Linda Williams O James Garden Rowan W Parks Damian J Mole 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(9):789-796
Background
The effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown.Objective
The aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP.Methods
A retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥ 2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan–Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Cox''s proportional hazards methods.Results
A total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4–10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2–11.9 years) (log-rank test, P = 0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72–2.176; P = 0.019] along with age (HR: 1.062; P < 0.001), alcohol-related aetiology (HR: 2.027; P = 0.001) and idiopathic aetiology (HR: 1.548; P = 0.048).Conclusions
Early organ dysfunction in AP is an independent predictor of long-term survival even when in-hospital deaths are accounted for. Negative predictors also include age, and idiopathic and alcohol-related aetiologies. 相似文献8.
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9.
Background
With modernization, rapid urbanization and industrialization, the price that the society is paying is tremendous load of “Non-Communicable” diseases, referred to as “Lifestyle Diseases”. Coronary artery disease (CAD), one of the lifestyle diseases that manifests at a younger age can have divesting consequences for an individual, the family and society. Prevention of these diseases can be done by studying the risk factors, analyzing and interpreting them using various statistical methods.Objective
To determine, using logistic regression the relative contribution of independent variables according to the intensity of their influence (proven by statistical significance) upon the occurrence of values of the dependent cardio vascular risk scores. Additionally, we wanted to assess whether non parametric smoothing of the cardio vascular risk scores can be used as a better statistical method as compared to the existing methods.Materials and methods
The study includes 498 students in the age group of 18–29 years.Findings
Prevalence of over weight (BMI 23–25 kg/m2) and obesity (BMI > 25 Kg/m2) was found among individuals of 22 years and above. Non smokers had decreased odds (OR = 0.041, CI = 0.015–0.107) and also increase in LDL Cholesterol (OR = 1.05, CI = 1.021–1.055) and BMI (OR = 1.42, CI = 1.244–1.631) were significantly contributing towards the risk of CVD. Localite students had decreased odds of developing CVD in the next 10 years (OR = 0.27, CI = 0.092–0.799) as compared to students residing in hostel or paying guests. 相似文献10.
Michelle van Ryn Rachel Hardeman Sean M. Phelan Diana J. Burgess PhD John F. Dovidio Jeph Herrin Sara E. Burke David B. Nelson Sylvia Perry Mark Yeazel Julia M. Przedworski 《Journal of general internal medicine》2015,30(12):1748-1756
BACKGROUND
Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.OBJECTIVE
To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school.DESIGN
Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school.PARTICIPANTS
A total of 3547 students from a stratified random sample of 49 U.S. medical schools.MAIN OUTCOME(S) AND MEASURE(S)
Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school.KEY RESULTS
In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students'' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias.CONCLUSIONS
Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.KEY WORDS: disparities, medical education, implicit racial bias, physician–patient relations, attitude of health personnel 相似文献11.
Michael D. Stein Debra S. Herman Genie L. Bailey John Straus Bradley J. Anderson Lisa A. Uebelacker Risa B. Weisberg 《Journal of general internal medicine》2015,30(7):935-941
BACKGROUND
Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients.OBJECTIVE
We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings.DESIGN
Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites.PARTICIPANTS
Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study.MAIN MEASURES
Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0–100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2).KEY RESULTS
Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3 %) and antidepressants (44.7 %), yet also used marijuana, alcohol, or cocaine (40.8 %) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04).CONCLUSION
Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain–depression nexus in novel ways.KEY WORDS: buprenorphine, chronic pain, depression 相似文献12.
William J. Hadden Philip R. de Reuver Kai Brown Anubhav Mittal Jaswinder S. Samra Thomas J. Hugh 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2016,18(3):209-220
Background
Colorectal cancer (CRC) accounts for 9.7% of all cancers with 1.4 million new cases diagnosed each year. 19–31% of CRC patients develop colorectal liver metastases (CRLM), and 23–38% develop extra-hepatic disease (EHD). The aim of this systematic review was to determine overall survival (OS) in patients resected for CRLM and known EHD.Methods
A systematic review was undertaken to identify studies reporting OS after resection for CRLM in the presence of EHD. Proportional meta-analyses and relative risk of death before five years were assessed between patient groups.Results
A total of 15,144 patients with CRLM (2308 with EHD) from 52 studies were included. Three and 5-year OS were 58% and 26% for lung, 37% and 17% for peritoneum, and 35% and 15% for lymph nodes, respectively. The combined relative risk of death by five years was 1.49 (95% CI = 1.34–1.66) for lung, 1.59 (95% CI = 1.16–2.17) for peritoneal and 1.70 (95% CI = 1.57–1.84) for lymph node EHD, in favour of resection in the absence of EHD.Conclusion
This review supports attempts at R0 resection in selected patients and rejects the notion that EHD is an absolute contraindication to resection. 相似文献13.
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14.
Helen Levy Alexander T. Janke Kenneth M. Langa 《Journal of general internal medicine》2015,30(3):284-289
Background
Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy.Objective
The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older.Design
We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans.Participants
Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users).Main Measures
Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine–Revised (REALM-R) and self-reported confidence filling out medical forms.Key Results
Only 9.7 % of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9 % of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95 % CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95 % CI 0.47 to 0.77]).Conclusion
Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide.KEY WORDS: health literacy, electronic health records, aging 相似文献15.
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James E. Aikens Ranak Trivedi Alicia Heapy Paul N. Pfeiffer John D. Piette 《Journal of general internal medicine》2015,30(6):797-803
Background
Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients’ trusted confidants.Objective
To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.Design
Patient preference trial.Participants
Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).Intervention
Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients’ clinicians were automatically notified of urgent patient issues.Main Measures
Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).Key Results
Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16–1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14–1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.Conclusions
Incorporating the “human factor” of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.KEY WORDS: depression, mHealth, self-management, caregiving, social support 相似文献17.
Simeon Isezuo Vijayakumar Subban Jaishankar Krishnamoorthy Ulhas Madhukarrao Pandurangi Ezhilan Janakiraman Latchumanadhas Kalidoss Mullasari Ajit Sankardas 《Indian heart journal》2014,66(2):156-163
Background
Coronary artery disease (CAD) is a major cause of death in India. Data on outcome of CAD is scarce in the Indian population. This study determined the characteristics, treatment and one-year outcomes of acute coronary syndrome (ACS) in an Indian Cardiac Centre.Methods
We carried out a cross sectional retrospective analysis of 1468 ACS patients hospitalized between January 2008 and December 2010 and followed up for 1 year in the Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai. Mortality at 1 year, its determinants and 1 year major adverse cardiac events (MACE) were determined.Results
The patients were aged 62.2 ± 11.2 years; males (75.2%) and had ST segment elevation myocardial infarction (STEMI) (33.9%), non ST segment elevation myocardial infarction (44.2%) and unstable angina (21.9%). Key pharmacotherapy included aspirin (98.2%), clopidogrel (95.1%), statins (95.6%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (50.6%) and beta blocker (83.1%). Angiography rate was 80.6%. In the STEMI group, 53.3% had primary angioplasty, 20.3% were thrombolysed and 16.1% received sole medical therapy. Overall coronary artery bypass graft rate was 12.4%. At one year, all-cause mortality and composite MACE were 2.5% and 9.7%, respectively. MACE included death (2.5%), reinfarction (4.0%), resuscitated cardiac arrest (1.8%), stroke (1.1%) and bleeding (0.4%). Main factors associated with mortality were combined left ventricular systolic and diastolic dysfunction (OR = 20.0, 95% CI = 6.63–69.4) and positive troponin I (OR = 12.56, 95% CI = 1.78–25.23). Troponin I independently predicted mortality.Conclusions
ACS population was older than previously described in India. Evidence-based pharmacotherapy and interventions, and outcomes were comparable to the developed nations. 相似文献18.
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19.
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Elizabeth H. Bradley Heather Sipsma Leora I. Horwitz Chima D. Ndumele Amanda L. Brewster Leslie A. Curry Harlan M. Krumholz 《Journal of general internal medicine》2015,30(5):605-611