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.     

Hip fracture

A prospective study of 79 patients with recent hip fracture revealed prior functional impairments with community mobility (49%), using a bathtub (40%), walking outdoors (26%), and stair-climbing (18%). Eighty-six per cent of patients (mean age 77.9 years) were admitted from home, with 95% surviving to discharge but only 28% returning directly home following surgical repair. In-hospital complications included confusion (49%), urinary tract infection (33%), and heart rhythm disturbance (26%). Mean length of stay was 21.7 days and mean hospital charges were $11,052. The outliers (15%) averaged 60.6 days in length of stay and $28,190 in charges. Stepwise multivariate regression revealed that lengths of stay varied significantly with prefracture functional status, presence of intertrochanteric fractures, and in-hospital complications, but not with patient age. Examination of these findings in relation to prospective reimbursement led to the conclusion that hip fracture patients are particularly vulnerable in the era of new hospital strategies to avoid high-cost patients and curtail hospital costs. Presented at the meeting of the Gerontological Society of America, November 1984. Supported by a grant from The Robert Wood Johnson Foundation.     

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.     

Social and clinical features as predictors of outcome in outpatient alcohol withdrawal

Objective:To identify patient features — both social and clinical — that may be associated with treatment failure in outpatient alcohol withdrawal. Design:A prospective observational cohort study of patients who underwent outpatient management of the alcohol withdrawal syndrome. Setting:Community hospital-based outpatient alcohol treatment program. Patients:The 179 patients who were eligible for and participated in a clinical trial of drug therapy for outpatient management of the alcohol withdrawal syndrome. Main results:Treatment failure occurred for 45% (80/179) of the patients. Failure rating did not vary according to diverse sociodemographic features such as age, level of education, income, medical insurance status, and marital status. Persons who were homeless did as well as those who were not. In contrast, two clinical features of withdrawal were associated with significantly higher rates of treatment failure: craving and withdrawal symptom severity. High cravers had a treatment failure rate of 56% (22/39), compared with 36% (41/115) for those with lower scores (p<0.03). Among those with moderate-to-high withdrawal symptom severity, 49% (74/151) represented treatment failures, compared with 22% (6/27) of those in the low-symptom group (p<0.01). Conclusions:While these data do not confirm that socially disadvantaged persons are at increased risk for withdrawal treatment failure, two clinical features — craving and withdrawal symptom severity — may help identify high-risk patients. Presented in part at the annual meeting of the Society of General Internal Medicine, April 27 – 29, 1988, Arlington, VA, and at the annual meeting of the Robert Wood Johnson Clinical scholars Program, October 2 – 5, 1988, Miami Lakes, FL. Supported in part by a grant from the Robert Wood Johnson Foundation.     

Determinants of resource utilization for patients admitted for evaluation of acute chest pain

Objective:To identify determinants of resource utilization among patients with suspected acute myocardial infarction. Design:Prospective cohort study, with prospective collection of detailed clinical data and retrospective collection of nonclinical data and resource utilization data. Setting:Urban, tertiary-care, teaching hospital. Patient population:992 consecutive patients over the age of 30 years, admitted from the emergency department for evaluation of acute chest pain unexplained by obvious trauma or chest roentgenographic abnormality, were eligible for the study. After excluding patients who had left against medical advice, who had been transferred to another bospital, or who had incomplete utilization data, 903 patients were included in the analyses. Measurements and outcomes:The authors evaluated the effects of 22 clinical and nonclinical factors on resource use. Resource use was primarily evaluated by length of stay; charges were evaluated in secondary analyses. Results:In the entire study population, increased length of stay was associated with a diagnosis of acute myocardial infarction or angina, severity of complications, use of invasive and noninvasive testing, and initial triage to the coronary care unit. In the 424 (47%) patients who had had completely uncomplicated courses after admission, high coefficients of variability were found for length of stay (0.88) and for total charges (0.78). In these uncomplicated patients, increased length of stay was associated with the use of noninvasive cardiac testing (66% longer for patients undergoing echocardiography or radionuclide ventriculography, and 46% longer for patients undergoing exercise tests or ambulatory arrhythmia monitoring), initial triage to the coronary care unit (23% longer), admission at the end of the week (21% longer), and insurance coverage other than Blue Cross/Blue Shield or a commercial carrier (21% for self-pay, 25% for Medicaid, and 48% for Medicare). Conclusions:These findings indicate that after adjustment for important clinical factors, nonclinical factors had a significant impact on length of stay among a large group of uncomplicated patients. Interventions aimed at reducing logistic difficulties in the performance of noninvasive testing and decreasing the number of low-risk patients who are triaged to coronary care unit beds may decrease resource utilization. Received from the Divisions of Clinical Epidemiology and General Medicine and the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School; and the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. Presented in part at the annual meeting of the American Federation for Clinical Research, April 28 – May 2, 1989, Washington, DC. Supported in part by grants from the National Center for Health Services Research (HS 05927), the Robert Wood Johnson Foundation, Princeton, NJ (678105), the John A. Hartford Foundation, New York, NY (83102-2H), and the Agency for Health Care Policy and Research (1-PO1-HS06431-02 and HS 06452-02). Dr. Lee is the recipient of an Established Investigator Award (900119) from the American Heart Association. Dr. Udvarhelyi is the recipient of a Medical Foundation Fellowship award.     

Hospitalized pneumonia

OBJECTIVES: To describe discharge rates, geographic and patient characteristics, treatment patterns, costs, and outcomes of patients hospitalized with community-acquired pneumonia (CAP) in Pennsylvania hospitals and compare these patients from rural and urban counties. DESIGN: A retrospective database study. PATIENTS: Adult patients (age ≥18) with an ICD-9-CM diagnosis of pneumonia discharged from 193 Pennsylvania hospitals (n=36,222) in 1991 from the MediQual Systems Pennsylvania database. MEASUREMENTS: Patient characteristics included a pneumonia-specific severity index, microbiologic etiology, and a number of comorbid conditions. Treatment indicators included the specialty of the admitting physician, length of stay, admittance to an intensive care unit, and mechanical ventilation. Cost indicators included charges and estimated costs. Outcomes measured were inpatient mortality and discharge disposition. Counties in Pennsylvania were classified into seven urban or rural groups, and patients were classified by the county of residence. RESULTS: The discharge rate for CAP was 4.0 per 1,000 and did not vary systematically across urban or rural counties. Most patients were treated in local hospitals. The average distance between residence and hospital was 5.4 miles and varied with urban or rural classification (range 2.5–9.3 miles). Among CAP patients, 37.8% were at low risk of mortality, with no systematic differences across rural or urban patients with respect to pneumonia severity. Rural patients were more likely to be treated by a family physician and somewhat less likely to be admitted to an intensive care unit or to be mechanically ventilated. Costs of treating rural patients were lower. In-hospital mortality rates, with controls for admission severity, were comparable or better for rural patients than for urban patients. CONCLUSIONS: Patients with CAP are treated in hospitals located in counties similar to ones in which they reside. The cost of treatment was lower for rural patients than for urban patients, but outcomes were not different. This work was funded in part by the Agency for Health Care Policy and Research (R01 HSO 6468) as part of the Pneumonia Patient Outcomes Research Team (PORT) Project. Dr. Fine is supported in part as a Robert Wood Johnson Foundation Generalist Faculty Scholar.     

Differences in access to zidovudine (AZT) among symptomatic HIV-infected persons

Object:To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT). Design:Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation’s AIDS Health Services Program. Setting:Public hospital clinics and community-based AIDS organizations in nine American cities. Patients:880 HIV-seropositive outpatients interviewed between October 1988 and May 1989. Main results:Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67 to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00; 95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis cariniipneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis cariniipneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11). Conclusion:The authors conclude that traditionally dis-advantaged groups have less access to AZT, the only antiretroviral agent demonstrated to increase survival of patients who have symptomatic HIV infection. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2–4, 1990. Supported in part by a grant from the Robert Wood Johnson Foundation (12044).     

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.     

The influence of age on clinical and patient-reported outcomes after cholecystectomy

Objective: To examine the relationship between the age of cholecystectomy patients and surgical complications, length of stay, symptom relief, and postdischarge functional status. Design: Patients’ medical records were reviewed and patients were sent a questionnaire three months after hospital discharge. Setting: Four university-affiliated teaching hospitals. Patients: 372 patients who had a primary operation of total cholecystectomy. Outcome measures: In-hospital complications, length of stay, patient satisfaction, symptom relief, and functional status after discharge. Results: Patients over the age of 60 years experienced a higher major postoperative complication rate than did younger patients (p<0.01), although the overall major complication rate was too low to determine whether factors other than age were important predictors. There was no age-related difference in minor postoperative complication rates. The older patients had a longer mean length of stay, even after statistical adjustment for covariates (p<0.05). The older patients reported similar levels of patient satisfaction, but reported recurrence of pre-operative abdominal pain less often than did the younger patients (OR=0.4, 95% CI=0.2, 0.7). There was no statistically significant difference between the older and younger patients in postoperative functioning, except for work performance. The younger patients reported improvement in postoperative work performance, while the older patients reported a decline (p < 0.01). Conclusions: Older cholecystectomy patients may experience more postoperative complications but report less recurrence of preoperative abdominal pain than do younger patients. The decline in work performance in older patients may indicate the need for a longer recuperation period. Supported in part by grants from the National Institute on Aging (AGO833101), the Robert Wood Johnson Foundation, and the John A. Hartford Foundation.     

Attitudes of house officers toward the autopsy

Study Objective:To assess the attitudes of house officers in internal medicine and pathology about the value and use of the autopsy. Design:Self-administered multiple-choice questionnaire. Setting:Two New York City urban teaching hospitals. Subjects:112 internal medicine and 37 pathology house officers who were on site during the survey period. Main results:Most internal medicine house officers (86%) felt that the autopsy rate was too low and needed to be increased. The most common reason the residents cited for the low rate was the reluctance of families to grant permission. A majority of medicine housestaff (78%) felt they needed more instruction on how to ask for an autopsy, and 34% had never received feedback from the pathology department on autopsy results. Most pathology residents (94%) felt the autopsy rate was too low; the most common reasons they cited for the low rate were reluctance of clinicians to request permission and clinicians’ fears of being sued for malpractice. Conclusions:House officers in internal medicine and pathology agreed that autopsies should be performed more frequently, and identified problems in obtaining autopsies that should be addressed by educational, organizational, and regulatory strategies. Supported in part by a grant from the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation.     

Racial differences in location before hospice enrollment and association with hospice length of stay

African Americans are less likely than Whites to enroll in hospice. In addition, patients are often referred to hospice very close to death, when they may not have time to take advantage of the full range of hospice services. Understanding how race and location before hospice enrollment are related to hospice length of stay (LOS) may inform the development of interventions to increase timely access to hospice care. Using data from a national hospice provider, African Americans and Whites admitted to routine home hospice care in a private residence between January 1, 2000, and December 31, 2003, were identified. Logistic regression was used to examine the association between race and hospice preadmission location (hospital vs other locations) and preadmission location and hospice LOS (≤7 days vs >7 days) after adjusting for demographic and hospice use variables. Of 43,869 enrollees, 15.3% were African American. One to 2 days before hospice enrollment, African Americans were more likely than Whites to be in the hospital than in all other locations (48.6% vs 32.3%, P<.001; adjusted odds ratio=1.83, 95% confidence interval=1.73-1.95). Regardless of race, those whose preadmission location was the hospital were more likely than those from other locations to die 7 days or less after hospice enrollment. Initiatives to improve end-of-life care should focus on increasing timely access to hospice referrals in settings outside of the hospital. Future research should examine whether racial differences in hospice preadmission location reflect differences in preferences for care or disparities in timely access to hospice referrals in non-acute care settings.     

The association between hypertension treatment,control, and functional status

The authors examined the relationship between hypertension treatment, control, and functional status among 356 “uncomplicated” hypertensive patients receiving care in 16 teaching hospital group ractices. Antihypertensive drug therapy and blood pressure control were determined from a medical record review. Functional status (health perceptions, mental health, role, and physical functioning) was assessed with a questionnaire. After adjustment for potential confounders, hypertensive patients without drug therapy were less likely to have impairment in mental health functioning, compared with patients receiving one or more than one antihypertensive medication (9% versus 25% and 20%, respectively, p<0.05). However, uncontrolled hypertensive patients were more likely to have role limitations than patients controlled only at the end or throughout the record review period (51% versus 39% and 36%, respectively, p<0.05). Patients controlled throughout the review period had the least impairment for each measure of functional status. These preliminary findings suggest that pharmacologic therapy may have a negative influence on the mental health of “uncomplicated” hypertensive patients, but that the dual goals of blood pressure control and positive functional status are not incompatible. Presented in part at the American Federation for Clinical Research Annual Meeting, May 1986. Supported by a grant from the Robert Wood Johnson Foundation. The conclusions are those of the authors and do not necessarily reflect the opinion of the Robert Wood Johnson Foundation or the Rand Corporation. Dr. Siscovick was a Teaching and Research Scholar of the American College of Physicians and an NHLBI Preventive Cardiology Academic Awardee.     

Clinical predictors of treatment reduction in hypertensive patients

Objective:To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction. Design:Observational study with 11-month follow-up. Setting:Outpatient hypertension clinic at the Seattle Veterans Administration Hospital. Patients:59 males (51% of those eligible) with diastolic BP<95 mm Hg for ≥6 months; 57 patients (97%) completed the study. Intervention:Gradual reduction of medications unless diastolic BP rose above 95 mm Hg. Measurements and main results:Intensity of treatment with BP medications was assessed using a scale of their comparative “vigors.” 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2±12.3 mm Hg (mean±SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7±1.7 vs. 1.3±0.5 “vigor units,” p=0.0001), and they had been enrolled in the clinic longer (5.5±3.0 vs. 3.1±2.3 years, p=0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age≤65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more “vigor units” had the highest specificity (79%) and likelihood ratio (3.3). Conclusions:Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 1988, and the annual meeting of the Robert Wood Johnson Clinical Scholars Program, Miami, Florida, October 1988. This study was conducted while Dr. Steiner was a Robert Wood Johnson Clinical Scholar at the University of Washington. Support was provided by the Northwest Health Services Research and Development Program of the Veterans Administration. The opinions, conclusions, and proposals in this paper are those of the authors, and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Veterans Administration.     

Care in the Months before Death and Hospice Enrollment Among Older Women with Advanced Breast Cancer

Background Variations in hospice use are not well understood. Objective Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment. Design/setting Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results—Medicare database. Patients There were 4,455 women aged ≥65 diagnosed with stage III/IV breast cancer during 1992–1999 who died before the end of 2001. Measurements Hospice use and, among enrollees, enrollment within 2 weeks of death. Independent variables of interest included hospitalizations, outpatient visits, and physicians seen before death. Results Adjusted hospice use rates were higher for hospitalized patients (45% if hospitalized for 1–7 days, 46% if 8–20 days, 35% if ≥21 days) than those not hospitalized (31%, P < 0.001). Adjusted rates were also higher among patients seeing a cancer specialist and primary care provider (PCP; 41%) and those seeing a cancer specialist and no PCP (38%) than among those seeing a PCP and no cancer specialist (30%) or neither type of physician (22%; P < 0.001). Hospice use also increased with increasing frequency of outpatient visits (P < 0.001). Hospitalizations, physicians seen, and visits were not associated with referral within 2 weeks of death (all P ≥ 0.10). Discussion Care before death is associated with hospice use among older women with advanced breast cancer. Additional research is needed to understand better how differences in patient characteristics and disease status influence cancer care before death and the role of various types of physicians in hospice referrals. This study was funded by a Clinical Scientist Development Award to Dr. Keating from the Doris Duke Charitable Foundation. Dr. Ayanian is a consultant to Research Triangle Institute and DxCG, Inc. on the development of DCG risk adjustment models. The study was presented on April 26, 2007 at the 30th Annual Meeting of the Society of General Internal Medicine, Toronto, Ontario, Canada.     

Improving patient quality of life with feedback to physicians about functional status

OBJECTIVE: To improve functional status among primary care patients. INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,” and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians. DESIGN: Randomized controlled trial. SETTING: University primary care clinic. PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients. MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems. RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more actions recommended by the feedback form (p<0.02). CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients. Supported by the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily represent the views of the Sepulveda VA, UCLA, CSUF, Rand, or the Robert Wood Johnson Foundation.     

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.     

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.     

Work satisfaction and career aspirations of internists working in teaching hospital group practices

This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training. assisted in preparing this report. Received from the Department of Medicine and the School of Public Health, UCLA Center for the Health Sciences. Los Angeles. California. Supported by Grant #59082 from the Robert Wood Johnson Foundation. The views expressed herein do not necessarily represent those of the Robert Wood Johnson Foundation.     

In pursuit of the abnormal serum alkaline phosphatase

The serum alkaline phosphatase (ALP) is often included among the tests used for case-finding among ambulatory patients. To determine the positive predictive value of the ALP, test results for all adults screened by a health maintenance organization between March and December 1969 were obtained by computer. The authors reviewed the charts of all 661 patients with abnormal tests whose primary source of medical care was at this facility. Complete two-year follow-up data were available for 91% of these patients. There were 56 patients (9%) with a diagnosis that could have explained an abnormal ALP. Of those cases in which ALP would have been clinically useful all but one could have been diagnosed by a simple, noninvasive work-up, and in that one case, no management change would have occurred. The authors conclude that in the absence of a small number of specific indications, extensive testing need not be performed to evaluate an isolated abnormal ALP obtained from a screening examination. Received from the Department of Medicine and the School of Public Health, University of California, Los Angeles, Los Angeles, California. Supported in part by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein do not necessarily represent those of 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.