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1.
Andrew W. Phillips MD MEd Trevor C. Yuen BA Elizabeth Retzer MD James Woodruff MD Vineet Arora MD MA Dana P. Edelson MD MS 《Journal of general internal medicine》2013,28(3):406-411
BACKGROUND
Patient hand-offs at physician shift changes have limited ability to convey the primary team’s longitudinal insight. The Patient Acuity Rating (PAR) is a previously validated, 7-point scale that quantifies physician judgment of patient stability, where a higher score indicates a greater risk of clinical deterioration. Its impact on cross-covering physician understanding of patients is not known.OBJECTIVE
To determine PAR contribution to sign-outs.DESIGN
Cross-sectional survey.SUBJECTS
Intern physicians at a university teaching hospital.INTERVENTIONS
Subjects were surveyed using randomly chosen, de-identified patient sign-outs, previously assigned PAR scores by their primary teams. For each sign-out, subjects assigned a PAR score, then responded to hypothetical cross-cover scenarios before and after being informed of the primary team’s PAR.MAIN MEASURE
Changes in intern assessment of the scenario before and after being informed of the primary team’s PAR were measured. In addition, responses between novice and experienced interns were compared.KEY RESULTS
Between May and July 2008, 23 of 39 (59 %) experienced interns and 25 of 42 (60 %) novice interns responded to 480 patient scenarios from ten distinct sign-outs. The mean PAR score assigned by subjects was 4.2?±?1.6 vs. 3.8?±?1.8 by the primary teams (p?<?0.001). After viewing the primary team’s PAR score, interns changed their level of concern in 47.9 % of cases, their assessment of the importance of immediate bedside evaluation in 48.7 % of cases, and confidence in their assessment in 43.2 % of cases. For all three assessments, novice interns changed their responses more frequently than experienced interns (p?=?0.03, 0.009, and <0.001, respectively). Overall interns reported the PAR score to be theoretically helpful in 70.8 % of the cases, but this was more pronounced in novice interns (81.2 % vs 59.6 %, p?<?0.001).CONCLUSIONS
The PAR adds valuable information to sign-outs that could impact cross-cover decision-making and potentially benefit patients. However, correct training in its use may be required to avoid unintended consequences. 相似文献2.
Kathleen Heist MD Mary Guese MD Michelle Nikels MD Rachel Swigris DO Karen Chacko MD 《Journal of general internal medicine》2014,29(8):1195-1199
BACKGROUND
Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4?+?1 block scheduling is one innovative approach to enhance ambulatory education.AIM
To determine the impact of 4?+?1 scheduling on resident clinic continuity.SETTING
Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4?+?1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective.PARTICIPANTS
First-year internal medicine residents.PROGRAM DESCRIPTION
We measured patient–provider visit continuity, phone triage encounter continuity, and lab follow-up continuity.PROGRAM EVALUATION
In traditional scheduling as opposed to 4?+?1 scheduling, patients saw their primary resident provider a greater percentage; 71.7 % vs. 63.0 % (p?=?0.008). In the 4?+?1 model, residents saw their own patients a greater percentage; 52.1 % vs. 37.1 % (p?=?0.0001). Residents addressed their own labs more often in 4?+?1 model; 90.7 % vs. 75.6 % (p?=?0.001). There was no significant difference in handling of triage encounters; 42.3 % vs. 35.8 % (p?=?0.12).DISCUSSION
4?+?1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity. 相似文献3.
4.
Samantha Hendren MD MPH Paul Winters MS Sharon Humiston MD MPH Amna Idris MPH Shirley X. L. Li B Sci Patricia Ford MS Raymond Specht MPA Stephen Marcus MS Michael Mendoza MD MPH Kevin Fiscella MD MPH 《Journal of general internal medicine》2014,29(1):41-49
Background
Cancer screening rates are suboptimal for low-income patients.Objective
To assess an intervention to increase cancer screening among patients in a safety-net primary care practice.Design
Patients at an inner-city family practice who were overdue for cancer screening were randomized to intervention or usual care. Screening rates at 1 year were compared using the chi-square test, and multivariable analysis was performed to adjust for patient factors.Subjects
All average-risk patients at an inner-city family practice overdue for mammography or colorectal cancer (CRC) screening. Patients’ ages were 40 to 74 years (mean 53.9, SD 8.7) including 40.8 % African Americans, 4.2 % Latinos, 23.2 % with Medicaid and 10.9 % without any form of insurance.Intervention
The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit.Main Measures
Rates of cancer screening at 1 year.Key Results
Three hundred sixty-six patients overdue for screening were randomly assigned to intervention (n?=?185) or usual care (n?=?181). Primary analysis revealed significantly higher rates of cancer screening in intervention subjects: 29.7 % vs. 16.7 % for mammography (p?=?0.034) and 37.7 % vs. 16.7 % for CRC screening (p?=?0.0002). In the intervention group, 20 % of mammography screenings and 9.3 % of CRC screenings occurred at the early assessment, while the remainder occurred after repeated interventions. Within the CRC intervention group 44 % of screened patients used the mailed FIT kit. On multivariable analysis the CRC screening rates remained significantly higher in the intervention group, while the breast cancer screening rates were not statistically different.Conclusions
A multimodal intervention significantly increased CRC screening rates among patients in a safety-net primary care practice. These results suggest that relatively inexpensive letters and automated calls can be combined for a larger effect. Results also suggest that mailed screening kits may be a promising way to increase average-risk CRC screening. 相似文献5.
Marion Danis MD Roseanna Sommers BA Jean Logan RN Beverly Weidmer MA Shirley Chen BA Susan Goold MD Steven Pearson MD Elizabeth McGlynn PhD 《Journal of general internal medicine》2014,29(1):223-229
BACKGROUND
Patients’ willingness to discuss costs of treatment alternatives with their physicians is uncertain.OBJECTIVE
To explore public attitudes toward doctor–patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians.DESIGN
Focus group discussions and pre-discussion and post-discussion questionnaires.PARTICIPANTS
Two hundred and eleven insured individuals with mean age of 48 years, 51 % female, 34 % African American, 27 % Latino, and 50 % with incomes below 300 % of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area.MAIN MEASUREMENTS
Attitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians’ role in controlling costs; receptivity toward recommended communication strategies regarding costs.KEY RESULTS
Participants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants (OR?=?1.8, p?=?0.004; OR?=?1.6, p?=?0.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs (OR?=?2.4, p?=?0.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one’s physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs.CONCLUSIONS
This study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor–patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter. 相似文献6.
Melissa H. Tukey MD MSc Renda Soylemez Wiener MD MPH 《Journal of general internal medicine》2014,29(3):485-490
BACKGROUND
At some academic hospitals, medical procedure services are being developed to provide supervision for residents performing bedside procedures in hopes of improving patient safety and resident education. There is limited knowledge of the impact of such services on procedural complication rates and resident procedural training opportunities.OBJECTIVE
To determine the impact of a medical procedure service (MPS) on patient safety and resident procedural training opportunities.DESIGN
Retrospective cohort analysis comparing characteristics and outcomes of procedures performed by the MPS versus the primary medical service.PARTICIPANTS
Consecutive adults admitted to internal medicine services at a large academic hospital who underwent a bedside medical procedure (central venous catheterization, thoracentesis, paracentesis, lumbar puncture) between 1 July 2010 and 31 December 2011.MAIN MEASURES
The primary outcome was a composite rate of major complications. Secondary outcomes included resident participation in bedside procedures and use of “best practice” safety process measures.KEY RESULTS
We evaluated 1,707 bedside procedures (548 by the MPS, 1,159 by the primary services). There were no differences in the composite rate of major complications (1.6 % vs. 1.9 %, p?=?0.71) or resident participation in bedside procedures (57.0 % vs. 54.3 %, p?=?0.31) between the MPS and the primary services. Procedures performed by the MPS were more likely to be successfully completed (95.8 % vs. 92.8 %, p?=?0.02) and to use best practice safety process measures, including use of ultrasound guidance when appropriate (96.8 % vs. 90.0 %, p?=?0.0004), avoidance of femoral venous catheterization (89.5 vs. 82.7 %, p?=?0.02) and involvement of attending physicians (99.3 % vs. 57.0 %, p?<?0.0001).CONCLUSIONS
Although use of a MPS did not significantly affect the rate of major complications or resident opportunities for training in bedside procedures, it was associated with increased use of best practice safety process measures. 相似文献7.
Priscilla M. Flynn DrPH Jennifer L. Ridgeway MPP Mark L. Wieland MD Mark D. Williams MD Lindsey R. Haas MPH Walter K. Kremers PhD Carmen Radecki Breitkopf PhD 《Journal of general internal medicine》2013,28(3):386-391
BACKGROUND
Patients requiring interpreters may utilize the health care system differently or more frequently than patients not requiring interpreters; those with mental health issues may be particularly difficult to diagnose.OBJECTIVE
To determine whether adult patients requiring interpreters exhibit different health care utilization patterns and rates of mental health diagnoses than their counterparts.Design
Retrospective cohort study examining patient visits to primary care (PC), express care (EC), or the emergency department (ED) of a large group practice within 1 year.PATIENTS
Adult outpatients (n?=?63,525) with at least one visit within the study interval and information regarding interpreter need.MAIN MEASURES
Mean visit counts, counts of mental disorders, and somatic symptom diagnoses between patients requiring interpreters (IS patients) and not requiring interpreters (non-IS patients).KEY RESULTS
IS patients (n?=?1,566) had a higher mean number of visits overall (3.10 vs. 2.52), in PC (2.54 vs. 1.95), and in ED (0.53 vs. 0.44) than non-IS patients (all p?<?0.01). IS patients had a lower mean number of visits in EC than non-IS patients (0.03 vs. 0.13; p?<?0.01). Interpreter need remained a significant predictor of visit count in multivariate analyses including age, sex, insurance, and clinical complexity. A greater proportion of IS patients were high utilizers (10+ visits) than non-IS patients (3.6 % vs. 1.7 %; p?<?0.01). IS patients had a lower frequency of mental health diagnoses (13.9 % vs. 16.7 %), but a higher frequency of diagnoses recognized as potential somatic symptoms including diseases of the nervous (29.3 % vs. 24.2 %), digestive (22.6 % vs. 14.5 %), and musculoskeletal systems (43.2 % vs. 34.5 %), and ill-defined conditions (61 % vs. 49.9 %), all p?<?0.01.CONCLUSIONS
IS patients visited PC more often than their counterparts and were more often high utilizers of care. Two sources of high utilization, mental health diagnoses and somatic symptoms, differed appreciably between our populations and may be contributing factors. 相似文献8.
Ki-Yong Ahn Hyuk Hur Dong-Hyun Kim Jihee Min Duck Hyoun Jeong Sang Hui Chu Ji Won Lee Jennifer A. Ligibel Jeffrey A. Meyerhardt Lee W. Jones Justin Y. Jeon Nam Kyu Kim 《International journal of colorectal disease》2013,28(5):643-651
Purpose
This study aimed to examine the effects of a postsurgical, inpatient exercise program on postoperative recovery in operable colon cancer patientsMethods
We conducted the randomized controlled trial with two arms: postoperative exercise vs. usual care. Patients with stages I–III colon cancer who underwent colectomy between January and December 2011 from the Colorectal Cancer Clinic, were recruited for the study. Subjects in the intervention group participated in the postoperative inpatient exercise program consisted of twice daily exercise, including stretching, core, balance, and low-intensity resistance exercises. The usual care group was not prescribed a structured exercise program. The primary endpoint was the length of hospital stay. Secondary endpoints were time to flatus, time to first liquid diet, anthropometric measurements, and physical function measurements.Results
A total of 31 (86.1 %) patients completed the trial, with adherence to exercise interventions at 84.5 %. The mean length of hospital stay was 7.82?±?1.07 days in the exercise group compared with 9.86?±?2.66 days in usual care (mean difference, 2.03 days; 95 % confidence interval (CI), ?3.47 to ?0.60 days; p?=?0.005) in per-protocol analysis. The mean time to flatus was 52.18?±?21.55 h in the exercise group compared with 71.86?±?29.2 h in the usual care group (mean difference, 19.69 h; 95 % CI, ?38.33 to ?1.04 h; p?=?0.036).Conclusions
Low-to-moderate-intensity postsurgical exercise reduces length of hospital stay and improves bowel motility after colectomy procedure in patients with stages I–III colon cancer. 相似文献9.
David T. Liss PhD Paul A. Fishman PhD Carolyn M. Rutter PhD David Grembowski PhD Tyler R. Ross MA Robert J. Reid MD PhD 《Journal of general internal medicine》2014,29(5):732-740
BACKGROUND
Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use.OBJECTIVE
To describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation.DESIGN
One-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods.PATIENTS
Adults aged 18–85 years with treated hypertension.INTERVENTION
System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009.MAIN MEASURES
Resource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties.KEY RESULTS
Compared to baseline, the study population averaged 7 % fewer adjusted specialty visits during implementation (P?<?0.001) and 4 % fewer adjusted specialty visits in the first post-implementation year (P?=?0.02). Patients were 12 % less likely to have any cardiology visits during implementation and 13 % less likely during the first post-implementation year (P?<?0.001). In interaction analysis, patients with low morbidity had at least 27 % fewer specialty visits during each of 3 years following baseline (P?<?0.001); medium morbidity patients had 9 % fewer specialty visits during implementation (P?<?0.001) and 5 % fewer specialty visits during the first post-implementation year (P?=?0.007); high morbidity patients had 3 % (P?=?0.05) and 5 % (P?=?0.009) higher specialty use during the first and second post-implementation years, respectively.CONCLUSIONS
Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients. 相似文献10.
Aims/hypothesis
This study is a 19 year observational follow-up of a pragmatic open multicentre cluster-randomised controlled trial of 6 years of structured personal diabetes care starting from diagnosis.Methods
A total of 1,381 patients aged ≥40 years and newly diagnosed with type 2 diabetes were followed up in national registries for 19 years. Clinical follow-up was at 6 and 14 years after diabetes diagnosis. The original 6 year intervention included regular follow-up and individualised goal setting, supported by prompting of doctors, clinical guidelines, feedback and continuing medical education (ClinicalTrials.gov NCT01074762). The registry-based endpoints were: incidence of any diabetes-related endpoint; diabetes-related death; all-cause mortality; myocardial infarction (MI); stroke; peripheral vascular disease; and microvascular disease.Results
At 14 year clinical follow-up, group differences in risk factors from the 6 year follow-up had levelled out, although the prevalence of (micro)albuminuria and level of triacylglycerols were lower in the intervention group. During 19 years of registry-based monitoring, all-cause mortality was not different between the intervention and comparison groups (58.9 vs 62.3 events per 1,000 patient-years, respectively; for structured personal care, HR 0.94, 95% CI 0.83, 1.08, p?=?0.40), but a lower risk emerged for fatal and non-fatal MI (27.3 vs 33.5, HR 0.81, 95% CI 0.68, 0.98, p?=?0.030) and any diabetes-related endpoint (69.5 vs 82.1, HR 0.83, 95% CI 0.72, 0.97, p?=?0.016). These differences persisted after extensive multivariable adjustment.Conclusions/interpretation
In concert with features such as prompting, feedback, clinical guidelines and continuing medical education, individualisation of goal setting and drug treatment may safely be applied to treat patients newly diagnosed with type 2 diabetes to lower the risk of diabetes complications. 相似文献11.
Vineet M. Arora MD MAPP McKenna C. Eastment MD Emily D. Bethea MD Jeanne M. Farnan MD MHPE Erica S. Friedman MD 《Journal of general internal medicine》2013,28(8):994-998
BACKGROUND
Although interns are expected to be competent in handoff communication, it is currently unclear what level of exposure, participation, and comfort medical students have with handoffs prior to graduation.OBJECTIVE
The aim of this study is to characterize passive and active involvement of third-year medical students in the major components of the handoff process.DESIGN
An anonymous voluntary retrospective cross-sectional survey administered in 2010.PARTICIPANTS
Rising fourth-year students at two large urban private medical schools.MAIN MEASURES
Participation and confidence in active and passive behaviors related to written signout and verbal handoffs during participants’ third-year clerkships.KEY RESULTS
Seventy percent of students (n?=?204) responded. As third-year medical students, they reported frequent participation in handoffs, such as updating a written signout for a previously admitted patient (58 %). Students who reported frequent participation (at least weekly) in handoff tasks were more likely to report being confident in that task (e.g., giving verbal handoff 62 % vs. 19 %, p?<?0.001). Students at one site that did not have a handoff policy for medical students reported greater participation, more confidence, and less desire for training. Nearly all students believed they had witnessed an error in written signout (98 %) and almost two-thirds witnessed an error due to verbal handoffs (64 %).CONCLUSIONS
During their third year, many medical students are participating in handoffs, although reported rates differ across training environments. Medical schools should consider the appropriate level of competence for medical student participation in handoffs, and implement corresponding curricula and assessment tools to ensure that medical students are able to effectively conduct handoffs. 相似文献12.
Ian M. Kronish MD MPH Michael A. Diefenbach PHD Donald E. Edmondson PhD L. Alison Phillips PhD Kezhen Fei MS Carol R. Horowitz MD MPH 《Journal of general internal medicine》2013,28(5):675-682
BACKGROUND
Even though medications can greatly reduce the risk of recurrent stroke, medication adherence is suboptimal in stroke survivors.OBJECTIVE
To identify key barriers to medication adherence in a predominantly low-income, minority group of stroke and transient ischemic attack (TIA) survivors.DESIGN
Cross-sectional study.PARTICIPANTS
Six hundred stroke or TIA survivors, age ≥ 40 years old, recruited from underserved communities in New York City.MAIN MEASURES
Medication adherence was measured using the 8-item Morisky Medication Adherence Questionnaire. Potential barriers to adherence were assessed using validated instruments. Logistic regression was used to test which barriers were independently associated with adherence. Models were additionally controlled for age, race/ethnicity, income, and comorbidity.KEY RESULTS
Forty percent of participants had poor self-reported medication adherence. In unadjusted analyses, compared to adherent participants, non-adherent participants had increased concerns about medications (26 % versus 7 %, p?<?0.001), low trust in their personal doctor (42 % versus 29 %, p?=?0.001), problems communicating with their doctor due to language (19 % versus 12 %, p?=?0.02), perceived discrimination from the health system (42 % versus 22 %, p?<?0.001), difficulty accessing health care (16 % versus 8 %, p?=?0.002), and inadequate continuity of care (27 % versus 20 %, p?=?0.05). In the fully adjusted model, only increased concerns about medications [OR 5.02 (95 % CI 2.76, 9.11); p?<?0.001] and perceived discrimination [OR 1.85 (95 % CI 1.18, 2.90); p?=?0.008] remained significant barriers.CONCLUSIONS
Increased concerns about medications (related to worry, disruption, long-term effects, and medication dependence) and perceived discrimination were the most important barriers to medication adherence in this group. Interventions that reduce medication concerns have the greatest potential to improve medication adherence in low-income stroke/TIA survivors. 相似文献13.
14.
Martin G. Tolsgaard MD PhD Sebastian Bjørck MD Maria B. Rasmussen MD Amandus Gustafsson MD Charlotte Ringsted MD MHPE PhD 《Journal of general internal medicine》2013,28(8):1072-1077
BACKGROUND
The rising number of medical students and the impact this has on students’ learning of clinical skills is a matter of concern. Cooperative learning in pairs, called dyad training, might help address this situation.OBJECTIVE
The aim of this study was to evaluate the effect of dyad training on students’ patient encounter skills.DESIGN
Experimental, randomized, observer-blinded trial.PARTICIPANTS
Forty-nine pre-clerkship medical students without prior clinical experience.INTERVENTION
All students underwent a 4-h course on how to manage patient encounters. Subsequently, the students were randomized into a dyad practice group (n?=?24) or a single practice group (n?=?25). Both groups practiced for 4 h on four different case scenarios, using simulated patients. Students in the dyad group practiced together and took turns as the active participant, whereas students in the single group practiced alone.MAIN MEASURE
Performance tests of patient encounter skills were conducted 2 weeks after the training by two blinded raters. Students had no clinical training during those weeks. A questionnaire-based evaluation surveyed students’ confidence in their patient management skills.KEY RESULTS
The dyad group scored significantly higher on the performance test, mean 40.7 % (SD 6.6), than the single group, mean 36.9 % (SD 5.8), P?=?0.04, effect size 0.61. Inter-rater reliability was 0.69. The dyad group expressed significantly higher confidence in managing future clinical patient encounters than the single group, mean 7.6 (SD 0.9) vs. mean 6.5 (SD 1.1), respectively, P?<?0.001, effect size 1.16.CONCLUSION
Dyad training of pre-clerkship medical students’ patient encounter skills is effective, efficient, and prompts higher confidence in managing future patient encounters compared to training alone. This training format may help maintain high-quality medical training in the face of an increasing number of students in medical schools. 相似文献15.
Sherrie H. Kaplan PhD MPH John Billimek PhD Dara H. Sorkin PhD Quyen Ngo-Metzger MD MPH Sheldon Greenfield MD 《Journal of general internal medicine》2013,28(10):1340-1349
BACKGROUND
Despite numerous efforts to change healthcare delivery, the profile of disparities in diabetes care and outcomes has not changed substantially over the past decade.OBJECTIVE
To understand potential contributors to disparities in diabetes care and glycemic control.DESIGN
Cross sectional analysis.SSETTING
Seven outpatient clinics affiliated with an academic medical center.PATIENTS
Adult patients with type 2 diabetes who were Mexican American, Vietnamese American or non-Hispanic white (n?=?1,484).MEASUREMENTS
Glycemic control was measured as hemoglobin A1c (HbA1c) level. Patient, provider and system characteristics included demographic characteristics; access to care; quality of process of care including clinical inertia; quality of interpersonal care; illness burden; mastery (diabetes management confidence, passivity); and adherence to treatment.RESULTS
Unadjusted HbA1c values were significantly higher for Mexican American patients (n?=?782) (mean?=?8.3 % [SD:2.1]) compared with non-Hispanic whites (n?=?389) (mean?=?7.1 % [SD:1.4]). There were no significant differences in HbA1c values between Vietnamese American and non-Hispanic white patients. There were no statistically significant group differences in glycemic control after adjustment for multiple measures of access, and quality of process and interpersonal care. Disease management mastery and adherence to treatment were related to glycemic control for all patients, independent of race/ethnicity.LIMITATIONS
Generalizability to other minorities or to patients with poorer access to care may be limited.CONCLUSIONS
The complex interplay among patient, physician and system characteristics contributed to disparities in HbA1c between Mexican American and non-Hispanic white patients. In contrast, Vietnamese American patients achieved HbA1c levels comparable to non-Hispanic whites and adjustment for numerous characteristics failed to identify confounders that could have masked disparities in this subgroup. Disease management mastery appeared to be an important contributor to glycemic control for all patient subgroups. 相似文献16.
Kimitake Imamura Akihiro Yoshida Asumi Takei Koji Fukuzawa Kunihiko Kiuchi Kaoru Takami Mitsuru Takami Mitsuaki Itoh Ryudo Fujiwara Atsushi Suzuki Tomoyuki Nakanishi Soichiro Yamashita Akinori Matsumoto Ken-ichi Hirata 《Journal of interventional cardiac electrophysiology》2013,36(3):223-231
Purpose
Dabigatran is effective for both the prevention of stroke and bleeding in patients with atrial fibrillation (AF). However, the safety and efficacy of the use of dabigatran in the peri-procedural period for radiofrequency catheter ablation (RFCA) of AF is unknown. Therefore, the purpose of this study was to evaluate the safety and efficacy of dabigatran in the peri-procedural period for RFCA of AF and the duration of hospital stay.Methods
Consecutive patients (n?=?227) who underwent RFCA for AF were prospectively analyzed. Peri-procedural anticoagulant therapy with dabigatran (n?=?101, D group) was compared with warfarin and heparin bridging (n?=?126, W group). Dabigatran was discontinued 12–24 h before and restarted 3 h after the procedure. Warfarin was stopped 3 days before the procedure and unfractionated heparin was administered.Results
Ischemic stroke occurred in one patient of the D group (0.8 %). There was no significant difference between the two groups in the incidence of major bleeding (three cases of cardiac tamponade in each group and one case of intracranial bleeding in the W group, p?=?0.93) or minor bleeding (five cases in the D group vs. five in the W group, p?=?0.54). The duration of hospital stay was significantly shorter in the D group than in the W group (7.2 vs. 10.3 days, p?=?0.0001).Conclusions
Peri-procedural anticoagulation therapy with dabigatran for RFCA of AF was equally safe and effective compared with warfarin and heparin bridging. The use of dabigatran for RFCA of AF shortened the duration of hospital stay. 相似文献17.
Takayuki Yamamoto Manabu Shiraki Maki Nakahigashi Satoru Umegae Koichi Matsumoto 《International journal of colorectal disease》2013,28(3):335-340
Purpose
The aim of this study was to investigate the long-term effect of enteral nutrition (EN) as a maintenance therapy in Crohn’s disease (CD) patients following surgery.Methods
This study was an extension of our previous study to prolong the duration of intervention and follow-up from 1 to 5 years. Forty consecutive patients who underwent resection for ileal or ileocolic CD were included. Following surgery, 20 patients received continuous elemental diet infusion during the nighttime plus a low-fat diet during the daytime (EN group). Another 20 patients received neither nutritional therapy nor food restriction (control group). All patients were followed for 5 years after operation. No patient received corticosteroid, immunosuppressants, or infliximab except patients who developed recurrence. The end point of this study was recurrence requiring biologic therapy or reoperation. Recurrence rates were analyzed on an intention-to-treat basis.Results
In the EN group, four patients could not continue tube intubation for elemental diet intake. Two patients (10 %) in the EN group and nine patients (45 %) in the control group developed recurrence requiring infliximab therapy (P?=?0.03). The cumulative recurrence incidence rate requiring infliximab was significantly lower in the EN group vs the control group (P?=?0.02). One patient (5 %) in the EN group and five patients (25 %) in the control group required reoperation for recurrence (P?=?0.18). The cumulative incidence of reoperation was lower in the EN group vs the control group, the difference not being significant (P?=?0.08).Conclusion
The outcomes of this study suggest that EN therapy reduces the incidence of postoperative CD recurrence. 相似文献18.
Mark L. Wieland MD MPH Andrew J. Halvorsen MS Rajeev Chaudhry MBBS MPH Darcy A. Reed MD MPH Furman S. McDonald MD MPH Kris G. Thomas MD 《Journal of general internal medicine》2013,28(8):1014-1019
BACKGROUND
There have been recent calls for improved internal medicine outpatient training, yet assessment of clinical and educational variables within existing models is lacking.OBJECTIVE
To assess the impact of clinic redesign from a traditional weekly clinic model to a 50/50 outpatient–inpatient model on clinical and educational outcomes.DESIGN
Pre-intervention and post-intervention study intervals, comparing the 2009–2010 and 2010–2011 academic years.PARTICIPANTS
Ninety-six residents in a Primary Care Internal Medicine site of a large academic internal medicine residency program who provide care for > 13,000 patients.INTERVENTION
Continuity clinic redesign from a traditional weekly clinic model to a 50/50 model characterized by 50 % outpatient and 50 % inpatient experiences scheduled in alternating 1 month blocks, with twice weekly continuity clinic during outpatient months and no clinic during inpatient months.MAIN MEASURES
1) Clinical outcomes (panel size, patient visits, adherence with chronic disease and preventive service guidelines, continuity of care, patient satisfaction, and perceived safety/teamwork in clinic); 2) Educational outcomes (attendance at teaching conference, resident and faculty satisfaction, faculty assessment of resident clinic performance, and residents’ perceived preparedness for outpatient management).RESULTS
Redesign was associated with increased mean panel size (120 vs. 137.6; p?≤ 0.001), decreased continuity of care (63 % vs. 48 % from provider perspective; 61 % vs. 51 % from patient perspective; p ≤ ?0.001 for both; team continuity was preserved), decreased missed appointments (12.5 % vs. 10.9 %; p ≤ ?0.01), improved perceived safety and teamwork (3.6 vs. 4.1 on 5-point scale; p ≤ ?0.001), improved mean teaching conference attendance (57.1 vs. 64.4; p ≤ ?0.001), improved resident clinic performance (3.6 vs. 3.9 on 5-point scale; p ≤ ?0.001), and little change in other outcomes.CONCLUSION
Although this model requires further study in other settings, these results suggest that a 50/50 model may allow residents to manage more patients while enhancing the climate of teamwork and safety in the continuity clinic, compared to traditional models. Future work should explore ways to preserve continuity of care within this model. 相似文献19.
Primary Care Careers Among Recent Graduates of Research-Intensive Private and Public Medical Schools
Phillip A. Choi BS Shuai Xu MSc John Z. Ayanian MD MPP 《Journal of general internal medicine》2013,28(6):787-792
BACKGROUND
Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade.OBJECTIVE
To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care.DESIGN
Observational study of United States medical schools.PARTICIPANTS
One hundred twenty-one allopathic medical schools.MAIN MEASURES
The primary outcomes included the proportion of each school’s graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school’s graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as “research-intensive.”KEY RESULTS
Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1 % vs. 33.4 %, p?<?0.001) and fewer recent graduates matching in family medicine residencies (median 2.4 % vs. 6.2 %, p?<?0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1 % vs. 36.3 %, p?=?0.87) and matching in family medicine residencies (median 7.4 % vs. 10.0 %, p?=?0.37) relative to the other 66 public medical schools.CONCLUSIONS
To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates. 相似文献20.
Melanie Jay MD Sheira Schlair MD Rob Caldwell MD Adina Kalet MD MPH Scott Sherman MD MPH Colleen Gillespie PhD 《Journal of general internal medicine》2010,25(5):415-422