Moi? Volunteer?

Guy Collier is a consultant in technical education, a contributor to theL’Enseignment Technique, a journal of technical education. He is also an occasional reporter and photographer and a CRICA volunteer.     

Racial disparities in preferences and perceptions regarding organ donation

OBJECTIVES: To identify reasons for lower organ donation rates by African Americans, we examined knowledge and attitudes about brain death, donation, and transplantation and trust in the health care system. METHODS: Data were collected from 1,283 subjects in Ohio using a random digit dial telephone survey. Items were developed based on focus group results. Willingness-to-donate indicators included a signed donor card and willingness to donate one’s own and a loved one’s organs. RESULTS: Compared with whites, African-Americans had lower rates of signing a donor card (39.1% vs 64.9%,P<.001), and willingness to donate their own organs (72.6% vs 88.3%,P<.001) or a loved one’s organs (53.0% vs 66.2%,P<.001). African Americans had lower scores on the Trust in the Health Care System scale (mean scores ± SD, 9.43 ± 3.05 vs 9.93 ± 2.88,P<.01) and were more likely to agree that “if doctors know I am an organ donor, they won’t try to save my life” (38.6% vs 25.9%,P<.001), the rich or famous are more likely to get a transplant (81.9% vs 75.7%,P<.05), and less likely to agree that doctors can be trusted to pronounce death (68.2% vs 82.9,P<.001). African Americans were also more likely to agree that families should receive money for donating organs (45.6% vs 28.0%,P<.001) and funeral expenses (63.1% vs 46.6%,P<.001). CONCLUSIONS: African Americans reported greater mistrust in the equity of the donation system and were more favorable about providing tangible benefits to donor families than white respondents. None of the authors have any conflicts of interest to declare. This project was funded by a grant R01-HS10047 from the Agency for Healthcare Research and Quality. Dr. Ibrahim is a recipient of a career development award from the VA Health Services Research and Development Office and the Robert Wood Johnson Foundation’s Harold Amos Faculty Development Award.     

Improving Death Certificate Completion: A Trial of Two Training Interventions

BACKGROUND AND OBJECTIVE: Effects of advances in Department of Veterans Affairs (VA) women’s health care on women veterans’ health care decision making are unknown. Our objective was to determine why women veterans use or do not use VA health care. DESIGN AND PARTICIPANTS: Cross-sectional survey of 2,174 women veteran VA users and VA-eligible nonusers throughout southern California and southern Nevada. MEASUREMENTS: VA utilization, attitudes toward care, and socio-demographics. RESULTS: Reasons cited for VA use included affordability (67.9%); women’s health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for sociodemographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use. VA users were less likely than non-VA users to have after-hours access to nonemergency care, but more likely to receive both general and gender-related care from the same clinic or provider, to use a WHC for gender-related care, and to consider WHC availability very important. CONCLUSIONS: Lack of information about VA, perceptions of VA quality, and inconvenience of VA care, are deterrents to VA use for many women veterans. VA WHCs may foster VA use. Educational campaigns are needed to fill the knowledge gap regarding women veterans’ VA eligibility and advances in VA quality of care, while VA managers consider solutions to after-hours access barriers. The author have no conflict of interest to declare. This study was funded by the Department of Veterans Affairs, Health Services Research and Development Service (#GEN-00-082). Dr. Washington is supported by an Advanced Research Career Development Award from the Veterans Affairs Health Services Research and Development Service (#RCD-00-017). The authors gratefully acknowledge Mark Canning for overall project management, Barbara Sasso for assistance with survey development, Martin Lee, PhD, for statistical assistance, and the site principal investigators Leslie Satz, MSN, ANP, Stuart Gilman, MD, MPH, Nancy McNulty, MSN, ANP, and Denise Bartlett-Chekal, MSN, FNP. We also thank James Strike and Rick Paulson of the VA Austin Automation Center and Patricia Murphy of the VA Information Resource Center (VIReC) for assistance with sample development, and California Survey Research Services Inc. for survey fieldwork. The views expressed within are solely those of the authors, and do not necessarily represent the views of the Department of Veterans Affairs.     

Symptomatic severity of prime-MD diagnosed episodes of panic and generalized anxiety disorder in primary care

BACKGROUND: Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial. OBJECTIVE: To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs’ agreement with these diagnoses. DESIGN: Cross-sectional interview. PATIENTS: Individuals aged 18 to 64 who presented for care at 4 primary care practices. MEASUREMENTS: The PRIME-MD, Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A), and the Panic Disorder Severity Scale (PDSS). RESULTS: Of the 6,700 patients who completed the PRIME-MD Patient Questionnaire (PQ), 2,926 (44%) screened positive for an anxiety disorder, and 1,216 (42%) met preliminary study eligibility and consented to the PRIME-MD Anxiety Module. Of these, 619 (51%) had either GAD (308), PD (94), or both (217) disorders. Later, 329 completed a telephone interview. Of these, 59% with GAD and 68% with PD reported moderate or greater levels of anxiety symptoms on the SIGH-A and PDSS, respectively, and PCPs agreed with the PRIME-MD diagnosis for 98% of these patients. CONCLUSIONS: The PRIME-MD can efficiently screen patients for PD and GAD. Although patients thus identified endorse a wide range of anxiety symptoms, PCPs often agree with the diagnosis. This paper was presented in part at the Society for General Internal Medicine’s 25th Annual Meeting in Atlanta, May 2002. This work was supported by NIMH grant R01 MH59395.     

Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians

OBJECTIVE: We evaluated the effect of implementing quality improvement (QI) programs for depression, relative to usual care, on primary care clinicians’ knowledge about treatment. DESIGN AND METHODS: Matched primary care clinics (46) from seven managed care organizations were randomized to usual care (mailed written guidelines only) versus one of two QI interventions. Self-report surveys assessed clinicians’ knowledge of depression treatments prior to full implementation (June 1996 to March 1997) and 18 months later. We used an intent-to-treat analysis to examine intervention effects on change in knowledge, controlling for clinician and practice characteristics, and the nested design. PARTICIPANTS: One hundred eighty-one primary care clinicians. INTERVENTIONS: The interventions included institutional commitment to QI, training local experts, clinician education, and training nurses for patient assessment and education. One intervention had resources for nurse follow-up on medication use (QI-meds) and the other had reduced copayment for therapy from trained, local therapists (QI-therapy). RESULTS: Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy (by 20% for QI-meds, P=.04 and by 33% for QI-therapy, P=.004), but there were no significant increases in medication knowledge. Significant increases in knowledge scores (P=.01) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group. Clinicians were exposed to multiple intervention components. CONCLUSIONS: Dissemination of QI programs for depression in managed, primary care practices improved clinicians’ treatment knowledge over 18 months, but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists. Presented at the Association for Health Services Research meeting, Chicago, Ill, June 1999. This research was supported by grants from the Agency for Health Care Policy and Research (R01-HS08349) and the National Institute of Mental Health (R29-MH55223-01).     

Community health centers as primary providers of health care

In their essay, Shelly Raymer Duncan and Cinthia L. Deye examine the experience of community health centers as primary providers of health care. These centers provide quality health care for their clientele and operate in an efficient manner. The authors argue that community health centers are a viable mechanism for the provision of comprehensive quality primary care for underserved persons. For some consumers, community health centers represent their only real choice for health care services, when their other options include no health care at all or severe financial duress. She directs the association’s efforts for implementation of technical services and related activities involving key association staff, association members, and agencies of local, state, and federal government. Prior to her current position, she served as director of plan development and compliance for Community Health Choice in Chicago, an HMO contracted with the State of Illinois. She is working on both an M.D. degree at the U of I College of Medicine and a Ph.D. in the Department of Community Health with a focus in health policy. Her research is on the impact of the State Children’s Health Insurance Program on health disparities among low-income children in Illinois. She recently co-authored the article, “The State Children’s Health Insurance Program: an Administrative Experiment in Federalism,” published in theU. of Illinois Law Review.     

Are contributory behaviors related to culture? Comparison of the oldest old in the United States and in China

The purpose of this study is to examine the impact of culture on contributory behaviors within the context of family, friends, and neighbors among the oldest old in the United States and in China. The study was conducted in suburban areas of Boston in 1996 (n=465), and later in 1999 a replication of the study was conducted by Chinese researchers in urban areas of Shanghai, China (n=539). This study found some common factors such as objective measure of health status, assistance received from others, and group affiliation. However, many differences emerged in the study. The range of contributory behaviors toward friends is quite different between the two samples. Some of the correlates’ impact is also culturally specific, such as sibling support. These differences reflect variation in respondents’ social support as well as social structural differences. Findings from this study suggest that providing more opportunities for elders to participate in groups would facilitate their participation in volunteer activities and improve their overall well-being. Her published articles cover variety of topics such as dementia, caregiving, health services utilization, health behavior, depression, long-term care, minority and immigrant health, and international aging. She has been working as principal investigator or co-investigator on several ongoing projects related to health care service utilization and long-term care. Yuwen Yue finished her study of nursing science at Tianjin Medical University in 1996, and is now working for her master’s degree in Public Health in West Virginia University. Her research interests include medical sociology and survey methods. She received her Ph.D. in 1980 from Brandeis University. Since 1984, she has worked closely with the Alzheimer’s Association on projects relating to the Association’s Helpline, its Safe Return Program, respite care, support groups for family caregivers, home safety adaptations, and environmental and behavioral issues in special care units for people with dementia. Doris Toby Axelrod is currently a consultant at McLean Hospital and serves on the advisory board of Springwell, an Area Agency on Aging in Eastern Massachusetts. She has conducted workshops on telephone and mail surveys involving the 85-plus cohort and has presented five times at the annual meetings of GSA, ASA, and the National Conference of Social Work Researchers. She received her Master of Sciences degree at the East China Normal University. Her research interests include productive aging, caregiving, and long-term care. Her research interests are medical sociology and social gerontology.     

Creating enduring change

BACKGROUND: Improved educational and evaluation methods are needed in continuing professional development programs. OBJECTIVE: To evaluate the long-term impact of a faculty development program in palliative care education and practice. DESIGN: Longitudinal self-report surveys administered from April 2000 to April 2005. PARTICIPANTS: Physician and nurse educators from North America and Europe. All program graduates (n=156) were invited to participate. INTERVENTION: Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development. MEASURES: Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up. RESULTS: Response rates: 96% (n=149) preprogram, 73% (n=114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up,P<.01); use of learner-centered teaching approaches (sum of 8 approaches used “a lot”: preprogram 0.7 ± 1.1, follow-up 3.1 ± 2.0,P<.0001); and palliative care topics taught (sum of 11 topics taught “a lot”: preprogram 1.6 ± 2.0, follow-up 4.9 ± 2.9,P<.0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up,P=.01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as “transformative.” CONCLUSIONS: This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators. None of the authors have any conflicts of interest to declare. PCEP Core faculty: Janet Abrahm, MD, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; Loring Conant, Jr., MD, Cambridge Hospital, Cambridge, MA, USA, and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Constance Dahlin, RNCS, MSN, OCNS, CHPN, Massachusetts General Hospital, Boston, MA, USA; Marshall Forstein, MD, Cambridge Hospital, Cambridge, MA, USA, and Harvard Medical School, Boston, MA, USA; Paul Montgomery, PhD, Massachusetts General Hospital, Boston, MA, USA; Joanne Wolfe, MD, Dana-Farber Cancer Institute, and Children’s Hospital, Harvard Medical School, Boston, MA, USA. This program and evaluation were made possible by a grant from the Robert Wood Johnson Foundation. We are grateful to the PCEP participants for their participation in this study.     

Delivery of primary care to women

OBJECTIVE: Women’s health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women’s health center compared with those at a general medicine clinic. DESIGN: Cross-sectional survey. SETTING: University hospital-affiliated women’s health and general internal medicine clinics. PARTICIPANTS: An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic. MEASUREMENTS AND MAIN RESULTS: Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women’s health center. Women’s health center users (n=357) were more likely than general medicine clinic users (n=349) to prefer a female provider (57% vs 32%, p=.0001) and to have sought care at the clinic because of its focus on women’s health (49% vs 17%, p=.0001). After adjusting for age and self-assessed health status, women’s health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2,6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction. CONCLUSIONS: These results suggest that, at least in this setting, women’s health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women’s health centers, the quality of general preventive care may be better in general medical clinics. Dr. Phelan was a Robert Wood Johnson Clinical Scholar at the University of Washington. The views, opinions, and conclusions in this article are those of the authors and not necessarily those of the Robert Wood Johnson Foundation.     

An empirically derived taxonomy of factors affecting physicians’ willingness to disclose medical errors

BACKGROUND: Physician disclosure of medical errors to institutions, patients, and colleagues is important for patient safety, patient care, and professional education. However, the variables that may facilitate or impede disclosure are diverse and lack conceptual organization. OBJECTIVE: To develop an empirically derived, comprehensive taxonomy of factors that affects voluntary disclosure of errors by physicians. DESIGN: A mixed-methods study using qualitative data collection (structured literature search and exploratory focus groups), quantitative data transformation (sorting and hierarchical cluster analysis), and validation procedures (confirmatory focus groups and expert review). RESULTS: Full-text review of 316 articles identified 91 impeding or facilitating factors affecting physicians’ willingness to disclose errors. Exploratory focus groups identified an additional 27 factors. Sorting and hierarchical cluster analysis organized factors into 8 domains. Confirmatory focus groups and expert review relocated 6 factors, removed 2 factors, and modified 4 domain names. The final taxonomy contained 4 domains of facilitating factors (responsibility to patient, responsibility to self, responsibility to profession, responsibility to community), and 4 domains of impeding factors (attitudinal barriers, uncertainties, helplessness, fears and anxieties). CONCLUSIONS: A taxonomy of facilitating and impeding factors provides a conceptual framework for a complex field of variables that affects physicians’ willingness to disclose errors to institutions, patients, and colleagues. This taxonomy can be used to guide the design of studies to measure the impact of different factors on disclosure, to assist in the design of error-reporting systems, and to inform educational interventions to promote the disclosure of errors to patients. None of the authors have any conflicts of interest to declare. Some of the data from this study were presented at the Society of General Internal Medicine’s 27th Annual Meeting, Chicago, May 15, 2004 and have been published as an abstract (J Gen Intern Med. 2004;19(S1):177). Dr. Kaldjian is supported by funding from the Robert Wood Johnson Foundation’s Generalist Physician Faculty Scholars Program (grant # 45446). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.     

Hungarian Hospital Antibiotic Consumption at the Regional Level, 1996–2005

Abstract Background:   Regional variations in antibiotic consumption in outpatients have been reported previously, but nothing is as yet known about the regional distribution of antibiotic consumption in the hospital sector in Hungary. This study was designed to explore regional variations and investigate determinants of antibiotic consumption in hospital care in Hungary. Materials and Methods:   Regional distribution-based antibiotic sales data were obtained for a 10-year period (1996–2005) for the 20 Hungarian counties. Systemic antibacterial use (Anatomical Therapeutic Chemical code: J01) was expressed as the number of defined daily doses (DDD) per 100 patient-days. The multiple linear regression model was applied to investigate the determinants of regional differences in hospital antibiotic consumption. Independent variables related to health care access, utilization of hospital resources, doctors’ workload, type of hospital care provided, and patient’s characteristics and infections were considered as possible determinants, and data on these variables were obtained for 2 years (2004, 2005). We also tested the association between hospital and ambulatory care antibiotic consumption in Hungarian regions using the Pearson correlation test. Results:   For each year during the 1996–2005 study period, there were large and stable variations in total hospital antibiotic consumption (e.g., min–max₁₉₉₆: 16.0–28.2; min–max₂₀₀₅: 15.2–32.2 DDD per 100 patient-days) depending on the region. In the two developed models (Model 1 and Model 2), the number of reported infections accounted for 53% of the observed regional variations in hospital antibiotic consumption (Model 1), and the number of reported infections together with the case-mix index were responsible for 61% (Model 2) . Total antibiotic consumption in hospitals showed a positive correlation (R = 0.71, p = 0.002) with total antibiotic consumption in ambulatory care. Conclusion:   The case-mix index and the number of reported infections explained some of the observed regional variations. However, the moderate value of the models in explaining these regional variations suggest that determinants which could not be explored in this preliminary study may also contribute to regional differences. Future studies should aim at collecting data for each individual hospital as well as data on possible determinants for hospital antibiotic consumption.     

Time analysis of a general medicine service

Objective: To describe a novel method of time analysis for health care settings by quantifying internal medicine housestaff’s work activities and contacts. Design: Observational work sampling study based on random sampling technique. Setting: General medicine service in a university hospital. Participants: All housestaff (18 interns, 18 residents) rotating through the general medicine service during a 12-week period. Main outcome measures: Proportion of time spent doing 22 work activities and proportion of time spent with 13 work contacts, reported separately for interns and residents and for on-call days and off-call days. Results: The authors sampled 6,599 unique time observations (3,533 from on-call days, 3,066 from off-call days) during 193 housestaff workdays. The housestaff spent a majority of their time engaged in direct patient care activities (81% of the interns’ workdays, and 64.5% of the residents’ workdays), primarily in patient evaluation and follow-up (48% of the interns’ and 39% of the residents’ workdays). Compared with the interns, the residents spent relatively more time in direct educational activities (conferences, reading, teaching): 27% of the residents’ workdays versus 10% of the interns’ workdays. Analysis of work contacts showed that the housestaff spent a large portion of the workday alone: 27% of the residents’ and 34% of the interns’ workdays. The housestaff also spent a large portion of the workday with attending physicians: 23% of the residents’ and 11% of the interns’ workdays. This translates into 21 hours/week of attending supervision for the residents and 10 hours/week for the interns. Conclusions: Using random work sampling, the authors found that the vast majority of the houseofficer’s workday was spent in direct patient care. This method of time analysis may be used to describe housestaff training and supervision, as well as to evaluate administrative interventions designed to change housestaff work experience. Presented at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29, 1993. Supported in part by the A. W. Mellon Foundation. Dr. Oddone is supported by the VA Health Services Research career development program.     

Are Physician Estimates of Asthma Severity Less Accurate in Black than in White Patients?

Background  Racial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities. Objective  We hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care. Design, Setting and Patients  We conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians’ estimates of their patients’ asthma severity. Physicians’ estimates of patients’ asthma as being less severe than patient-reported symptoms were classified as underestimates of severity. Measurements  Frequency of underestimation, asthma care, and communication. Results  Three thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08–1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04). Conclusions  Biased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians’ assessments of asthma severity and patient–physician communication may minimize racial disparities in asthma care.     

Consumer choice and employer-sponsored health insurance

Robert Kaestner addresses the tensions between employers and employees in providing consumer choice and health insurance. The author points out that the dominance of employer-sponsored insurance in the private payer market stems from the favorable tax considerations of such insurance that allows employees to obtain insurance without being taxed on its value, and from the market and administrative efficiencies associated with insuring large groups. Given its numerical importance, changes in employer-sponsored insurance related to benefits provided, choice of providers, and employee contributions largely determine the amount of choice non-elderly consumers have with respect to health insurance. More importantly, it is widely believed that the design of, and changes to, employer-sponsored health insurance plans are under the control of the employer with little input from employees. However, Kaestner emphasizes that it is theemployee who pays for health insurance, despite the perception that this is an employer cost. These beliefs lead to the conclusion that consumers don’t have much choice about health insurance and are dependent on the employer. The author’s goal in this essay is to show that this conventional wisdom is incorrect. Robert Kaestner, Ph.D. received his Ph.D. in economics from the City University of New York, and he is currently a professor in the Institute of Government and Public Affairs and the Department of Economics at the University of Illinois at Chicago. Dr. Kaestner is also a research associate of the National Bureau of Economic Research. Dr. Kaestner’s areas of research interest are health and labor economics.     

Strength Perspective: An Analysis of Ageing in Place Care Model in Taiwan Based on Traditional Filial Piety

In the 1990s, the government in Taiwan proposed a series of community care related policies, in which the main care model was designed to be ‘the local taking care of the local’. In response to the social problems arising from the ageing of the population and the growing demands for welfare, Executive Yuan of Taiwan formulated the Development Program for the Care Service Industry in 2001. The government designed the elderly care policies based on the notions of community care in promoting the care industry. The community care policies would better serve the elderly and encourage families to purchase affordable services. The government aimed to encourage the non-profit sector and the commercial sector to provide care services. In Taiwan, with the notion of ‘in place’ care, the community care model has become a new trend. This study first analyzes the policies and the practices of community care in Taiwan. Secondly, it discusses how to make use of the ‘strength culture’ among Chinese people to construct a community care model based on the strength perspective of traditional filial piety. Finally, it analyzes the ‘community care centers’ that Taiwan is currently running with the aim of constructing a system of ‘ageing-in-place’ community care based upon the tenets of filial piety.

Family members’ perspectives on environmental changes in a long-term care facility: Lessons from a case study

Social models of care focus on residents’ needs, preferences, and quality of life. This case study examines one nursing home’s attempt to convert to this type of care model and the environmental renovation that was planned to accompany changes in care delivery. A family member for each of 15 residents was interviewed prior to the renovation and two years later after its completion. At pre-renovation, they expressed a preference for the facility to be more attractive and less institutional in appearance and care routines, and for care to be more personalized and sensitive. At follow-up, family members were appreciative of the facility’s improved aesthetics, but remained dissatisfied with the continued institutional nature of the setting and lack of change in care routines. Successful conversion to social models of care requires involvement of families and multiple levels of staff in planning and implementation, and coordination of environmental and care delivery changes. Teresa M. Cooney received her doctoral training in human development and family studies, with an emphasis on aging and families, from The Pennsylvania State University. She is currently associate professor of Human Development and Family Studies at the University of Missouri—Columbia. As a family gerontologist, she focuses her work on relationships between adult offspring and aging parents, and has primarily addressed how recent sociodemographic changes have influenced these relationships. Jill McClintock holds a B.A. in Human Development and Family Studies from the University of Missouri-Columbia, and an M.A. degree with an emphasis in lifespan development from the same department. She has held a variety of positions in long-term care and residential facilities for older adults. She recently completed an internship dealing with adult learners in formal education programs.     

Adherence to methotrexate in juvenile idiopathic arthritis

Non-adherence to treatments for chronic diseases may jeopardize patients’ health, increase costs of care, and cause unnecessary clinic appointments and diagnostic studies, as well as additional treatments with potentially serious side effects. Little is known about adherence to methotrexate in pediatric rheumatology. Because this medication is commonly used in JIA, we assessed adherence among children receiving methotrexate in two countries. A total of 76 outpatients (M:F 21:55) with JIA seen in Rio de Janeiro (Brazil) and in Boston (US) taking methotrexate for >2 months were enrolled. Questionnaires were completed by the parents from both centers. Non-adherence was defined as omission of ≥3 prescribed doses in the previous 8 weeks. Patients’ ages ranged from 1 to 17 years. Mean time on methotrexate was 20.5 months (±25). Overall rate of non-adherence was 18%. The rate of reported non-adherence was 8% in Boston and 24% in Rio de Janeiro (P = 0.012). The main reason for non-adherence in Boston was “child refused”; in Rio de Janeiro, the main reason was inability to obtain medication. Age had a negative association with adherence (P < 0.0001). Sex, time on methotrexate, route of administration, or concomitant use of other medications were not associated with adherence. Eighteen percent of children with JIA prescribed methotrexate were non-compliant. The difference in reasons for poor adherence between patients in Rio de Janeiro and Boston suggests that different strategies may be needed to improve adherence in these 2 settings. The rate of non-adherence warrants further investigation.     

How do women compare with internal medicine residents in breast lump detection?

Objective:Manufactured silicone breast models were used to compare the accuracy of breast examination by 300 women and 62 internal medicine residents. Design:The study design was cross-sectional. Setting:The study took place in two teaching-hospital general medicine clinics. Patients/Participants:Women were continuing care patients, ages 40 to 68, with no current breast complaint; 300 of 467 (66%) randomly selected women participated. Physicians were internal medicine residents with at least one-half day per week of ambulatory care practice; 62 of 64 (97%) participated. Measurements and Main Results:Sensitivity equalled the percentage of 18 lumps correctly detected in examination of six silicone breast models. Specificity equalled the percentage of six models examined without a false-positive detection. Women’s sensitivity was lower than physicians’ (40% vs. 58%), but their specificity was higher (66% vs. 52%). For both women and physicians, sensitivity varied according to lump size, hardness, and depth, with women’s sensitivity lower than physicians’ for each characteristic. Examination duration was the technique most strongly and consistently related to accuracy. Physicians spent more time examining models than did women (2.5 vs. 2.1 minutes per model). For both groups duration related positively to sensitivity (r=0.46, women; 0.55, physicians) and negatively to specificity (r=−0.35, women; −0.59, physicians). After adjusting for differences in technique, women’s sensitivity remained lower than physicians’, whereas specificity generally remained higher. The sensitivity of physicians with prior tactile experience with breast lumps was higher than that of physicians without such experience (60% vs. 51%, p=0.01). Too few women (2%) had prior tactile experience to permit analysis. Conclusions:Women’s and physicians’ breast examination accuracies differ, but for the two groups accuracies vary similary by lump characteristics and examination technique. Programs to improve breast examination should focus on specificity as well as sensitivity. Training that includes tactile experience may be important. Supported by a grant from the National Center for Health Services Research and Health Care Technology Assessment (R01HS05184) and by a grant from the Center for Disease Control and the University of North Carolina Center for Health Promotion and Disease Prevention. Presented at Advances in Cancer Control VI, March 1988, Washington, DC; and at the 11th Annual Meeting of the Society of General Internal Medicine, April 1988, Arlington, Virginia.     

Assessing physicians’ orientation toward lifelong learning

BACKGROUND: Despite the importance of lifelong learning as an element of professionalism, no psychometrically sound instrument is available for its assessment among physicians. OBJECTIVE: To assess the validity and reliability of an instrument developed to measure physicians’ orientation toward lifelong learning. DESIGN: Mail survey. PARTICIPANTS: Seven hundred and twenty-one physicians, of whom 444 (62%) responded. MEASUREMENT: The Jefferson Scale of Physician Lifelong Learning (JSPLL), which includes 19 items answered on a 4-point Likert scale, was used with additional questions about respondents’ professional activities related to continuous learning. RESULTS: Factor analysis of the JSPLL yielded 4 subscales entitled: “professional learning beliefs and motivation,” “scholarly activities,” “attention to learning opportunities,” and “technical skills in seeking information,” which are consistent with widely recognized features of lifelong learning. The validity of the scale and its subscales was supported by significant correlations with a set of criterion measures that presumably require continous learning. The internal consistency reliability (coefficient α) of the JSPLL was 0.89, and the test-retest reliability was 0.91. CONCLUSIONS: Empirical evidence supports the validity and reliability of the JSPLL. The authors have no conflict of interest to declare for this article or this research. The study, its findings, and interpretations of the outcomes do not necessarily reflect NBME policy, and NBME support provides no official endorsement.     

Decision making and counseling around mammography screening for women aged 80 or older

BACKGROUND: Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography. OBJECTIVE: To explore decision-making and physician counseling of oldest-old women around mammography screening. DESIGN: Qualitative research using in-depth semi-structured interviews. PARTICIPANTS: Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center. APPROACH: We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old. RESULTS: Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient’s health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician’s recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions. CONCLUSIONS: Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography. The authors have no conflicts of interest to declare. This paper was presented in part at the 2005 National Meeting of the Society of General Internal Medicine, May 13, 2005, New Orleans, LA. Grant support was obtained from the National Research Service Award from the National Cancer Institute (1 F32 CA110424-01).