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1.
James S. Goodwin Kristin Sheffield Shuang Li Alai Tan 《Journal of general internal medicine》2016,31(11):1308-1314
Background
Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening.Objective
To determine the association between receipt of screening mammography or PSA and overall survival.Design
Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001–2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening.Participants
A 5 % sample of Medicare beneficiaries aged 69–90 years as of 1/1/2003 (n?=?906,723).Interventions
Receipt of screening mammography in 2001–2002 for women, or a screening PSA test in 2002 for men.Main Measures
Survival from 1/1/2003 through 12/31/2012.Key Results
Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR?=?1.52; 95 % CI?=?1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR?=?1.23; 1.22, 1.25).Conclusions
Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.2.
Kristina Maria Würth Stella Reiter-Theil Wolf Langewitz Sylvie Schuster 《Journal of general internal medicine》2018,33(11):1885-1891
Background
While the need to address language barriers to provide quality care for all is generally accepted, little is known about the complexities of decision-making around patients’ limited language proficiency in everyday clinical encounters.Objective
To understand how linguistic complexities shape cross-cultural encounters by incorporating the perspective of both, patients and physicians.Design
A qualitative hospital study with semi-structured interviews and participant-observation in a Swiss University Hospital. Thirty-two encounters were observed and 94 interviews conducted.Participants
Sixteen patients of Turkish and 16 of Albanian origin and all actors (administration, nurses, physicians, if required, interpreters) involved in the patients’ entire process.Main Approach
Interviews were audio-recorded and transcribed verbatim. A thematic content analysis was conducted using MAXQDA. For reporting, the COREQ guidelines were used.Key Results
Three themes were relevant to patients and physicians alike: Assessment of the language situation, the use of interpreters, and dealing with conversational limits. Physicians tend to assess patients’ language proficiency by their body language, individual demeanor, or adequacy of responses to questions. Physicians use professional interpreters for “high-stakes” conversations, and “get by” through “low-stakes” topics by resorting to bilingual family members, for example. Patients are driven by factors like fearing costs or the wish to manage on their own. High acceptance of conversational limits by patients and physicians alike stands in stark contrast to the availability of interpreters.Conclusions
The decision for or against interpreter use in the “real world” of clinical care is complex and shaped by small, frequently inconspicuous decisions with potential for suboptimal health care. Physicians occupy a key position in the decision-making to initiate the process of medical interpreting. The development and testing of a conceptual framework close to practice is crucial for guiding physicians’ assessment of patients’ language proficiency and their decision-making on the use of interpreting services.3.
Marilyn?M.?Schapira Brian?L.?Sprague Carrie?N.?Klabunde Anna?N.?A.?Tosteson Asaf?Bitton Jane?S.?Chen Elisabeth?F.?Beaber Tracy?Onega Charles?D.?MacLean Kimberly?Harris Kathleen?Howe Loretta?Pearson Sarah?Feldman Phyllis?Brawarsky Jennifer?S.?Haas 《Journal of general internal medicine》2016,31(10):1148-1155
Background
Despite substantial resources devoted to cancer screening nationally, the availability of clinical practice-based systems to support screening guidelines is not known.Objective
To characterize the prevalence and correlates of practice-based systems to support breast and cervical cancer screening, with a focus on the patient-centered medical home (PCMH).Design
Web and mail survey of primary care providers conducted in 2014. The survey assessed provider (gender, training) and facility (size, specialty training, physician report of National Committee for Quality Assurance (NCQA) PCMH recognition, and practice affiliation) characteristics. A hierarchical multivariate analysis clustered by clinical practice was conducted to evaluate characteristics associated with the adoption of practice-based systems and technology to support guideline-adherent screening.Participants
Primary care physicians in family medicine, general internal medicine, and obstetrics and gynecology, and nurse practitioners or physician assistants from four clinical care networks affiliated with PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium research centers.Main Measures
The prevalence of routine breast cancer risk assessment, electronic health record (EHR) decision support, comparative performance reports, and panel reports of patients due for routine screening and follow-up.Key Results
There were 385 participants (57.6 % of eligible). Forty-seven percent (47.0 %) of providers reported NCQA recognition as a PCMH. Less than half reported EHR decision support for breast (48.8 %) or cervical cancer (46.2 %) screening. A minority received comparative performance reports for breast (26.2 %) or cervical (19.7 %) cancer screening, automated reports of patients overdue for breast (18.7 %) or cervical (16.4 %) cancer screening, or follow-up of abnormal breast (18.1 %) or cervical (17.6 %) cancer screening tests. In multivariate analysis, reported NCQA recognition as a PCMH was associated with greater use of comparative performance reports of guideline-adherent breast (OR 3.23, 95 % CI 1.58–6.61) or cervical (OR 2.56, 95 % CI 1.32–4.96) cancer screening and automated reports of patients overdue for breast (OR 2.19, 95 % CI 1.15–41.7) or cervical (OR. 2.56, 95 % CI 1.26–5.26) cancer screening.Conclusions
Providers lack systems to support breast and cervical cancer screening. Practice transformation toward a PCMH may support the adoption of systems to achieve guideline-adherent cancer screening in primary care settings.4.
Elyse R. Park Sharon L. Bober Eric G. Campbell Christopher J. Recklitis Jean S. Kutner Lisa Diller 《Journal of general internal medicine》2009,24(2):407
BACKGROUND
Sexual dysfunction is an important issue that affects many cancer survivors who are increasingly being cared for by internists.OBJECTIVE
To examine the attitudes and reported practices of internists regarding survivorship care as it pertains to sexual dysfunction.DESIGN
Surveys were sent to 406 physicians affiliated with the Department of Internal Medicine at the University of Colorado Denver School of Medicine. Of the 319 eligibles, 227 were returned (71% RR).MAIN RESULTS
Of the 227 responders, 46% were “somewhat/very” likely to initiate a conversation about sexual dysfunction; 62% “never/rarely” addressed sexual dysfunction. Each additional weekly hour spent in patient care was associated with a 2% increase in the likelihood of sexual dysfunction being addressed or discussions about sexual dysfunction being initiated. Reported inadequate preparation/formal training around survivorship issues was associated with sexual dysfunction being addressed less often (odds ratio [OR]?=?0.45). Perception of patient anxiety or fears about health was associated with sexual dysfunction being addressed more often (OR?=?2.38). Perceived preparedness to evaluate long-term effects was associated with a greater likelihood of physicians initiating discussions about sexual functioning (OR?=?2.49).CONCLUSIONS
Cancer survivors receive their long-term care from internists. Our results suggest that sexual dysfunction is often not addressed during their follow-up care. Additional training is needed to prepare physicians to negotiate this difficult issue.5.
Anna N. A. Tosteson Elisabeth F. Beaber Jasmin Tiro Jane Kim Anne Marie McCarthy Virginia P. Quinn V. Paul Doria-Rose Cosette M. Wheeler William E. Barlow Mackenzie Bronson Michael Garcia Douglas A. Corley Jennifer S. Haas Ethan A. Halm Aruna Kamineni Carolyn M. Rutter Tor D. Tosteson Amy Trentham-Dietz Donald L. Weaver 《Journal of general internal medicine》2016,31(4):372-379
Background
Primary care providers and health systems have prominent roles in guiding effective cancer screening.Objective
To characterize variation in screening abnormality rates and timely initial follow-up for common cancer screening tests.Design
Population-based cohort undergoing screening in 2011, 2012, or 2013 at seven research centers comprising the National Cancer Institute-sponsored Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.Participants
Adults undergoing mammography with or without digital breast tomosynthesis (n = 97,683 ages 40–75 years), fecal occult blood or fecal immunochemical tests (n = 759,553 ages 50–75 years), or Papanicolaou with or without human papillomavirus tests (n = 167,330 ages 21–65 years).Intervention
Breast, colorectal, or cervical cancer screening.Main Measures
Abnormality rates per 1000 screens; percentage with timely initial follow-up (within 90 days, except 9-month window for BI-RADS 3). Primary care clinic-level variation in percentage with screening abnormality and percentage with timely initial follow-up.Key Results
There were 10,248/97,683 (104.9 per 1000) abnormal breast cancer screens, 35,847/759,553 (47.2 per 1000) FOBT/FIT-positive colorectal cancer screens, and 13,266/167,330 (79.3 per 1000) abnormal cervical cancer screens. The percentage with timely follow-up was 93.2 to 96.7 % for breast centers, 46.8 to 68.7 % for colorectal centers, and 46.6 % for the cervical cancer screening center (low-grade squamous intraepithelial lesions or higher). The primary care clinic variation (25th to 75th percentile) was smaller for the percentage with an abnormal screen (breast, 8.5–10.3 %; colorectal, 3.0–4.8 %; cervical, 6.3–9.9 %) than for the percentage with follow-up within 90 days (breast, 90.2–95.8 %; colorectal, 43.4–52.0 %; cervical, 29.6–61.4 %).Conclusions
Variation in both the rate of screening abnormalities and their initial follow-up was evident across organ sites and primary care clinics. This highlights an opportunity for improving the delivery of cancer screening through focused study of patient, provider, clinic, and health system characteristics associated with timely follow-up of screening abnormalities.6.
Heritage J Robinson JD Elliott MN Beckett M Wilkes M 《Journal of general internal medicine》2007,22(10):1429-1433
Context
In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.Objective
To test an intervention to reduce patients’ unmet concerns.Design
Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.Setting
Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.Participants
A volunteer sample of 20 family physicians (participation rate?=?80%) and 224 patients approached consecutively within physicians (participation rate?=?73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.Intervention
After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).Main Outcome Measures
Patients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.Results
Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR)?=?.154, p?=?.001). The ANY intervention could not be significantly distinguished from the control condition (p?=?.122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.Conclusions
Patients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.7.
Justin P. Lafreniere Rebeca Rios Hillary Packer Sharon Ghazarian Scott M. Wright Rachel B. Levine 《Journal of general internal medicine》2016,31(2):203-208
Background
Burnout is high among resident physicians and may be associated with suboptimal patient care and reduced empathy.Objective
To investigate the relationship between patient perceptions of empathy and enablement and physician burnout in internal medicine residents.Design
Cross-sectional, survey-based observational study between December 2012 and March 2013 in a resident continuity clinic located within a large urban academic primary care practice in Baltimore, Maryland.Participants
Study participants were 44 PGY1-3 residents and a convenience sample of their English-speaking adult primary care patients (N?=?244).Main Measures
Patients rated their resident physicians using the Consultation and Relational Empathy Measure (CARE) and the Patient Enablement Instrument (PEI). Residents completed the Maslach Burnout Inventory (MBI). We tested for associations between resident burnout and patients’ perceptions of resident empathy (CARE) and enablement (PEI) using multilevel regression analysis.Key Results
Multilevel regression analyses indicated significant positive associations between physician depersonalization scores on the MBI and patient ratings of empathy (B?=?0.28, SE?=?0.17, p?<?0.001) and enablement (B?=?0.11, SE?=?0.11, p?=?0.02). Emotional exhaustion scores on the MBI were not significantly related to either patient outcome.Conclusions
Patients perceived residents who reported higher levels of depersonalization as more empathic and enabling during their patient care encounters. The relationship between physician distress and patient perceptions of care has important implications for medical education and requires further study.8.
Sanja Percac-Lima Lydia E. Pace Kevin H. Nguyen Charis N. Crofton Katharine A. Normandin Sara J. Singer Meredith B. Rosenthal Alyna T. Chien 《Journal of general internal medicine》2018,33(4):415-422
Background
Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.Objective
To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.Design
Cross-sectional study using explicit chart abstraction methods.Participants
Three hundred adults, 40–80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.Main Measures
1) The frequency at which colorectal cancer risk factors were documented in patients’ charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations.Key Results
Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50–64 years of age than in those aged 40–50 years (OR?=?2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR?=?4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR?=?0.85, 95% CI: 0.75, 0.96).Conclusions
Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients’ other concurrent medical problems.9.
Deirdre A. Hill Jennifer S. Haas Robert Wellman Rebecca A. Hubbard Christoph I. Lee Jennifer Alford-Teaster Karen J. Wernli Louise M. Henderson Natasha K. Stout Anna N. A. Tosteson Karla Kerlikowske Tracy Onega 《Journal of general internal medicine》2018,33(3):275-283
Background
Breast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice.Objective
To assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications.Design
Prospective cohort study conducted between 2007 and 2014.Participants
In five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI.Main measures
Lifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression.Key results
Among women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7–2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9–14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0–60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%–84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1–37.9%) among women considered at low-to-average breast cancer risk.Conclusion
Utilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.10.
11.
BACKGROUND
Recent changes in health care delivery may reduce continuity with the patient’s primary care provider (PCP). Little is known about the association between continuity and quality of communication during ongoing efforts to redesign primary care in the Veterans Administration (VA).OBJECTIVE
To evaluate the association between longitudinal continuity of care (COC) with the same PCP and ratings of patient–provider communication during the Patient Aligned Care Team (PACT) initiative.DESIGN
Cross-sectional survey.PARTICIPANTS
Four thousand three hundred ninety-three VA outpatients who were assigned to a PCP, had at least three primary care visits to physicians or physician extenders during Fiscal Years 2009 and 2010 (combined), and who completed the Survey of Healthcare Experiences of Patients (SHEP) following a primary care visit in Fiscal Year (FY)2011.MAIN MEASURES
Usual Provider of Continuity (UPC), Modified Modified Continuity Index (MMCI), and duration of PCP care were calculated for each primary care patient. UPC and MMCI values were categorized as follows: 1.0 (perfect), 0.75–0.99 (high), 0.50–0.74 (intermediate), and < 0.50 (low). Quality of communication was measured using the four-item Consumer Assessment of Healthcare Providers and Systems-Health Plan program (CAHPS-HP) communication subscale and a two-item measure of shared decision-making (SDM). Excellent care was defined using an “all-or-none” scoring strategy (i.e., when all items within a scale were rated “always”).KEY RESULTS
UPC and MMCI continuity remained high (0.81) during the early phase of PACT implementation. In multivariable models, low MMCI continuity was associated with decreased odds of excellent communication (OR?=?0.74, 95 % CI?=?0.58–0.95) and SDM (OR?=?0.70, 95 % CI?=?0.49, 0.99). Abbreviated duration of PCP care (< 1 year) was also associated with decreased odds of excellent communication (OR?=?0.35, 95 % CI?=?0.18, 0.71).CONCLUSIONS
Reduced PCP continuity may significantly decrease the quality of patient–provider communication in VA primary care. By improving longitudinal continuity with the assigned PCP, while redesigning team-based roles, the PACT initiative has the potential to improve patient–provider communication.12.
Elliott J. Goytia David W. Lounsbury Mary S. McCabe Elisa Weiss Meghan Newcomer Deena J. Nelson Debra Brennessel Bruce D. Rapkin M. Margaret Kemeny 《Journal of general internal medicine》2009,24(2):451
INTRODUCTION
Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.AIMS
To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.SETTING
Adult cancer patients treated at a public city hospital cancer center.PROGRAM DESCRIPTION
The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.PROGRAM EVALUATION
Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.DISCUSSION
This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.13.
Ethan A. Halm Elisabeth F. Beaber Dale McLerran Jessica Chubak Douglas A. Corley Carolyn M. Rutter Chyke A. Doubeni Jennifer S. Haas Bijal A. Balasubramanian 《Journal of general internal medicine》2016,31(10):1190-1197
Background
Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.Objective
To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).Design
Population-based cohort study.Participants
A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.Measures
Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.Results
Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).Conclusions
Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.14.
15.
Background
Living through cancer often involves developing new identities which may strongly influence well-being and relationships with care providers, yet little is currently known about these post-cancer identities.Objectives
To examine (1) the extent to which four post-cancer identities (patient, person who has had cancer, victim, and survivor) are adopted, (2) relations between each identity and involvement in cancer-related activities and mental and physical well-being, and (3) correlates of these identities.Design
Cross-sectional questionnaire-based study.Participants
168 young to middle-aged adults who had previously experienced cancer.Measurements
Cancer identifications, background variables, psychological functioning, cancer risk appraisals and coping, cancer-related activities, and mental and physical well-being.Results
At least somewhat, 83% endorsed survivor identity, 81% identity of “person who has had cancer”, 58% “patient”, and 18% “victim”. Identities were minimally correlated with one another and differentially associated with involvement in cancer-related activities. Survivor and person who has had cancer identities correlated with involvement in most cancer-related activities such as wearing cancer-related items and talking about prevention (ps?<? 0.5). Survivor identity correlated with better psychological well-being and post-traumatic growth, victim identity with poorer well-being (ps?<? 0.5); neither identifying as a patient nor a person with cancer was related to well-being. Through regression analyses, identities were shown to be explained by unique combination of background, functioning, appraisal and coping variables.Conclusions
Survivor identity appears most common and most associated with active involvement and better psychological well-being, but other identifications are also common and simultaneously held. Adoption of specific cancer identities is likely to impact interactions with health care providers, including those in general internal medicine, and health behavior changes.16.
Peter C. Smith Susan M. Schmidt Donald Allensworth-Davies Richard Saitz 《Journal of general internal medicine》2009,24(7):783-788
BACKGROUND
Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings.OBJECTIVE
To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).DESIGN
Cross-sectional study.PARTICIPANTS
Adult English-speaking patients recruited from primary care waiting rooms.MEASUREMENTS
Participants were asked the single screening question, “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of >1 is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method.MAIN RESULTS
Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics.CONCLUSIONS
The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.17.
Krishna K. Patel Nirav Vakharia James Pile Erik H. Howell Michael B. Rothberg 《Journal of general internal medicine》2016,31(6):597-601
Background
Rates of preventable admissions will soon be publicly reported and used in calculating performance-based payments. The current method of assessing preventable admissions, the Agency of Healthcare Research and Quality (AHRQ) Preventable Quality Indicators (PQI) rate, is drawn from claims data and was originally designed to assess population-level access to care.Objective
To identify the prevalence and causes of preventable admissions by attending physician review and to compare its performance with the PQI tool in identifying preventable admissions.Design
Cross-sectional survey.Setting
General medicine service at an academic medical center.Participants
Consecutive inpatient admissions from December 1–15, 2013.Main Measures
Survey of inpatient attending physicians regarding the preventability of the admissions, primary contributing factors and feasibility of prevention. For the same patients, the PQI tool was applied to determine the claims-derived preventable admission rate.Key Results
Physicians rated all 322 admissions and classified 122 (38 %) as preventable, of which 31 (25 %) were readmissions. Readmissions were more likely to be rated preventable than other admissions (49 % vs. 35 %, p?=?0.04). Application of the AHRQ PQI methodology identified 75 (23 %) preventable admissions. Thirty-one admissions (10 %) were classified as preventable by both methods, and the majority of admissions considered preventable by the AHRQ PQI method (44/78) were not considered preventable by physician assessment (K?=?0.04). Of the preventable admissions, physicians assigned patient factors in 54 (44 %), clinician factors in 36 (30 %) and system factors in 32 (26 %).Conclusions
A large proportion of admissions to a general medicine service appeared preventable, but AHRQ’s PQI tool was unable to identify these admissions. Before initiation of the PQI rate for use in pay-for-performance programs, further study is warranted.18.
Shawna V. Hudson Karissa A. Hahn Pamela Ohman-Strickland Regina S. Cunningham Suzanne M. Miller Benjamin F. Crabtree 《Journal of general internal medicine》2009,24(2):487
BACKGROUND
Cancer survivors have cancer surveillance and preventive screening needs that require monitoring. Little is known regarding their patterns of care in community primary care practices.METHODS
Secondary analysis of 750 baseline patient surveys and medical record audits for patients ages 50+ years in 25 community-based primary care practices (RESULTS
Patient self-reported screening rates for breast cancer (72%), colorectal cancer (81%) and prostate cancer (77%) were higher for cancer survivors compared to noncancer patients (69%, 67%, 53%, respectively). Screening rates documented in the primary care records were lower for all cancers. Cancer survivors were more likely than others to report having been screened for colorectal cancer (P?=?0.034). Male cancer survivors were more likely to report being screened for prostate cancer than those without cancer (P?=?0.020). There were no significant differences in either self-reported or medical record report of breast cancer screening rates among cancer survivors and noncancer patients.CONCLUSIONS
Cancer survivors were more likely to self-report receipt of cancer screening than noncancer patients. Medical record reports of cancer screening were lower than self-reports for cancer survivors and noncancer patients. Identifying factors that affect cancer screening among cancer survivors is important and has implications for intervention design.19.
Julie K. Johnson Donna M. Woods David P. Stevens Judith L. Bowen Lloyd P. Provost Connie S. Sixta Ed H. Wagner 《Journal of general internal medicine》2010,25(4):581-585
BACKGROUND
Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.OBJECTIVE
We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.DESIGN
The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.PARTICIPANTS
Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.APPROACH
Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).KEY RESULTS
At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.CONCLUSIONS
The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.20.
David A. Haggstrom Paul Helft Ingrid Oakley-Girvan 《Journal of general internal medicine》2009,24(2):472