Patient preferences for novel therapy

The authors used the N-of-1 clinical trial methodology to obtain insights about a patient’s preference for garlic for the management of his hypertension. The 61-year-old man received garlic, 500 mg by mouth three times a day (3 weeks), or identical placebo (3 weeks) in three treatment pairs. While the patient was taking garlic the mean systolic blood pressure decreased by 2 mm Hg (95% confidence interval 0.4 to 4.7, p<0.05), and the diastolic blood pressure decreased by 2.4 mm Hg (95% confidence interval 0.4 to 4, p<0.025). The treatment effect of garlic was small, but the patient believed continuing garlic for the management of his hypertension was justified. Received from the Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.     

Patient safety in the ambulatory setting

BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis. OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting. DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice. SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year. MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period. CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.     

Patient desire for information and decision making in health care decisions

OBJECTIVES: To compare results on the Autonomy Preference Index (API) and the Health Opinion Survey (HOS), two instruments that measure patient desire for information and involvement in decision making. DESIGN: Cross-sectional survey. SETTING: University-based primary care outpatient longitudinal and acute care clinic. PATIENTS: 167 patients with benign prostatic hyperplasia, back pain, or mild hypertension seen from October 1991 to December 1992. MEASUREMENTS AND MAIN RESULTS: On the API and the HOS (both scaled from 0 to 1), the patients had intermediate desire for involvement in decision making (median API: 0.42; HOS: 0.36) and higher desire for information (median API: 0.97; HOS: 0.57). With either instrument, the desire for information exceeded that for involvement in decision making (p<0.0001). The API information scores were higher than the HOS information scores (p < 0.0001), probably because the HOS focuses on patient behavior rather than desire. Variation in desire for information and involvement in decision making was substantial and largely unexplained. CONCLUSIONS: Most patients have a high desire for information, the desire for information and involvement in decision making varies substantially among patients, and the API is preferable to the HOS for researchers interested in focusing solely on patient desire for information. Received from the Department of Medicine, Dartmouth — Hitchcock Medical Center, Lebanon, New Hampshire. Preliminary analyses were presented at the annual meeting of the Society for Medical Decision Making, Portland, Oregon, October 17–20, 1992. Supported by a grant from the Pew Charitable Trusts. Dr. Nease is a Picker/Commonwealth Scholar.     

Patient satisfaction in resident and attending ambulatory care clinics

OBJECTIVE: To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics. DESIGN: A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998. SETTING: Four clinics based at a university teaching hospital and the associated Veterans' Affairs (VA) hospital. PARTICIPANTS: Two hundred eighty-eight patients of 76 resident and 25 attending physicians. RESULTS: Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: "personal manner (courtesy, respect, sensitivity, friendliness) of the doctor" (P 相似文献   

Women’s preferences for specialists who provide cancer screening and general medical care

In order to determine what types of specialists women prefer for medical care, we examined responses from a cross-sectional survey of adult female patients in a health plan of the independent practice association model in the Minneapolis–St. Paul metropolitan area ( n = 1,204). The response rate for the survey was 90%. The women expressing a preference (60% of responders) overwhelmingly preferred to see obstetrician-gynecologists for their breast examinations and Pap smears and strongly preferred family physicians or internists for the remainder of their cancer screening and general medical care. Thus, the majority of women expressed preferences for physicians of different specialties to provide their medical care.     

Racial and ethnic differences in patients' preferences for initial care by specialists

PURPOSE: To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences. METHODS: We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes. RESULTS: Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites. CONCLUSION: Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.     

Informal consultations provided to general internists by the gastroenterology department of an HMO

OBJECTIVE: To study the process, outcomes, and time spent on informal consultations provided by gastroenterologists to the primary care general internists of an HMO. DESIGN: Observational study. SETTING: A large, urban staff-model HMO. PATIENTS/PARTICIPANTS: Seven gastroenterologists constituting the total workforce of the gastroenterology department of the HMO. MEASUREMENTS AND MAIN RESULTS: Data on 91 informal consultations were obtained, of which 55 (60%) involved the acute management of a patient with new symptoms or test results, and 36 (40%) were for questions related to nonacute diagnostic test selection or medical therapy. Questions regarding patients previously unknown to the gastroenterology department accounted for 74 (81%) of the consultations. Formal referral was recommended in only 16 (22%) of these cases. As judged by the time data gathered on the 91 consultations, the gastroenterologists spent approximately 7.2 hours per week to provide informal consultation for the entire HMO. CONCLUSIONS: Gastroenterologists spend a significant amount of time providing informal consultation to their general internist colleagues in this HMO. The role informal consultation plays in the workload of physicians and in the clinical care of populations is an important question for health care system design, policy, and research. Received from the Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, and the Gastroenterology Department, Harvard Vanguard Medical Associates, Boston, Mass.     

Views of older adults on patient participation in medication-related decision making

BACKGROUND: Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making. OBJECTIVE: To explore the views of older adults regarding participation in medication decision making. DESIGN: Qualitative study. PARTICIPANTS: Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices. APPROACH: One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis. RESULTS: The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making. CONCLUSIONS: While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.     

Patients’ perceived involvement in care scale:

This report describes the development of the Perceived Involvement in Care Scale (PICS), a self-report questionnaire for patients, and its relation to primary care patients’ attitudes regarding their illnesses and the management of them. The questionnaire was administered to three independent samples of adult primary care patients. Patients’ satisfaction and their attitudes regarding their illnesses are evaluated after their medical visits. This instrument is designed to examine three relatively distinct factors: 1) doctor facilitation of patient involvement, 2) level of information exchange, and 3) patient participation in decision making. Of these factors, doctor facilitation and patient decision making were related significantly to patients’ satisfaction with care. Doctor facilitation and information exchange related consistently to patients’ perceptions of post-visit changes in their understanding, reassurance, perceived control over illness, and expectations for improvement in functioning. The role of physicians in enhancing patient involvement in care and the potential therapeutic benefits of physician facilitative behavior are addressed.     

Communication breakdown in the outpatient referral process

OBJECTIVE: To evaluate primary care and specialist physicians' satisfaction with interphysician communication and to identify the major problems in the current referral process. DESIGN: Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information. SETTING: Academic tertiary care medical center. PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists. MEASUREMENTS AND MAIN RESULTS: The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists. CONCLUSIONS: Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.