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1.
Phelan EA Burke W Deyo RA Koepsell TD LaCroix AZ 《Journal of general internal medicine》2000,15(1):8-15
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. 相似文献
2.
Snyder CF Earle CC Herbert RJ Neville BA Blackford AL Frick KD 《Journal of general internal medicine》2008,23(3):254-259
Background As cancer patients transition from treatment to survivorship, the responsibility of primary care providers (PCPs) versus oncology
specialists is unclear.
Objectives To explore (1) physician types (PCPs versus oncology specialists) survivors visit during survivorship year 1, (2) preventive
care received, (3) how preventive care receipt relates to physician types visited, and (4) trends in physician types visited
and preventive care received over time.
Design Retrospective cross-sectional study of 5 cohorts of cancer survivors in survivorship year 1.
Subjects Twenty thousand sixty-eight survivors diagnosed with stage 1–3 colorectal cancer between 1997 and 2001.
Measurements Using the SEER-Medicare database, we assessed the mean number of visits to different physician types, the percentage of survivors
receiving preventive services, how receipt of preventive services related to physician types visited, and trends over time
in physician visits and preventive care.
Results There was a trend over time of increased visits to all physician types, which was statistically significant for oncology specialists
and other physicians (p < .001) but not PCPs. The percentage of survivors receiving preventive services remained relatively stable across the 5 cohorts,
except for an increase in bone densitometry (p < .05). Survivors who visited both a PCP and oncology specialist were most likely to receive each preventive care service
(p < .05).
Conclusions Oncology specialist follow-up in survivorship year 1 is intensifying over time. Survivors not being followed-up by both PCPs
and oncology specialists were less likely to receive preventive care. Clarifying the roles of PCPs and oncology specialists
during follow-up can improve the quality of care for survivors.
Presented at the 2007 Society for General Internal Medicine Annual Meeting. 相似文献
3.
4.
Dr. Barbara J. Turner MD MSEd Susan C. Day MD MPH Bette Borenstein PhD 《Journal of general internal medicine》1989,4(5):403-409
Objective:To improve the delivery of preventive care in a medical clinic, a controlled trial was conducted of two interventions that
were expected to influence delivery of preventive services differently, depending on level of initiative required of the physician
or patient to complete a service.
Design:A prospective, controlled trial of five-months’ duration.
Setting:A university hospital-based, general medical clinic.
Participants:Thirty-nine junior and senior medical residents who saw patients in stable clinic teams throughout the study.
Intervention:A computerized reminder system for physicians and a patient questionnaire and educational handout on preventive care.
Measurements and main results:Delivery of five of six audited preventive services improved significantly after the interventions were introduced. The computerized
reminder alone increased completion rates of services that relied primarily on physician initiative; the questionnaire alone
increased completion rate of the service that depended more on patient compliance as well as on some physician-dependent services.
Both interventions used together were slightly less effective in improving performance of physician-dependent services than
the computerized reminder used alone.
Conclusions:These interventions can improve the delivery of preventive care but they differ in their impacts on physician and patient
behaviors. Overall, the computer reminder was the more effective intervention.
This study was conducted when the senior author was a clinical scholar in the Robert Wood Johnson Clinical Scholars Program
at the University of Pennsylvania, Philadelphia, Pennsylvania.
Presented in part at the 26th Annual Conference of Research in Medical Education, sponsored by the Association of American
Medical Colleges, November, 1987, Washington, DC. 相似文献
5.
BACKGROUND: Little is known about the relation between perceptions of health care discrimination and use of health services. OBJECTIVES: To determine the prevalence of perceived discrimination in health care, its association with use of preventive services, and the contribution of perceived discrimination to disparities in these services by race/ethnicity, gender, and insurance status. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 54,968 respondents to the 2001 California Health Interview Survey. MEASUREMENTS: Subjects were asked about experience with discrimination in receiving health care and use of 6 preventive health services, all within the previous 12 months. METHODS: We used multivariate logistic regression with propensity-score methods to examine the adjusted relationship between perceived discrimination and receipt of preventive care. RESULTS: Discrimination was reported by 4.7% of respondents, and among these respondents the most commonly reported reasons were related to type of insurance (27.6%), race or ethnicity (13.7%), and income (6.7%). In adjusted analyses, persons who reported discrimination were less likely to receive 4 preventive services (cholesterol testing for cardiovascular disease, hemoglobin A1c testing and eye exams for diabetes, and flu shots), but not 2 other services (aspirin for cardiovascular disease, prostate specific antigen testing). Adjusting for perceived discrimination did not significantly change the relative likelihood of receipt of preventive care by race/ethnicity, gender, and insurance status. CONCLUSIONS: Persons who report discrimination may be less likely to receive some preventive health services. However, perceived discrimination is unlikely to account for a large portion of observed disparities in receipt of preventive care. 相似文献
6.
Dr. J. Randall Curtis MD MPH Douglas S. Paauw MD Marjorie D. Wenrich MPH Jan D. Carline PhD Dr. Paul G. Ramsey MD 《Journal of general internal medicine》1995,10(7):395-399
This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians
from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial
blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and
71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate
diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate
for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive
prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant
delay in diagnosis and treatment had these physicians been treating an actual patient with PCP.
Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993.
Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert
Wood Johnson Clinical Scholars Program.
The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy
and Research or the Robert Wood Johnson Foundation. 相似文献
7.
OBJECTIVE: To examine the impact of provider continuity on preventive care among adults who have a regular site of care. DESIGN: Logistic regression analyses were conducted to explore whether continuity, categorized as having no regular care, site continuity, or provider continuity, was associated with receipt of 3 preventive care services (influenza vaccination, receipt of a mammogram, and smoking cessation advice), independent of predisposing, need, and enabling factors. PARTICIPANTS: This study examined 42664 persons with private, Medicaid, Medicare, or no health insurance coverage who reported either having no site of care or being seen in a physician's office, HMO, hospital outpatient department, or other health center. SETTING: The 1996/1997 Community Tracking Study (CTS) household survey, a telephone-based survey providing a cross-sectional sample of 60446 U.S. adults aged 18 and older representing the U.S. housed, noninstitutionalized population. MEASUREMENTS AND MAIN RESULTS: After adjustment for differences in predisposing, enabling, and need factors, site continuity was associated with significant increases of 10.4% in influenza vaccinations (P =.006) and 12.6% in mammography (P =.001), and a nonsignificant increase of 5.6% in smoking cessation advice (P =.13) compared to having no regular site of care. After adjustment for these factors, provider continuity was associated with an additional improvement of 6.0% in influenza vaccinations (P =.01) and 6.2% in mammography (P =.04), and a nonsignificant increase of 2.5% in smoking cessation advice (P =.30) compared to site continuity. CONCLUSIONS: Provider continuity and site continuity are independently associated with receipt of preventive services. Compared to having no regular site of care, having site continuity was associated with increased receipt of influenza vaccination and mammography and, compared to having site continuity, having provider continuity was associated with further increases in the receipt of these two preventive services. 相似文献
8.
Dr. Wayne C. McCormick MD MPH Thomas S. Inui ScM MD Richard A. Deyo MD MPH Robert W. Wood MD 《Journal of general internal medicine》1991,6(6):524-528
Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care
settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3)
the impact of these views on the resulting discharge dispositions.
Design:Prospective cohort study.
Setting:Medical wards of five Seattle tertiary care hospitals.
Participants:120 consecutive hospitalized persons with AIDS and their primary care providers.
Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care.
Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers.
Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three
had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1;
95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate
for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy
emerged as important factors to persons with AIDS considering long-term care.
Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term
care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability,
preference, and appropriateness for long-term care.
Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part
at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991.
Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and
the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood
Johnson Clinical Scholars Program during this project.
The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation
or the Department of Veterans Affairs. 相似文献
9.
Improving patient quality of life with feedback to physicians about functional status 总被引:14,自引:0,他引:14
Dr. Lisa V. Rubenstein MD J. Michael McCoy MD Dennis W. Cope MD Pamela Anne Barrett BA Susan H. Hirsch MPH Karen S. Messer PhD Roy T. Young MD 《Journal of general internal medicine》1995,10(11):607-614
OBJECTIVE: To improve functional status among primary care patients.
INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,”
and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians.
DESIGN: Randomized controlled trial.
SETTING: University primary care clinic.
PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients.
MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire
(FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician
attitude about whether internists should address functional status problems.
RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those
of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the
elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental
group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more
actions recommended by the feedback form (p<0.02).
CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can
increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems,
and can assist physicians in improving emotional well-being and social functioning among their patients.
Supported by the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily
represent the views of the Sepulveda VA, UCLA, CSUF, Rand, or the Robert Wood Johnson Foundation. 相似文献
10.
Dr. Paul D. Cleary PhD Barbara J. Burns PhD Gregory R. Nycz 《Journal of general internal medicine》1990,5(4):355-360
Objective:This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their
primary care physicians.
Design:Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using
the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental bealth problems
was abstracted from the medical records.
Setting:The study was conducted at a multispecialty group practice in a semirural area of Wisconsin.
Patients:Study participants consisted of a stratified probability sample of 247 patients seeking primary care.
Results:Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by
a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled,
men and women had comparable identification rates.
Supported in part by a contract (DBE-77-0071) and grant from the National Institute of Mental Health (MH-33940) and a grant
from the Robert Wood Johnson Foundation. 相似文献
11.
Dr. Patrick G. O’Connor MD MPH Louis D. Gottlieb MD Mark L. Kraus MD Sam R. Segal MA Ralph I. Horwitz MD 《Journal of general internal medicine》1991,6(4):312-316
Objective:To identify patient features — both social and clinical — that may be associated with treatment failure in outpatient alcohol
withdrawal.
Design:A prospective observational cohort study of patients who underwent outpatient management of the alcohol withdrawal syndrome.
Setting:Community hospital-based outpatient alcohol treatment program.
Patients:The 179 patients who were eligible for and participated in a clinical trial of drug therapy for outpatient management of the
alcohol withdrawal syndrome.
Main results:Treatment failure occurred for 45% (80/179) of the patients. Failure rating did not vary according to diverse sociodemographic
features such as age, level of education, income, medical insurance status, and marital status. Persons who were homeless
did as well as those who were not. In contrast, two clinical features of withdrawal were associated with significantly higher
rates of treatment failure: craving and withdrawal symptom severity. High cravers had a treatment failure rate of 56% (22/39),
compared with 36% (41/115) for those with lower scores (p<0.03). Among those with moderate-to-high withdrawal symptom severity,
49% (74/151) represented treatment failures, compared with 22% (6/27) of those in the low-symptom group (p<0.01).
Conclusions:While these data do not confirm that socially disadvantaged persons are at increased risk for withdrawal treatment failure,
two clinical features — craving and withdrawal symptom severity — may help identify high-risk patients.
Presented in part at the annual meeting of the Society of General Internal Medicine, April 27 – 29, 1988, Arlington, VA, and
at the annual meeting of the Robert Wood Johnson Clinical scholars Program, October 2 – 5, 1988, Miami Lakes, FL.
Supported in part by a grant from the Robert Wood Johnson Foundation. 相似文献
12.
Dr. Michael D. Stein MD John Piette MS Vincent Mor PhD Tom J. Wachtel MD John Fleishman PhD Kenneth H. Mayer MD Charles C. J. Carpenter MD 《Journal of general internal medicine》1991,6(1):35-40
Object:To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT).
Design:Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation’s AIDS Health Services Program.
Setting:Public hospital clinics and community-based AIDS organizations in nine American cities.
Patients:880 HIV-seropositive outpatients interviewed between October 1988 and May 1989.
Main results:Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67
to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00;
95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds
ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were
non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis cariniipneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis cariniipneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11).
Conclusion:The authors conclude that traditionally dis-advantaged groups have less access to AZT, the only antiretroviral agent demonstrated
to increase survival of patients who have symptomatic HIV infection.
Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2–4, 1990.
Supported in part by a grant from the Robert Wood Johnson Foundation (12044). 相似文献
13.
BACKGROUND The implications of measuring and rewarding performance for patients with multiple chronic conditions have not been explored
empirically.
OBJECTIVE To examine whether the number of chronic conditions was associated with patient’s receipt of recommended preventive care.
METHODS We evaluated the association between the likelihood of receiving recommended preventive care and the number of chronic conditions
in the diabetic population by analyzing the 2003 Medical Expenditure Panel Survey using logistic regression. Demographic characteristics
and the number of chronic conditions were compared using χ2 tests.
OUTCOME MEASURES Hemoglobin A1C test and diabetic eye exam.
RESULTS In 2003, approximately 14.2 million non-institutionalized Americans had diabetes and 23% of them had five or more chronic
conditions besides diabetes. Those patients were 67% (p < 0.05) and 50% (p < 0.001) more likely to receive hemoglobin A1C test and eye exams compared with diabetic patients with no additional chronic
conditions. After adjusting for the number of office-based physician visits, a larger number of chronic conditions did not
significantly affect the likelihood of receiving recommended care. Diabetic patients with more chronic conditions had more
frequent office-based physician visits (p < 0.0001), and patients with 11 or more annual office-based physician visits were 43% (p < 0.05) and 40% (p < 0.01) more likely to receive hemoglobin A1C test and eye exam, respectively, compared with diabetic patients who had less
than two office-based physician visits.
CONCLUSIONS Diabetic patients with more chronic conditions may receive better quality of preventive care, partly due to their higher number
of office-based physician visits.
Financial support: Harvard School of Public Health Institutional Funding 相似文献
14.
When a Usual Source of Care and Usual Provider Matter: Adult Prevention and Screening Services
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OBJECTIVE To examine whether the usual source of preventive care, (having a usual place for care only or the combination of a usual
place and provider compared with no usual source of preventive care) is associated with adults receiving recommended screening
and prevention services.
DESIGN Using cross-sectional survey data for 24,138 adults (ages 18–64) from the 1999 National Health Interview Survey (NHIS), we
estimated adjusted odds ratios using separate logistic regression models for receipt of five preventive services: influenza
vaccine, Pap smear, mammogram, clinical breast exam, and prostate specific antigen.
RESULTS Having both a usual place and a usual provider was consistently associated with increased odds for receiving preventive care/screening
services compared to having a place only or neither. Adults ages 50–64 with a usual place/provider had 2.8 times greater odds
of receiving a past year flu shot compared with those who had neither. Men ages 50–64 with a usual place/provider had nearly
10 times higher odds of receiving a PSA test compared with men who had neither. Having a usual place/provider compared with
having neither was associated with 3.9 times higher odds of clinical breast exam among women ages 20–64, 4.1 times higher
odds of Pap testing among women ages 21–64, and 4.8 times higher odds of mammogram among women ages 40–64.
CONCLUSIONS Having both a usual place and usual provider is a key variable in determining whether adults receive recommended screening
and prevention services and should be considered a fundamental component of any medical home model for adults. 相似文献
15.
Comfort of General Internists and General Pediatricians in Providing Care for Young Adults with Chronic Illnesses of Childhood
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Okumura MJ Heisler M Davis MM Cabana MD Demonner S Kerr EA 《Journal of general internal medicine》2008,23(10):1621-1627
Background As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young
adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about
how comfortable physicians are caring for this population.
Objectives To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses
originating in childhood as well as the factors associated with comfort.
Participants In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate
= 53%).
Methods We measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis
(CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics.
Results Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported
being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF (p < .001) and 35% for SCD (p > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult
patients with CF and SCD.
Conclusions A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic
illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the
transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.
This work was funded by the Robert Wood Johnson Clinical Scholars Program and the UCSF Division of Pediatrics. Dr. Heisler
is a VA Health Services Research and Development Career Development Awardee. 相似文献
16.
Dr. Michael S. Wilkes MD MPH R. Nathan Link MD MPH Troy A. Jacobs MPH August H. Fortin MD Juan C. Felix MD 《Journal of general internal medicine》1990,5(2):122-125
Study Objective:To assess the attitudes of house officers in internal medicine and pathology about the value and use of the autopsy.
Design:Self-administered multiple-choice questionnaire.
Setting:Two New York City urban teaching hospitals.
Subjects:112 internal medicine and 37 pathology house officers who were on site during the survey period.
Main results:Most internal medicine house officers (86%) felt that the autopsy rate was too low and needed to be increased. The most common
reason the residents cited for the low rate was the reluctance of families to grant permission. A majority of medicine housestaff
(78%) felt they needed more instruction on how to ask for an autopsy, and 34% had never received feedback from the pathology
department on autopsy results. Most pathology residents (94%) felt the autopsy rate was too low; the most common reasons they
cited for the low rate were reluctance of clinicians to request permission and clinicians’ fears of being sued for malpractice.
Conclusions:House officers in internal medicine and pathology agreed that autopsies should be performed more frequently, and identified
problems in obtaining autopsies that should be addressed by educational, organizational, and regulatory strategies.
Supported in part by a grant from the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the
authors and do not necessarily represent the views of the Robert Wood Johnson Foundation. 相似文献
17.
Bradley KA Epler AJ Bush KR Sporleder JL Dunn CW Cochran NE Braddock CH McDonell MB Fihn SD 《Journal of general internal medicine》2002,17(5):315-326
OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions
about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared.
DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months.
PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general
medicine appointment with a consenting provider during the study period. Participating patients (N=47) and providers (N=17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus.
INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit.
MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about
alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related
discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening,
and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers
offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change
and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control
providers (82.4% vs 39.6% of visits; P=.026).
CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not
give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.
This research was supported by grants from the University of Washington Royalty Research Fund, and the Department of Veterans
Affairs, Health Services Research and Development Service (SDR 96-002). Dr. Bradley is an investigator at the VA Puget Sound
Health Care System, and is currently supported by National Institute of Alcohol Abuse and Alcoholism grant no. K23AA00313)
and is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Views expressed in this article are those of
the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington,
the National Institute of Alcohol Abuse and Alcoholism, or the Robert Wood Johnson Foundation. 相似文献
18.
Decreased alcohol consumption in outpatient drinkers is associated with improved quality of life and fewer alcohol-related consequences
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Kraemer KL Maisto SA Conigliaro J McNeil M Gordon AJ Kelley ME 《Journal of general internal medicine》2002,17(5):382-386
This study’s objective was to determine whether changes in alcohol consumption are associated with changes in quality of life
and alcohol-related consequences in an outpatient sample of drinkers. Two hundred thirteen subjects completed the Short Form
36-item (SF-36) Health Survey and the Short Inventory of Problems at baseline, 6 months, and 12 months. Subjects who sustained
a 30% or greater decrease in drinks per month reported improvement in SF-36 Physical Component Summary (P=.058) and Mental Component Summary (P=.037) scores and had fewer alcohol-related consequences (P<.001) when compared to those with a <30% decrease. These findings suggest another benefit of alcohol screening and intervention
in the primary care setting.
This research was supported by grant AA1029 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Dr. Kraemer
is supported by a Mentored Career Development Award from NIAAA (K23 AA00235). Dr. Conigliaro is supported by an Advanced Career
Development Award from the Department of Veterans Affairs HSR&D Service (CD-97324-A) and a Robert Wood Johnson Foundation
Generalist Physician Faculty Scholar Award (no. 031500). 相似文献
19.
20.
OBJECTIVE: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals.
DESIGN: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective.
SETTING: A senior center and a multilevel retirement community in Los Angeles.
PARTICIPANTS: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with
end-of-life decision making.
MAIN RESULTS: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might
be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities.
Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of
having lived a “full life.” Decisionmaking authority was granted both to physicians (for their technical expertise) and family
members (for their concern for the patient’s interests), and shifted from physician to family as the patient’s prognosis for
functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors
to end-of-life treatment decisions.
CONCLUSIONS: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and
valued life activities may be better suited to patients’ end-of-life care goals than those that focus on specific medical
interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families
and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision
or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients’ and families’
goals for care.
This research was partially funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed above are those
of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation. 相似文献