From the Patient’s Perspective: The Impact of Training on Resident Physician’s Obesity Counseling

BACKGROUND

It is uncertain whether training improves physicians’ obesity counseling.

OBJECTIVE

To assess the impact of an obesity counseling curriculum for residents.

DESIGN

A non-randomized, wait-list/control design.

PARTICIPANTS

Twenty-three primary care internal medicine residents; 12 were assigned to the curriculum group, and 11 were assigned to the no-curriculum group. Over a 7-month period (1–8 months post-intervention) 163 of the residents’ obese patients were interviewed after their medical visits.

INTERVENTION

A 5-hour, multi-modal obesity counseling curriculum based on the 5As (Assess, Advise, Agree, Assist, Arrange) using didactics, role-playing, and standardized patients.

MAIN MEASURES

Patient-report of physicians’ use of the 5As was assessed using a structured interview survey. Main outcomes were whether obese patients were counseled about diet, exercise, or weight loss (rate of counseling) and the quality of counseling provided (percentage of 5As skills performed during the visit). Univariate statistics (t-tests) were used to compare the rate and quality of counseling in the two resident groups. Logistic and linear regression was used to isolate the impact of the curriculum after controlling for patient, physician, and visit characteristics.

KEY RESULTS

A large percentage of patients seen by both groups of residents received counseling about their weight, diet, and/or exercise (over 70%), but the quality of counseling was low in both the curriculum and no curriculum groups (mean 36.6% vs. 31.2% of 19 possible 5As counseling strategies, p?=?0.21). This difference was not significant. However, after controlling for patient, physician and visit characteristics, residents in the curriculum group appeared to provide significantly higher quality counseling than those in the control group (std β?=?0.18; R ² change?=?2.9%, P?<?0.05).

CONCLUSIONS

Residents who received an obesity counseling curriculum were not more likely to counsel obese patients than residents who did not. Training, however, is associated with higher quality of counseling when patient, physician, and visit characteristics are taken into account.     

Patient Preferences for the Management of High-Grade Dysplasia in Barrett’s Esophagus

Surgical esophagectomy, intensive endoscopic surveillance, and mucosal ablative techniques, particularly photodynamic therapy (PDT), have been proposed as possible management strategies for Barretts high-grade dysplasia (HGD). Each option has advantages and disadvantages, and no firm consensus exists for the preferred strategy at this time. The purpose of this pilot study was to gain insight into patient preferences in Barretts HGD management. Twenty patients with Barretts esophagus were enrolled in a questionnaire study. The three possible management options for Barretts HGD including each options potential benefits and harms were presented to the subject in a formalized presentation that was designed to be easily comprehendible by patients. The subjects rated each strategy using a health-related quality of life instrument and chose one of the management strategies assuming they were found to have HGD. The average feeling thermometer rating scale values for the management strategies were as follows: endoscopic surveillance, 79; esophagectomy, 46; and PDT, 60. When asked to choose a strategy, 14 (70%) chose endoscopic surveillance, 3 (15%) chose esophagectomy, and 3 (15%) chose PDT. These findings were statistically significant (P = 0.0024). The patients who chose endoscopic surveillance felt comfortable with endoscopy, while the most common concern about esophagectomy, and PDT was the risk of death and the unknown risk of recurrence, respectively. In summary, when patients with Barretts esophagus were presented with three options to manage HGD, the majority chose endoscopic surveillance. Familiarity with endoscopic surveillance was the predominant reason for the choice.     

Management of Raynaud’s Phenomenon in the Patient with Connective Tissue Disease

Raynaud’s phenomenon is characterized by intense vasospasm of digital arteries on cold exposure or with emotional stress, leading to well-defined color changes of digital skin. It may be primary (Raynaud’s disease) or secondary to an underlying condition, including autoimmune rheumatic diseases. Although Raynaud’s disease is predominantly a vasospastic condition, Raynaud’s phenomenon in connective tissue diseases often is a result of an underlying vaso-occlusive process. As a result, the manifestations are more severe and persistent and often warrant pharmacologic therapy. Dihydropyridine calcium channel blockers are by far the most commonly studied and prescribed class of agents for the treatment of Raynaud’s phenomenon. There is some evidence for the efficacy of other classes of drugs, such as topical nitrates, α-antagonists, angiotensin receptor blockers, selective serotonin reuptake inhibitors, and pentoxifylline. However, the data on the efficacy of these agents are not as convincing, and they are not proven to be more effective than calcium channel blockers. Hence, their place in the therapy of Raynaud’s phenomenon is limited to patients who fail to respond adequately to or are unable to tolerate calcium channel blockers. More expensive second-line agents, such as phosphodiesterase-5 inhibitors, endothelin receptor antagonists, and intravenous prostanoids, are reserved for refractory cases of secondary Raynaud’s phenomenon with severe digital ischemia leading to ulceration or gangrene. These drugs may be used in isolation or as adjunct therapy to the first-line agents. Chemical and/or surgical sympathectomy may be considered if sympathetically driven digital ischemia is severe and resistant to pharmacologic intervention. These procedures may temporarily reverse the digital ischemia and help tide over the crisis, whereas the improvement thus achieved can be maintained by continuing medical therapy. In cases of ischemic digital ulceration, it is important to achieve adequate analgesia and to identify and treat superadded infection.     

What’s New in the Management of Bacterial Septic Arthritis?

Septic arthritis is a common rheumatological emergency requiring prompt diagnosis and treatment, since delays in management can lead to high morbidity and mortality. In this review article, we discuss the epidemiology and recent advances in knowledge of the pathogenesis of septic arthritis, with a special emphasis on various bacterial and host factors involved in mediating the inflammatory process and the potential for targeted therapy to modulate the immune response. Recent advances in laboratory and imaging techniques are reviewed along with treatment and potential new therapies.     

Approaches to Display of Multiple-Point Glucose Profiles: A UK Patient’s Perspective

Multiple-point glucose profiles are now acknowledged, in the diabetes literature, as a key way for people with diabetes to analyze and interpret blood glucose control (BGC).^1-3 Combined methods to visualize relevant blood glucose information are increasingly recognized as a more effective method of explaining actionable glucose profiles.^4,15(p564) This commentary is written from the perspective of a person with type 1 diabetes and might add value to the existing understanding about relevant ways to display BGC data. Through discussion of the limits to current multiple-point glucose displays, for example, AGP “dashboard,” a proposed alternative method of graphical display that brings together HbA1c and self-monitored blood glucose (SMBG) test data is presented.     

Physician Groups’ Use of Data from Patient Experience Surveys

Background

In Massachusetts, physician groups’ performance on validated surveys of patient experience has been publicly reported since 2006. Groups also receive detailed reports of their own performance, but little is known about how physician groups have responded to these reports.

Objective

To examine whether and how physician groups are using patient experience data to improve patient care.

Design and Participants

During 2008, we conducted semi-structured interviews with the leaders of 72 participating physician groups (out of 117 groups receiving patient experience reports). Based on leaders’ responses, we identified three levels of engagement with patient experience reporting: no efforts to improve (level 1), efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and efforts to improve group-wide performance (level 3).

Main Measures

Groups’ level of engagement and specific efforts to improve patient care.

Key Results

Forty-four group leaders (61%) reported group-wide improvement efforts (level 3), 16 (22%) reported efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and 12 (17%) reported no performance improvement efforts (level 1). Level 3 groups were more likely than others to have an integrated medical group organizational model (84% vs. 31% at level 2 and 33% at level 1; P < 0.005) and to employ the majority of their physicians (69% vs. 25% and 20%; P < 0.05). Among level 3 groups, the most common targets for improvement were access, communication with patients, and customer service. The most commonly reported improvement initiatives were changing office workflow, providing additional training for nonclinical staff, and adopting or enhancing an electronic health record.

Conclusions

Despite statewide public reporting, physician groups’ use of patient experience data varied widely. Integrated organizational models were associated with greater engagement, and efforts to enhance clinicians’ interpersonal skills were uncommon, with groups predominantly focusing on office workflow and support staff.KEY WORDS: patient experience, quality of care, quality improvement, physician groups, public reporting     

Cell biology of osteoarthritis: The chondrocyte’s response to injury

Cartilage is comprised of a large amount of functional extracellular matrix that is made and maintained by a small number of chondrocytes, the sole resident cell type. Normal cartilage exists in a relatively steady state: that is, the anabolic processes (those that result in the synthesis of cartilage matrix components) are in equilibrium with the catabolic processes (those that result in the normal turnover of matrix molecules). If the functional extracellular matrix is disturbed by physical or molecular means, the cells respond in an attempt to repair the matrix. This stimulated activity does not result in repair due to the extent and complexity of the extracellular matrix. Eventually, the newly synthesized and activated catabolic enzymes degrade the matrix components. This review presents the cellular and molecular mechanisms that account for this activity and provides some possible solutions.     

Management of perianal Crohn’s disease

Opinion statement Perianal manifestations of Crohn’s disease usually coexist with active inflammation of other primary sites of the disease. Although treatment of active proximal disease may sometimes alleviate perianal symptoms, it is reasonable to separately treat symptomatic perianal disease. The diversity of perianal manifestations in Crohn’s disease mandates a tailored, individualized approach in every case. Medical therapy is the best treatment option for hemorrhoids and anal fissures. The medical management of patients with perianal Crohn’s disease includes the use of systemic antibiotics, immunosuppressive agents, and infliximab. Infliximab is now recognized as a very efficacious agent for treating fistulizing Crohn’s disease, including perianal fistulae. It may also reduce the need for surgical intervention in specific cases. Abscesses and fistulae are treated by control of sepsis, resolution of inflammation and optimal preservation of continence, and quality of life. Abscesses require surgical drainage that may need to be prolonged to achieve complete healing. Fistulae may be treated medically, especially in cases of concurrent proctitis. Refractory fistulae may require surgical treatment including an occasional need for fecal diversion or proctectomy. The role of new treatment options such as natalizumab and CDP571 is evolving and requires further investigation.     

Management of Cardiac Amyloidosis: Do’s and Don’ts

Cardiac amyloidosis is a potentially deadly disease characterized by progressive infiltration of amyloid fibrils, and it is increasingly recognized as an underdiagnosed but important cause of heart failure. Given its unique pathogenesis, there are key differences in the management of cardiac amyloidosis compared with other forms of heart failure. Moreover, the 2 common forms of cardiac amyloidosis, transthyretin and light-chain amyloidosis, are distinct entities with varying clinical manifestations and prognoses, leading to the need for tailored approaches to management. In the past decade, there have been many significant advances in the diagnosis and treatment of both forms of cardiac amyloidosis. For example, in selected cases, transthyretin cardiac amyloidosis can be diagnosed noninvasively with the use of bone scintigraphy imaging, avoiding the need for a biopsy. Effective, more targeted therapies have been developed for both transthyretin and light-chain amyloidosis. However, these treatments are much more effective in early stages of disease before significant end-organ amyloid deposition has occurred. Consequently, it is increasingly imperative that clinicians aggressively screen at-risk groups, identify early signs of disease, and initiate treatment. Finally, once thought to be ill advised, heart transplantation should be considered in carefully selected patients with end-stage cardiac amyloidosis, because transplant outcomes in these patients is now similar to other those for other cardiomyopathies. Given these and other recent changes in clinical practice, this article discusses several key considerations for the clinical care of patients with cardiac amyloidosis.     

Management of portopulmonary hypertension:New perspectives

Portopulmonary hypertension(PPHTN)is a known complication of cirrhosis.Moderate-to-severe PPHTN implies an extremely poor prognosis.It occurs in 5%-10%of patients referred for liver transplantation(LT),and probably with an higher incidence in patients with large portosystemic shunts.Patients with moderate-tosevere pulmonary hypertension have been previously excluded from LT because of the extremely high surgical risk and since the post-transplant outcome reported was poor.Recently,new perspectives in the management of patients with portopulmonary hypertension are emerging.In fact,some pulmonary vasoactive drugs have become routine in the treatment of patients with idiopathic pulmonary hypertension.These drugs,particularly epoprostenol,have been recently introduced in the treatment of patients with PPHTN,and have been shown to be effective in reducing pulmonary artery pressure as well as pulmonary vascular resistances.Furthermore,recent studies seem to demonstrate that treatment with pulmonary vasoactive drugs could allow liver transplantation with acceptable surgical risks and excellent survival.Although there are not large series nor prospective studies addressing this topic,the clinical scenario of patients with PPHTN seems to be positively changing.