Physician and Patient Characteristics Associated With Clinical Inertia in Blood Pressure Control

Clinical inertia, the failure to adjust antihypertensive medications during patient visits with uncontrolled hypertension, is thought to be a common problem. This retrospective study used 5 years of electronic medical records from a multispecialty group practice to examine the association between physician and patient characteristics and clinical inertia. Hierarchical linear models (HLMs) were used to examine (1) differences in physician and patient characteristics among patients with and without clinical inertia, and (2) the association between clinical inertia and future uncontrolled hypertension. Overall, 66% of patients experienced clinical inertia. Clinical inertia was associated with one physician characteristic, patient volume (odds ratio [OR]=0.998). However, clinical inertia was associated with multiple patient characteristics, including patient age (OR=1.021), commercial insurance (OR=0.804), and obesity (OR=1.805). Finally, patients with clinical inertia had 2.9 times the odds of uncontrolled hypertension at their final visit in the study period. These findings may aid the design of interventions to reduce clinical inertia.     

Factors Associated with Surveillance Adenoma and Sessile Serrated Polyp Detection Rates

Digestive Diseases and Sciences - Adenoma detection rate (ADR) and sessile serrated polyp detection rate (SSPDR) data in surveillance colonoscopy are limited. Our aim was to determine surveillance...     

Specialty Differences in Polyp Detection, Removal, and Biopsy during Colonoscopy

Background

Colonoscopy is a technically complex procedure commonly performed to detect and remove colorectal pathology. This study examined the influence of provider characteristics on polyp detection, polyp removal, and diagnostic biopsy rates.

Methods

We conducted a retrospective cross-sectional study using a 20% sample of 2003 Medicare claims. Primary outcome measures were use of diagnostic biopsy, polyp detection, and polyp removal. We used generalized estimating equations to identify independent predictors of the outcomes, adjusting for patient and provider characteristics.

Results

Among 328,167 outpatient colonoscopies, polyp detection and removal rates were significantly lower for nongastroenterologists than gastroenterologists, with adjusted relative risk for polyp detection between 0.80 (95% confidence interval [CI], 0.77-0.83) for general surgeons and 0.93 (95% CI, 0.89-0.98) for internists. Compared with gastroenterologists, diagnostic biopsy was significantly less likely for general (relative risk [RR] 0.69; 95% CI, 0.65-0.74) or colorectal surgeons (RR 0.58; 95% CI, 0.52-0.65). The likelihood of polyp detection and removal was higher for physicians in the middle 2 quartiles of annual colonoscopy volume, but similar for physicians in the highest and lowest volume quartiles. Polyp detection and removal were significantly less likely for examinations in ambulatory surgery centers or offices than hospital outpatient settings, while diagnostic biopsy was significantly less likely in office settings.

Conclusions

Physician specialty, annual colonoscopy volume, and site of service are significant predictors of polyp detection, polyp removal, and diagnostic biopsy. These findings may have important implications for the effectiveness of colonoscopy.     

Patient, Primary Care Physician and Specialist Expectations of Primary Care Physician Involvement in Cancer Care

Background  

In Canada, many health authorities recommend that primary care physicians (PCP) stay involved throughout their patients’ cancer journey to increase continuity of care. Few studies have focused on patient and physician expectations regarding PCP involvement in cancer care.     

结肠镜学习时间与结肠息肉检出率关系的临床研究

目的探讨结肠镜息肉检出率是否随着结肠镜的学习时间的增加而不断提高。 方法回顾性分析2016年7月至2018年12月经福建漳州正兴医院4名有经验的肠镜医师A、B、C、D及2名肠镜初学者E、F每半年的结肠镜息肉检出率变化趋势，并进行分析和比较。 结果A、B、C、D、E、F医生总的息肉检出率分别为43.8%(1 107/2 529)、31.8%(420/1 322)、35.3%(619/1 753)、25.2%(194/771)、42.8% (166/388)和29.3%(129/440)。6名肠镜医师之间、4名有经验肠镜医师之间及2名肠镜初学者之间的息肉检出率差异均具有统计学显著性差异。肠镜初学者E医生一年半时间，每半年息肉检出率分别为48.39%(15/31)、42.86%(42/98)和42.08%(109/259)，而F医生仅为21.84%(19/87)、32.73%(36/110)和30.45%(74/243)，检出率无明显统计学差异。 结论结肠镜息肉检出率并不随着结肠镜的学习时间的增加而提高。     

Incidence,Frequency, and Clinical Characteristics of Type 3 Myocardial Infarction in Clinical Practice

Objectives

Cardiac death in a patient with symptoms and electrocardiographic changes indicative of myocardial ischemia but without available measurements of cardiac biomarkers is designated a type 3 myocardial infarction. We wanted to investigate the incidence, the frequency, and the characteristics of patients diagnosed as type 3 myocardial infarction.

Short Procedure of GHRH Plus Arginine Test in Clinical Practice

Either in children or in adults, arginine (ARG) alone and combined with GHRH (GHRH + ARG) are reliable tests for the diagnosis of GH deficiency. The procedures of these tests generally include GH measurement every 15 min from baseline up to 90–120 min. Aim of our study was to verify if the procedure of these tests could be usefully shortened in clinical practice. To this goal we have studied 173 normally growing children and adolescents (C, 117 M and 56 F, age: 11.3 ± 0.4 yr.) and 125 young and middle aged normal adults (A, 68 M and 57 F, age: 30.0 ± 0.6 yr.). ARG alone test was performed by 81 C and 33 A (0.5 g/kg arginine, iv, from 0 to +30 min, up to a maximum of 30 g) while GHRH (1 g/kg iv bolus at 0 min) + ARG test was performed by 92 C and 92 A. After ARG alone, taking into account data from +15 to +105 min, GH values above the 3rd centile limit of arbitrary cut-off (7 or 10 g/1 in C and 5 g/1 in A) occurred in 85% or 64% and 94% subjects, respectively. After GHRH + ARG test, taking into account only data at +30, +45, +60 min GH values above the 3rd centile limit (20 g/1 in C and 16.5 g/1 in A) occurred in 99% of subjects in both groups. Taking into account only these 3 timing points, the percentage of GH peak above the third centile limits after ARG alone was never higher than 60% in C and 85% in A. In conclusion, this study shows that single GHRH + arginine test can be reliably performed in a shortened procedure which makes easier the clinical practice and further reduces costs.     

Pneumonia Recovery; Discrepancies in Perspectives of the Radiologist,Physician and Patient

BACKGROUND  

Chest radiographs are often used to diagnose community-acquired pneumonia (CAP), to monitor response to treatment and to ensure complete resolution of pneumonia. However, radiological exams may not reflect the actual clinical condition of the patient.     

Patient and Physician Satisfaction with Proton Pump Inhibitors (PPIs): Are There Opportunities for Improvement?

Background  

Few studies have explored the satisfaction with proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD).     

A Reliable Screening Procedure for Coeliac Disease in Clinical Practice

Background: The main autoantigen recognized by the sera of patients with coeliac disease (CD) is tissue transglutaminase (tTG). A human-recombinant form of tTG was used to develop an ELISA to measure anti-tTG serum antibodies for the diagnosis of CD. Preliminary retrospective reports suggest that the human tTG-based ELISA could identify coeliac patients missed by the IgA-anti-endomysium antibody test (AEA). Whether the human recombinant tTG ELISA is sufficiently accurate to become the main diagnostic CD tool in everyday clinical practice is unknown. The objective was to determine, in a prospective study, the sensitivity and specificity of an ELISA test based on the use of human tTG compared with AEA, to analyse the discordant cases for HLA DQ2-8 and for clinical and intestinal biopsy characteristics. Methods: 1106 patients referred to a gastrointestinal outpatient clinic for symptoms attributable to CD, 52 first-degree relatives of CD patients and 200 healthy controls were tested for both anti-human tTG and AEA antibodies. Results: Out of 1158 subjects, 146 were tested positive for anti-tTG antibodies and 140 were biopsy-proven coeliacs. The AEA test identified 126/1158 coeliacs who also tested positive for anti-tTG antibodies. The 14 patients missed by the AEA test carried the typical HLA-DQ for CD; they had normal levels of total serum IgA and had milder pathology than those with both anti-tTG and AEA positivity ( P < 0001). Conclusions: These results prove that human tTG-based ELISA is an excellent diagnostic tool for CD, for mass screening by both the specialist and the general clinic.     

Capsule Endoscopy Changes Patient Management in Routine Clinical Practice

Our objective was to evaluate the diagnostic yield and effect of capsule endoscopy on patient management in routine clinical practice. Three hundred examinations were performed (176 females; mean age, 51 years), with a median follow-up of 17 months. Indications included overt bleeding (n = 55), anemia (n = 104), suspected Crohn’s disease (n = 68), celiac disease (n = 35), suspected functional symptoms (n = 23), polyposis (n = 5), and miscellaneous (n = 10). The overall diagnostic yield was 39%, but it was notably higher in overt bleeders, 66%, compared to 46% in the anemia group (P<0.025), 32% in the suspected Crohn’s group (P<0.001), and 17% in the functional group (P<0.001). As a result of capsule endoscopy, management was altered in 26% of patients. This study shows that capsule endoscopy has both a high diagnostic yield and an impact on subsequent patient management. These data further support the role of capsule endoscopy in routine clinical practice. R.S. wrote the initial draft; all five authors were involved in the subsequent revisions and final draft. M.E.M. is the guarantor for this paper.     

Coronary Stenting in Clinical Practice: Patient Profile, Immediate Outcome, Clinical and Angiographic Follow-up in 243 Consecutive Patients

The purpose of this study is to assess immediate outcome and long term results in unselected consecutive patients (pts) representing a spectrum of clinical and angiographic subgroups and stent designs. RESULTS: From first implantation in November 1989 through to October 1995, 243 pts underwent coronary stent insertion (307 stents, males n=188, females n=55, mean age 57.8 years. Palmaz-Schatz stents were implanted in 210 pts, Wiktor in 30 pts, both in 3. Bailout stenting was performed in 11 patients. Overall procedural success was 97%. Complete revascularization was achieved in 155 (64%) patients. Stenting of an infarct-related artery within 6 hours of an acute myocardial infarction was performed in 6 patients, and for unstable angina in 107. Pre-procedure 223 (92%) pts had class III/IV angina. Stenting of 11 vein grafts and 5 left main arteries was performed. Subacute stent thrombosis occurred in 13 (5%) pts while 6 (2.5%) pts died in hospital, and 8 (3%) had a Q-wave myocardial infarction. At a mean (SD) 7.3 (12.9) months follow-up 233 (96%) pts were alive, 213 (91%) had no or mild angina. Angiographic follow-up in 201 (83%) pts at 19 (30) weeks showed a 13% in stent restenosis rate. CONCLUSIONS: In an unselected, consecutive series of patients undergoing coronary stenting, mortality was low, procedural success was high and late clinical and angiographic results were satisfactory. Subacute stent thrombosis, though uncommon remains a challenge.