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1.
Saima I. Chaudhry MD MSHS Sandy Balwan MD Karen A. Friedman MD FACP Suzanne Sunday PhD Basit Chaudhry MD PhD Deborah DiMisa Alice Fornari EdD 《Journal of general internal medicine》2013,28(8):1100-1104
BACKGROUND
Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.AIM
To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.SETTING
A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.PARTICIPANTS
Residents, faculty, and administrative staff.PROGRAM DESCRIPTION
Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.PROGRAM EVALUATION
A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).DISCUSSION
A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2387-3) contains supplementary material, which is available to authorized users.KEY WORDS: ambulatory training, 4 + 1 model 相似文献2.
Joseph A. Simonetti Gwen T. Lapham Emily C. Williams 《Journal of general internal medicine》2015,30(8):1097-1104
BACKGROUND
Brief alcohol intervention, including advice to reduce or abstain from drinking, is widely recommended for general medical outpatients with unhealthy alcohol use, but it is challenging to implement. Among other implementation challenges, providers report reluctance to deliver such interventions, citing concerns about negatively affecting their patient relationships.OBJECTIVE
The purpose of this study was to determine whether patient-reported receipt of brief intervention was associated with patient-reported indicators of high-quality care among veteran outpatients with unhealthy alcohol use.DESIGN
Cross-sectional secondary data analysis was performed using the Veterans Health Administration (VA) Survey of Healthcare Experiences of Patients (SHEP).PARTICIPANTS
The study included veteran outpatients who (1) responded to the outpatient long-form SHEP (2009–2011), (2) screened positive for unhealthy alcohol use (Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) questionnaire score ≥ 3 for women, ≥ 4 for men), and (3) responded to questions assessing receipt of brief intervention and quality of care.MAIN MEASURES
We used logistic regression models to estimate the adjusted predicted prevalence of reporting two indicators of high-quality care—patient ratings of their VA provider and of overall VA healthcare (range 0–10, dichotomized as ≥ 9 indicating high quality)—for both patients who did and did not report receipt of brief intervention (receiving alcohol-related advice from a provider) within the previous year.KEY RESULTS
Among 10,612 eligible veterans, 43.8 % reported having received brief intervention, and 84.2 % and 79.1 % rated their quality of care as high from their provider and the VA healthcare system, respectively. In adjusted analyses, compared to veterans who reported receiving no brief intervention, a higher proportion of veterans reporting receipt of brief intervention rated the quality of healthcare from their provider (86.9 % vs. 82.0 %, p < 0.01) and the VA overall (82.7 % vs. 75.9 %, p < 0.01) as high.CONCLUSIONS
In this cross-sectional analysis of veterans with unhealthy alcohol use, a higher proportion of those who reported receipt of brief intervention reported receiving high-quality care compared to those who reported having received no such intervention. These findings do not support provider concerns that delivering brief intervention adversely affects patients’ perceptions of care.KEY WORDS: Alcoholism and addictive behavior, Quality assessment, Veterans, Patient satisfaction 相似文献3.
Riess H Kelley JM Bailey RW Dunn EJ Phillips M 《Journal of general internal medicine》2012,27(10):1280-1286
Background
Physician empathy is an essential attribute of the patient–physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims.Objective
We tested whether an innovative empathy training protocol grounded in neuroscience could improve physician empathy as rated by patients.Design
Randomized controlled trial.Intervention
We randomly assigned residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (N = 99, 52% female, mean age 30.6 ± 3.6) to receive standard post-graduate medical education or education augmented with three 60-minute empathy training modules.Main Measure
Patient ratings of physician empathy were assessed within one-month pre-training and between 1–2 months post-training with the use of the Consultation and Relational Empathy (CARE) measure. Each physician was rated by multiple patients (pre-mean = 4.6 ± 3.1; post-mean 4.9 ± 2.5), who were blinded to physician randomization. The primary outcome was change score on the patient-rated CARE.Key Results
The empathy training group showed greater changes in patient-rated CARE scores than the control (difference 2.2; P = 0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P < 0.001) and in ability to decode facial expressions of emotion (difference 1.9; P < 0.001).Conclusions
A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.KEY WORDS: empathy, randomized controlled trial, communication skills, graduate medical education, patient–physician relationship 相似文献4.
Vashitz G Pliskin JS Parmet Y Kosashvili Y Ifergane G Wientroub S Davidovitch N 《Journal of general internal medicine》2012,27(10):1265-1271
Background
Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians.Objective
To evaluate whether physicians’ judgment is affected by another medical opinion given to a patient.Design
Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician’s opinion was (study group), and the other group was not told what it was (control group).Participants
A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population).Measurements
Scoring was by choice of less or more interventional treatment in the scenarios. We used χ2 tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician’s responses.Results
Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) = 4.6, p = 0.03; OR = 1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p = 0.039; scenario 2, p < 0.001; scenario 3, p = 0.033; scenario 6, p < 0.001). These effects were insignificant among the neurologists [F (1,158) = 0.44, p = 0.51; OR = 1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) = 0.752, p = 0.473; neurologists: F (2,154) = 1.951, p = 0.146].Conclusions
The exploratory survey showed that in some cases physicians’ judgments may be affected by other physicians’ opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2056-y) contains supplementary material, which is available to authorized users.KEY WORDS: second-opinion, differential diagnosis, diagnostic reasoning, medical decision-making, health policy, surgery, orthopedics, neurology, surveys, consultation 相似文献5.
Rosette J. Chakkalakal MD MHS Stacy M. Higgins MD Lisa B. Bernstein MD Kristina L. Lundberg MD Victor Wu MD MPH Jacqueline Green MD MPH Qi Long PhD Joyce P. Doyle MD 《Journal of general internal medicine》2013,28(4):561-566
Background
Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam.Objective
To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain.Design
Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents’ performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse.Participants
One hundred forty-nine incoming residents.Main Measures
Residents’ performance for each skill was classified as correct, incorrect, or unknown.Key Results
One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46–0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41–0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16–0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01).Conclusions
We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.KEY WORDS: cardiovascular disease, clinical skills assessment, disparities, women’s health, medical student and residency education 相似文献6.
Helen T. Paradise MD MPH Dan R. Berlowitz MD MPH Al Ozonoff PhD Donald R. Miller ScD Elaine M. Hylek MD MPH Arlene S. Ash PhD Guneet K. Jasuja PhD Shibei Zhao MPH Joel I. Reisman AB Adam J. Rose MD MSc FACP 《Journal of general internal medicine》2014,29(6):855-861
Background
Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes.Objective
To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy.Design
Retrospective cohort analysis.Participants
We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007–2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders.Main Measures
Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations.Key Results
Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates.Conclusion
Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2784-2) contains supplementary material, which is available to authorized users.KEY WORDS: anticoagulation, mental health, veterans, warfarin therapy, psychiatric conditions 相似文献7.
Feinberg RA Swygert KA Haist SA Dillon GF Murray CT 《Journal of general internal medicine》2012,27(1):65-70
BACKGROUND
The United States Medical Licensing Examination® (USMLE®) Step 3® examination is a computer-based examination composed of multiple choice questions (MCQ) and computer-based case simulations (CCS). The CCS portion of Step 3 is unique in that examinees are exposed to interactive patient-care simulations.OBJECTIVE
The purpose of the following study is to investigate whether the type and length of examinees’ postgraduate training impacts performance on the CCS component of Step 3, consistent with previous research on overall Step 3 performance.DESIGN
Retrospective cohort studyPARTICIPANTS
Medical school graduates from U.S. and Canadian institutions completing Step 3 for the first time between March 2007 and December 2009 (n = 40,588).METHODS
Post-graduate training was classified as either broadly focused for general areas of medicine (e.g. pediatrics) or narrowly focused for specific areas of medicine (e.g. radiology). A three-way between-subjects MANOVA was utilized to test for main and interaction effects on Step 3 and CCS scores between the demographic characteristics of the sample and type of residency. Additionally, to examine the impact of postgraduate training, CCS scores were regressed on Step 1 and Step 2 Clinical Knowledge (CK) scores. Residuals from the resulting regressions were plotted.RESULTS
There was a significant difference in CCS scores between broadly focused (μ = 216, σ = 17) and narrowly focused (μ=211, σ = 16) residencies (p < 0.001). Examinees in broadly focused residencies performed better overall and as length of training increased, compared to examinees in narrowly focused residencies. Predictors of Step 1 and Step 2 CK explained 55% of overall Step 3 variability and 9% of CCS score variability.CONCLUSIONS
Factors influencing performance on the CCS component may be similar to those affecting Step 3 overall. Findings are supportive of the validity of the Step 3 program and may be useful to program directors and residents in considering readiness to take this examination.KEY WORDS: USMLE, Step 3, CCS, postgraduate training, graduate medical education 相似文献8.
Jean Yoon PhD MHS Danielle E. Rose PhD MPH Ismelda Canelo MPA Anjali S. Upadhyay MS Gordon Schectman MD Richard Stark MD Lisa V. Rubenstein MD MSPH Elizabeth M. Yano PhD MSPH 《Journal of general internal medicine》2013,28(9):1188-1194
Background
As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.Objective
We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.Design
Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.Participants
2,853,030 patients from 814 VHA primary care clinicsMain Measures
Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.Key Results
The overall mean home builder score in the study clinics was 88 (SD = 13) or 69 %. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3 % (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).Conclusion
Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.KEY WORDS: medical home, avoidable hospitalizations, access, care coordination 相似文献9.
Wright A Poon EG Wald J Feblowitz J Pang JE Schnipper JL Grant RW Gandhi TK Volk LA Bloom A Williams DH Gardner K Epstein M Nelson L Businger A Li Q Bates DW Middleton B 《Journal of general internal medicine》2012,27(1):85-92
BACKGROUND
Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied.OBJECTIVE
To determine whether providing reminders directly to patients via an electronic Personal Health Record (PHR) improved adherence to care recommendations.DESIGN
We conducted a cluster randomized trial without blinding from 2005 to 2007 at 11 primary care practices in the Partners HealthCare system.PARTICIPANTS
A total of 21,533 patients with access to a PHR were invited to the study, and 3,979 (18.5%) consented to enroll.INTERVENTIONS
Patients in the intervention arm received health maintenance (HM) reminders via a secure PHR “eJournal,” which allowed them to review and update HM and family history information. Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications, allergies and diabetes management.MAIN MEASURES
The primary outcome measure was adherence to guideline-based care recommendations.KEY RESULTS
Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography (48.6% vs 29.5%, p = 0.006) and influenza vaccinations (22.0% vs 14.0%, p = 0.018). No significant improvement was observed in rates of other screenings. Although Pap smear completion rates were higher in the intervention arm (41.0% vs 10.4%, p < 0.001), this finding was no longer significant after excluding women’s health clinics. Additional on-treatment analysis showed significant increases in mammography (p = 0.019) and influenza vaccination (p = 0.015) for intervention arm patients who opened an eJournal compared to control arm patients, but no differences for any measure among patients who did not open an eJournal.CONCLUSIONS
Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1859-6) contains supplementary material, which is available to authorized users.KEY WORDS: health maintenance reminders, personal health record, preventive care, clinical decision support, Patient Gateway 相似文献10.
Turner BJ Hollenbeak CS Liang Y Pandit K Joseph S Weiner MG 《Journal of general internal medicine》2012,27(10):1258-1264
OBJECTIVE
Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure.DESIGN AND SUBJECTS
A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension.INTERVENTION
Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease.MAIN MEASURES
Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months.KEY RESULTS
At baseline, the 136 intervention and 144 control subjects’ mean 4-year coronary heart disease risk did not differ (intervention = 5.8 % and control = 6.4 %, P = 0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p = 0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference −0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p = 0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a >5 mmHg reduction (61 % versus 45 %, respectively, p = 0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference −6.47 mmHg, 95 % confidence interval: −10.69 to −2.25, P = 0.003). One patient died in each study arm.CONCLUSIONS
Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure.KEY WORDS: coronary heart disease, hypertension, African American, peer support 相似文献11.
Jennie Wei Triveni Defries Mia Lozada Natalie Young William Huen Jacqueline Tulsky 《Journal of general internal medicine》2015,30(3):365-370
BACKGROUND
Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized.AIM
Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence.SETTING
The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital.PARTICIPANTS
Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service.PROGRAM DESCRIPTION
We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment.PROGRAM EVALUATION
Rates of medication-assisted treatment increased from 0 % to 64 % (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4 % to 8.2 % (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8 % to 6.1 % (p value = 0.056).DISCUSSION
Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2968-9) contains supplementary material, which is available to authorized users.KEY WORDS: alcoholism and addictive behavior, care transitions, medical student and residency education, substance abuse, medical education-clinical skills training 相似文献12.
Tang JW Kushner RF Cameron KA Hicks B Cooper AJ Baker DW 《Journal of general internal medicine》2012,27(8):933-939
Background
Physicians often do not recognize when their patients are overweight and infrequently counsel them about weight loss.Objective
To evaluate a set of electronic health record (EHR)-embedded tools to assist with identification and counseling of overweight patients.Design
Randomized controlled trial.Participants
Physicians at an academic general internal medicine clinic were randomized to activation of the EHR tools (n = 15) or to usual care (n = 15). Patients of these physicians were included in analyses if they had a body mass index (BMI) between 27 and 29.9 kg/m2.Intervention
The EHR tool set included: a physician point-of-care alert for overweight (BMI 27–29. 9 kg/m2); a counseling template to help physicians counsel patients on action plans; and an order set to facilitate entry of overweight as a diagnosis and to order relevant patient handouts.Main Measures
Physician documentation of overweight as a problem; documentation of weight-specific counseling; physician perceptions of the EHR tools; patient self-reported progress toward their goals and perspectives about counseling received.Key Results
Patients of physicians receiving the intervention were more likely than those of usual care physicians to receive a diagnosis of overweight (22% vs. 7%; p = 0.02) and weight-specific counseling (27% vs. 15%; p = 0.02). Most patients receiving counseling in the intervention group reported increased motivation to lose weight (90%) and taking steps toward their goal (93%). Most intervention physicians agreed that the tool alerted them to patients they did not realize were overweight (91%) and improved the effectiveness of their counseling (82%); more than half (55%) reported counseling overweight patients more frequently (55%). However, most physicians used the tool infrequently because of time barriers.Conclusions
EHR-based alerts and management tools increased documentation of overweight and counseling frequency; the majority of patients for whom the tools were used reported short-term behavior change.KEY WORDS: overweight, counseling, electronic health record 相似文献13.
Gardener H Rundek T Markert M Wright CB Elkind MS Sacco RL 《Journal of general internal medicine》2012,27(9):1120-1126
BACKGROUND
Diet and regular soft drinks have been associated with diabetes and the metabolic syndrome, and regular soft drinks with coronary heart disease.OBJECTIVE
To determine the association between soft drinks and combined vascular events, including stroke.DESIGN
A population-based cohort study of stroke incidence and risk factors.PARTICANTS
Participants (N = 2564, 36% men, mean age 69 ± 10, 20% white, 23% black, 53% Hispanic) were from the Northern Manhattan Study.MAIN MEASURES
We assessed diet and regular soft drink consumption using a food frequency questionnaire at baseline, and categorized: none (<1/month, N = 1948 diet, N = 1333 regular), light (1/month-6/week, N = 453 diet, N = 995 regular), daily (≥1/day, N = 163 diet, N = 338 regular). Over a mean follow-up of 10 years, we examined the association between soft drink consumption and 591 incident vascular events (stroke, myocardial infarction, vascular death) using Cox models.KEY RESULTS
Controlling for age, sex, race/ethnicity, education, smoking, physical activity, alcohol consumption, BMI, daily calories, consumption of protein, carbohydrates, total fat, saturated fat, and sodium, those who drank diet soft drinks daily (vs. none) had an increased risk of vascular events, and this persisted after controlling further for the metabolic syndrome, peripheral vascular disease, diabetes, cardiac disease, hypertension, and hypercholesterolemia (HR = 1.43, 95% CI = 1.06–1.94). There was no increased risk of vascular events associated with regular soft drinks or light diet soft drink consumption.CONCLUSIONS
Daily diet soft drink consumption was associated with several vascular risk factors and with an increased risk for vascular events. Further research is needed before any conclusions can be made regarding the potential health consequences of diet soft drink consumption.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1968-2) contains supplementary material, which is available to authorized users.KEY WORDS: diet, epidemiology, myocardial infarction, stroke, cardiovascular disease 相似文献14.
Boustani MA Campbell NL Khan BA Abernathy G Zawahiri M Campbell T Tricker J Hui SL Buckley JD Perkins AJ Farber MO Callahan CM 《Journal of general internal medicine》2012,27(5):561-567
Background
Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.Objective
Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.Design
A randomized controlled clinical trial.Setting
A public hospital in Indianapolis.Population
A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.Intervention
A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.Measurements
Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.Results
Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).Conclusion
A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-1994-8) contains supplementary material, which is available to authorized users.KEY WORDS: cognitive impairment, clinical trial, decision support, hospitalized elders 相似文献15.
16.
Impact of a 360-degree Professionalism Assessment on Faculty Comfort and Skills in Feedback Delivery
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Background
Professionalism is identified as a competency of resident education. Best approaches to teaching and evaluating professionalism are unknown, but feedback about professionalism is necessary to change practice and behavior. Faculty discomfort with professionalism may limit their delivery of feedback to residents.Objectives
A pilot program to implement a 360-degree evaluation of observable professionalism behaviors and determine how its use impacts faculty feedback to residents.Design
Internal Medicine (IM) residents were evaluated during ambulatory rotations using a 360-degree assessment of professional behaviors developed by the National Board of Medical Examiners®. Faculty used evaluation results to provide individual feedback to residents.Patients/Participants
Fifteen faculty members.Measurements and Main Results
Faculty completed pre- and post-intervention surveys. Using a 7-point Likert scale, faculty reported increased skill in giving general feedback (4.85 vs 4.36, p < .05) and feedback about professionalism (4.71 vs 3.57, p < .01) after the implementation of the 360-degree evaluation. They reported increased comfort giving feedback about professionalism (5.07 vs 4.35, p < .05) but not about giving feedback in general (5.43 vs 5.50).Conclusions
A 360-degree professionalism evaluation instrument used to guide feedback to residents improves faculty comfort and self-assessed skill in giving feedback about professionalism.KEY WORDS: professionalism, feedback, 360-degree evaluation, internship, residency 相似文献17.
Erica S. Spatz MD MHS Sameer D. Sheth MD Kensey L. Gosch MS Mayur M. Desai PhD MPH John A. Spertus MD MPH Harlan M. Krumholz MD SM Joseph S. Ross MD MHS 《Journal of general internal medicine》2014,29(6):862-869
Background
The quality of the relationship between a patient and their usual source of care may impact outcomes, especially after an acute clinical event requiring regular follow-up.Objective
To examine the association between the presence and strength of a usual source of care with mortality and readmission after hospitalization for acute myocardial infarction (AMI).Design
Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, 19-center study.Patients
AMI patients discharged between January 2003 and June 2004.Main Measures
The strength of the usual source of care was categorized as none, weak, or strong based upon the duration and familiarity of the relationship. Main outcome measures were readmissions and mortality at 6 months and 12 months post-AMI, examined in multivariable analysis adjusting for socio-demographic characteristics, access and barriers to care, financial status, baseline risk factors, and AMI severity.Key Results
Among 2,454 AMI patients, 441 (18.0 %) reported no usual source of care, whereas 247 (10.0 %) and 1,766 (72.0 %) reported weak and strong usual sources of care, respectively. When compared with a strong usual source of care, adults with no usual source of care had higher 6-month mortality rates [adjusted hazard ratio (aHR) = 3.15, 95 % CI, 1.79–5.52; p < 0.001] and 12-month mortality rates (aHR = 1.92, 95 % CI, 1.19–3.12; p = 0.01); adults with a weak usual source of care trended toward higher mortality at 6 months (aHR = 1.95, 95 % CI, 0.98–3.88; p = 0.06), but not 12 months (p = 0.23). We found no association between the usual source of care and readmissions.Conclusions
Adults with no or weak usual sources of care have an increased risk for mortality following AMI, but not for readmission.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2794-0) contains supplementary material, which is available to authorized users.KEY WORDS: doctor and patient relationship, usual source of care, myocardial infarction 相似文献18.
VG Press AA Pappalardo WD Conwell AT Pincavage MH Prochaska VM Arora 《Journal of general internal medicine》2012,27(8):1001-1015
OBJECTIVES
To systematically review the literature to characterize interventions with potential to improve outcomes for minority patients with asthma.DATA SOURCES
Medline, PsycINFO, CINAHL, Cochrane Trial Databases, expert review, reference review, meeting abstracts.STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTEVENTIONS
Medical Subject Heading (MeSH) terms related to asthma were combined with terms to identify intervention studies focused on minority populations. Inclusion criteria: adult population; intervention studies with majority of non-White participants.STUDY APPRAISAL AND SYNTHESIS OF METHODS
Study quality was assessed using Downs and Black (DB) checklists. We examined heterogeneity of studies through comparing study population, study design, intervention characteristics, and outcomes.RESULTS
Twenty-four articles met inclusion criteria. Mean quality score was 21.0. Study populations targeted primarily African American (n = 14), followed by Latino/a (n = 4), Asian Americans (n = 1), or a combination of the above (n = 5). The most commonly reported post-intervention outcome was use of health care resources, followed by symptom control and self-management skills. The most common intervention-type studied was patient education. Although less-than half were culturally tailored, language-appropriate education appeared particularly successful. Several system–level interventions focused on specialty clinics with promising findings, although health disparities collaboratives did not have similarly promising results.LIMITATIONS
Publication bias may limit our findings; we were unable to perform a meta-analysis limiting the review’s quantitative evaluation.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS
Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. Few were culturally tailored and one included a comparison group, limiting the conclusions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Future research should evaluate the role of tailoring educational strategies, focus on patient-centered education, and incorporate outpatient follow-up and/or a team-based approach.KEY WORDS: asthma, disparities, interventions, culturally tailored 相似文献19.
Devon A. Dobrosielski PhD Bethany Barone Gibbs PhD Pamela Ouyang MBBS Susanne Bonekamp DVM Jeanne M. Clark MD Nae-Yuh Wang PhD Harry A. Silber MD PhD Edward P. Shapiro MD Kerry J. Stewart EdD 《Journal of general internal medicine》2012,27(11):1453-1459