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1.
Ann S. O’Malley MD MPH Peter J. Cunningham PhD 《Journal of general internal medicine》2009,24(2):170-177
BACKGROUND Coordination across a patient’s health needs and providers is important to improving the quality of care.
OBJECTIVES (1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and
specialists and (2) determine whether visit continuity with one’s PCP and the PCP as the referral source for specialist visits
are associated with higher coordination ratings.
DESIGN Cross-sectional study of the 2007 Health Tracking Household Survey.
PARTICIPANTS A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months.
MEASUREMENTS Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received,
(2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different
doctors caring for a patient’s chronic condition work together to manage that care.
RESULTS Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity
with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the
same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do
not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient’s recent specialist visit was based on PCP
referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist
care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist
visit (vs. 47%, p < 0.0001).
CONCLUSIONS Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would
likely enhance care coordination. 相似文献
2.
Haas JS Earle CC Orav JE Brawarsky P Neville BA Acevedo-Garcia D Williams DR 《Journal of general internal medicine》2007,22(3):396-399
Background Although hospice care can alleviate suffering at the end of life for patients with cancer, it remains underutilized, particularly
by African Americans and Hispanics.
Objective To examine whether the racial composition of the census tract where an individual resides is associated with hospice use.
Design Retrospective analysis of the Surveillance, Epidemiology, and End Results–Medicare file for individuals dying from breast,
colorectal, lung, or prostate cancer (n = 70,669).
Measurements Hospice use during the 12 months before death.
Results Hospice was most commonly used by individuals who lived in areas with fewer African-American and Hispanic residents (47%),
and was least commonly used by individuals who lived in areas with a high percentage of African-American and Hispanic residents
(35%). Hispanics (odds ratio 0.51, 95% confidence interval 0.29–0.91) and African Americans (0.56, 0.44–0.71) were less likely
to use hospice if they lived in a census tract with a high percentage of both African Americans and Hispanics than if they
lived in a low minority tract. African Americans and whites were less likely to receive hospice care if they lived in a census
tract with a high percentage of Hispanics than if they lived in a low minority area.
Conclusions Increasing hospice use may require interventions to improve the delivery of hospice care in minority communities. 相似文献
3.
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
4.
Claire F. Snyder PhD Kevin D. Frick PhD Kimberly S. Peairs MD Melinda E. Kantsiper MD Robert J. Herbert Amanda L. Blackford ScM Antonio C. Wolff MD Craig C. Earle MD MSc 《Journal of general internal medicine》2009,24(4):469-474
BACKGROUND Deficiencies in care for cancer survivors may result from unclear roles for primary care providers (PCPs) and oncology specialists
in follow-up.
OBJECTIVES To compare cancer survivors’ care to non-cancer controls.
DESIGN Retrospective, longitudinal, controlled study starting 366 days post-diagnosis.
SUBJECTS Stage 1-3 breast cancer survivors age 65+ diagnosed in 1998 (n = 1961) and matched non-cancer controls (n = 1961).
MEASUREMENTS Using the SEER-Medicare database, we examined the number of visits to PCPs, oncology specialists, and other physicians; receipt
of influenza vaccination, cholesterol screening, colorectal cancer screening, bone densitometry, and mammography; and whether
care receipt was associated with physician mix visited.
RESULTS Survivors were consistently less likely to receive influenza vaccination, cholesterol screening, colorectal cancer screening,
and bone densitometry but more likely to receive mammograms than controls (all p < 0.05). Over time, colorectal cancer screening
and mammography decreased and influenza vaccination increased for both groups (all p < 0.0001). Trends over time in care receipt
were similar for survivors and controls. In Year 1, survivors had more visits to PCPs but fewer visits to other physicians
than controls (both p < 0.05). Over time, survivors’ visits to PCPs and other physicians increased and to oncology specialists
decreased (all p < 0.0001). Controls’ visits to PCPs increased (p < 0.0001) faster than survivors’ (p = 0.003). Controls’
visits to other physicians increased (p < 0.0001) at a rate similar to survivors. Survivors who visited both a PCP and oncology
specialist were most likely to receive each service.
CONCLUSIONS Better coordination between PCPs and oncology specialists may improve care for older breast cancer survivors. 相似文献
5.
David M. Maslove Richard E. Leiter Joshua Griesman Corinne Arnott Ophyr Mourad Chi-Ming Chow Chaim M. Bell 《Journal of general internal medicine》2009,24(9):995-1001
BACKGROUND Patient care transitions are periods of enhanced risk. Discharge summaries have been used to communicate essential information
between hospital-based physicians and primary care physicians (PCPs), and may reduce rates of adverse events after discharge.
OBJECTIVE To assess PCP satisfaction with an electronic discharge summary (EDS) program as compared to conventional dictated discharge
summaries.
DESIGN Cluster randomized trial.
PARTICIPANTS Four medical teams of an academic general medical service.
MEASUREMENTS The primary endpoint was overall discharge summary quality, as assessed by PCPs using a 100-point visual analogue scale. Other
endpoints included housestaff satisfaction (using a 100-point scale), adverse outcomes after discharge (combined endpoint
of emergency department visits, readmission, and death), and patient understanding of discharge details as measured by the
Care Transition Model (CTM-3) score (ranging from 0 to 100).
RESULTS 209 patient discharges were included over a 2-month period encompassing 1 housestaff rotation. Surveys were sent out for 188
of these patient discharges, and 119 were returned (63% response rate). No difference in PCP-reported overall quality was
observed between the 2 methods (86.4 for EDS vs. 84.3 for dictation; P = 0.53). Housestaff found the EDS significantly easier to use than conventional dictation (86.5 for EDS vs. 49.2 for dictation;
P = 0.03), but there was no difference in overall housestaff satisfaction. There was no difference between discharge methods
for the combined endpoint for adverse outcomes (22 for EDS [21%] vs. 21 for dictation [20%]; P = 0.89), or for patient understanding of discharge details (CTM-3 score 80.3 for EDS vs. 81.3 for dictation; P = 0.81)
CONCLUSION An EDS program can be used by housestaff to more easily create hospital discharge summaries, and there was no difference in
PCP satisfaction. 相似文献
6.
Rodriguez HP Rogers WH Marshall RE Safran DG 《Journal of general internal medicine》2007,22(6):787-793
Background Visit continuity is important to patients and valued by physicians. However, it is virtually impossible for primary care physicians
(PCPs) to provide care during every paneled patient visit. It remains unclear whether PCP visit discontinuity can be planned
in a way that is least disruptive to patients’ experiences with care.
Objective This study aims to clarify whether visit continuity affects patients’ experiences with primary care equally for all patients.
Design From January 2004 through March 2005, a large multispecialty practice in Massachusetts administered the Ambulatory Care Experience
Survey (ACES) monthly to a random sample of patients visiting each of 145 PCPs. The analytic sample includes 14,835 patients
with 2 or more primary care visits over the 6 months before being surveyed. Usual Provider Continuity (UPC), an administratively
based measure of PCP visit continuity, was calculated for all respondents. Multilevel regression models that accounted for
the clustering of patients within physicians modeled the relationship between UPC and each ACES measure. Interaction effects
between UPC and gender, education, self-rated health, and PCP–patient relationship duration were tested.
Results Physician–patient interaction quality, including physician communication, knowledge of the patient, health promotion support,
and organizational access were more strongly influenced by visit continuity among respondents in early stages of a PCP–patient
relationship (P < 0.01) and with worse self-rated health (P < 0.01).
Conclusions Improvements in physician–patient relationship quality can be achieved by targeting visit continuity improvement efforts to
patients who benefit most, particularly those in early stages of a PCP–patient relationship and/or perceive their health as
poor. 相似文献
7.
Computers in the Exam Room: Differences in Physician–Patient Interaction May Be Due to Physician Experience
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Background The use of electronic medical records can improve the technical quality of care, but requires a computer in the exam room.
This could adversely affect interpersonal aspects of care, particularly when physicians are inexperienced users of exam room
computers.
Objective To determine whether physician experience modifies the impact of exam room computers on the physician–patient interaction.
Design Cross-sectional surveys of patients and physicians.
Setting and Participants One hundred fifty five adults seen for scheduled visits by 11 faculty internists and 12 internal medicine residents in a VA
primary care clinic.
Measurements Physician and patient assessment of the effect of the computer on the clinical encounter.
Main Results Patients seeing residents, compared to those seeing faculty, were more likely to agree that the computer adversely affected
the amount of time the physician spent talking to (34% vs 15%, P = 0.01), looking at (45% vs 24%, P = 0.02), and examining them (32% vs 13%, P = 0.009). Moreover, they were more likely to agree that the computer made the visit feel less personal (20% vs 5%, P = 0.017). Few patients thought the computer interfered with their relationship with their physicians (8% vs 8%). Residents
were more likely than faculty to report these same adverse effects, but these differences were smaller and not statistically
significant.
Conclusion Patients seen by residents more often agreed that exam room computers decreased the amount of interpersonal contact. More
research is needed to elucidate key tasks and behaviors that facilitate doctor–patient communication in such a setting. 相似文献
8.
Background For patients to experience the benefits of total joint arthroplasty (TJA), primary care physicians (PCPs) ought to know when
to refer a patient for TJA and/or optimize nonsurgical treatment options for osteoarthritis (OA).
Objective To evaluate the ability of physicians to make clinical treatment decisions.
Design and participants A survey, using ten clinical vignettes, of PCPs in Indiana.
Measurements A test score (range 0 to 10) was computed based on the number of correct answers consistent with published explicit appropriateness
criteria for TJA. We also collected demographic characteristics and physicians’ perceived success rate of TJA in terms of
pain relief and functional improvement.
Results There were 149 PCPs (response rate = 61%) who participated. The mean test score was 6.5 ± 1.5. Only 17% correctly identified
the published success rate of TJA (i.e., ≥90%). In multivariate analysis, the only physician-related variables associated
with test score were ethnicity, board status, and perceived success rate of TJA. Physicians who were white (P = .001), board-certified (P = .04), and perceived a higher success rate of TJA (P = .004) had higher test scores.
Conclusions PCP knowledge with respect to guideline-concordant care for OA could be improved, specifically in deciding when to consider
TJA versus optimizing nonsurgical options. Moreover, the perception of the success rate of TJA may influence a clinician’s
decision making.
Potential Financial Conflicts of Interest: None disclosed. 相似文献
9.
Carrie N. Klabunde Anita Ambs Nancy L. Keating Yulei He William R. Doucette Diana Tisnado Steven Clauser Katherine L. Kahn 《Journal of general internal medicine》2009,24(9):1029-1036
BACKGROUND The demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is
the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care.
OBJECTIVE To characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater
PCP involvement in cancer care.
DESIGN National survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium.
PARTICIPANTS 1694 PCPs; 1621 oncologists.
MEASUREMENTS Questionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients.
MAIN RESULTS Over 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic
pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved
in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only
cancer care roles in which ≥50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer
care roles while 19% reported heavy involvement. PCPs who were aged ≥50 years, were internists or geriatricians, taught medical
students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not
associated with greater PCP involvement in cancer care.
CONCLUSIONS PCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists
in delivering and coordinating cancer care is an important area for future research. 相似文献
10.
The association of ambulatory care with breast cancer stage at diagnosis among medicare beneficiaries
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Keating NL Landrum MB Ayanian JZ Winer EP Guadagnoli E 《Journal of general internal medicine》2005,20(1):38-44
OBJECTIVE: Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis. DESIGN: Retrospective cohort study using cancer registry and Medicare claims data. PATIENTS: Population-based sample of 11,291 women aged > or =67 diagnosed with breast cancer during 1995 to 1996. MEASUREMENTS AND MAIN RESULTS: Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P> or =.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P<.001). The rate of advanced cancer also decreased with increasing number of visits (P<.001). CONCLUSIONS: Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits. 相似文献
11.
Variations in the Associations Between Psychiatric Comorbidity and Hospital Mortality According to the Method of Identifying Psychiatric Diagnoses
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Summary
Objective Little is known about associations between psychiatric comorbidity and hospital mortality for acute medical conditions. This
study examined if associations varied according to the method of identifying psychiatric comorbidity and agreement between
the different methods.
Patients/Participants The sample included 31,218 consecutive admissions to 168 Veterans Affairs facilities in 2004 with a principle diagnosis of
congestive heart failure (CHF) or pneumonia. Psychiatric comorbidity was identified by: (1) secondary diagnosis codes from
index admission, (2) prior outpatient diagnosis codes, (3) and prior mental health clinic visits. Generalized estimating equations
(GEE) adjusted in-hospital mortality for demographics, comorbidity, and severity of illness, as measured by laboratory data.
Measurements and Main Results Rates of psychiatric comorbidities were 9.0% using inpatient diagnosis codes, 27.4% using outpatient diagnosis codes, and
31.0% using mental health visits for CHF and 14.5%, 33.1%, and 34.1%, respectively, for pneumonia. Agreement was highest for
outpatient codes and mental health visits (κ = 0.51 for pneumonia and 0.50 for CHF). In GEE analyses, the adjusted odds of death for patients with psychiatric comorbidity
were lower when such comorbidity was identified by mental health visits for both pneumonia (odds ratio [OR] = 0.85; P = .009) and CHF (OR = 0.70; P < .001) and by inpatient diagnosis for pneumonia (OR = 0.63; P ≤ .001) but not for CHF (OR = 0.75; P = .128). The odds of death were similar (P > .2) for psychiatric comorbidity as identified by outpatient codes for pneumonia (OR = 1.04) and CHF (OR = 0.93).
Conclusions The method used to identify psychiatric comorbidities in acute medical populations has a strong influence on the rates of
identification and the associations between psychiatric illnesses with hospital mortality. 相似文献
12.
BACKGROUND The contribution of physician and organizational factors to visit length, quality, and satisfaction remains uncertain, in
part, because of confounding by patient presentation.
OBJECTIVE To determine associations among visit length, quality, and satisfaction when patient presentation is controlled.
DESIGN A factorial experiment using standardized patients to make primary care visits presenting with either major depression or
adjustment disorder, and a musculoskeletal complaint.
PARTICIPANTS One hundred fifty-two primary care physicians, each seeing 2 standardized patients.
MEASUREMENTS Visit length was determined from surreptitiously obtained audiorecordings. Other key measures were derived from physician
and standardized patient report.
RESULTS Mean visit length for 294 completed encounters was 22.3 minutes (range = 5.8–72.2, SD = 9.4). Key factors associated with
visit length were: physician style (ρ = 0.68 and 0.54 after multivariate adjustment), nonprofessional experience with depression (11% longer, 95% CI = 0–23%),
practicing within an HMO (26% shorter, 95% CI = 61–90%), and greater practice volume (those working >9 half-day clinic sessions/week
had 15% shorter visits than those working fewer than 6, 95% CI = 0–27%, and those seeing >12 patients/half-day had 27% shorter
visits than those seeing <10 patients/half-day, 95% CI = 13–39%). Suicidal inquiry (a process-based quality-of-care measure
for depression) was not associated with adjusted visit length. Satisfaction was linearly associated with visit length but
not with suicide inquiry or follow-up interval.
CONCLUSIONS Despite experimental control for clinical presentation, wide variation in visit length persists, largely reflecting individual
physician styles. Visit length is a significant determinant of standardized patient satisfaction. 相似文献
13.
Can Primary Care Visits Reduce Hospital Utilization Among Medicare Beneficiaries at the End of Life?
Kronman AC Ash AS Freund KM Hanchate A Emanuel EJ 《Journal of general internal medicine》2008,23(9):1330-1335
Background Medical care at the end of life is often expensive and ineffective.
Objective To explore associations between primary care and hospital utilization at the end of life.
Design Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number
of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics,
comorbidities, and geography in end-of-life healthcare utilization.
Subjects National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects
with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.
Measurements Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive
Conditions) during the final 6 months of life.
Results Sample characteristics: 38% had 0 primary care visits; 22%, 1–2; 19%, 3–5; 10%, 6–8; and 11%, 9+ visits. More primary care
visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary
care visits vs. 13.4 for those with ≥9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death
(44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio,
aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).
Conclusions Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased
primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life. 相似文献
14.
Campbell DG Felker BL Liu CF Yano EM Kirchner JE Chan D Rubenstein LV Chaney EF 《Journal of general internal medicine》2007,22(6):711-718
BACKGROUND Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe
psychiatric symptomatology and factors that complicate treatment.
OBJECTIVE To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics
of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD).
DESIGN Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients.
PARTICIPANTS Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months.
Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary
care practices in 5 states.
MEASUREMENTS The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen ≥ 3. Regression-based
techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics.
RESULTS Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical
illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical
illness comorbidity.
CONCLUSIONS PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients
is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should
consider recommending psychotherapeutic interventions for depressed patients with PTSD. 相似文献
15.
Virnig BA Moscovice IS Durham SB Casey MM 《Journal of the American Geriatrics Society》2004,52(5):731-735
OBJECTIVES: To examine whether there are urban-rural differences in use of the Medicare hospice benefit before death and whether those differences suggest that there is a problem with access to hospice care for rural Medicare beneficiaries. DESIGN: Observational study using 100% of Medicare enrollment, hospice, and hospital claims data. SETTING: Inpatient hospitals and hospices. PARTICIPANTS: Persons aged 65 and older in the Medicare program who died in 1999. MEASUREMENTS: Rates of hospice use before death and in-hospital death rates were calculated. RESULTS: In 1999, there were 1.76 million deaths of Medicare beneficiaries aged 65 and older. Hospice services were used by 365,700 of these beneficiaries. Rates of hospice care before death were negatively associated with degree of rurality. The lowest rate of hospice use, 15.2% of deaths, was seen in rural areas not adjacent to an urban area. The highest rate of use, 22.2% of deaths, was seen in urban areas. Rural areas adjacent to urban areas had an intermediate level of hospice use (17.0% of deaths). Hospices based in rural areas had a smaller number of elderly patients each year than hospices based in urban areas (P<.001) and were more likely to have very low volumes (average daily census of three patients or less). CONCLUSION: The consistently lower use of Medicare hospice services before death and smaller sizes of rural hospices suggest that the combination of Medicare hospice payment policies and hospice volumes are problematic for rural hospices. Adjusting Medicare payment policies might be a critical step to assure availability of hospice services forterminally ill beneficiaries regardless of where they live. 相似文献
16.
Ayanian JZ Sequist TD Zaslavsky AM Johannes RS 《Journal of general internal medicine》2008,23(6):762-767
Background Most colorectal cancers develop from adenomatous polyps. National guidelines recommend surveillance colonoscopy within 5 years
after such polyps are removed.
Objective To determine whether surveillance colonoscopy can be increased among overdue patients by reminders to their primary physicians.
Design Randomized, controlled trial of patient-specific reminders mailed to 141 physicians in 2 Massachusetts primary care networks
during April, 2006.
Patients Seven hundred seventeen patients who had colorectal adenomas removed during 1995 through 2000 and no follow-up colonoscopy
identified via automated review of electronic records through March, 2006.
Measurements and Main Results The use of colonoscopy and detection of new adenomas or cancer were assessed at 6 months by a blinded medical record review
in all patients. Among 358 patients whose physicians received reminders, 33 (9.2%) patients underwent colonoscopy within 6 months,
compared with 16 (4.5%) of 359 patients whose physicians did not receive reminders (P = 0.009). In prespecified subgroups, this effect did not differ statistically between 2 primary care networks, elderly and
nonelderly patients, or women and men (all P > 0.60 by Breslow–Day test). New adenomas or cancer were detected in 14 (3.9%) intervention patients and 6 (1.7%) control
patients (P = 0.06), representing 42.4% and 37.5% of patients who underwent colonoscopy in each group, respectively. Despite using advanced
electronic health records to identify eligible patients, 22.5% of enrolled patients had a prior follow-up colonoscopy ascertained
only by visual record review, and physicians reported 27.9% of intervention patients were no longer active in their practice.
Conclusions Among patients with prior colorectal adenomas, physician reminders increased the use of surveillance colonoscopy, but better
systems are needed to identify eligible patients (ClinicalTrials.gov ID number NCT00397969).
The study was presented at the Annual Meeting of the Society of General Internal Medicine in Toronto, Ontario on April 26,
2007. 相似文献
17.
18.
Background The use of brand rather than generic names for medications can increase health care costs. However, little is known at a national
level about how often physicians refer to drugs using their brand or generic names.
Objective To evaluate how often physicians refer to drugs using brand or generic terminology.
Design and Participants We used data from the 2003 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of 25,288 community-based
outpatient visits in the United States. After each visit, patient medications were recorded on a survey encounter form by
the treating physician or transcribed from office notes.
Measurements Our main outcome measure was the frequency with which medications were recorded on the encounter form using their brand or
generic names.
Results For 20 commonly used drugs, the median frequency of brand name use was 98% (interquartile range, 81–100%). Among 12 medications
with no generic competition at the time of the survey, the median frequency of brand name use was 100% (range 92–100%). Among
8 medications with generic competition at the time of the survey (“multisource” drugs), the median frequency of brand name
use was 79% (range 0–98%; P < .001 for difference between drugs with and without generic competition).
Conclusions Physicians refer to most medications by their brand names, including drugs with generic formulations. This may lead to higher
health care costs by promoting the use of brand-name products when generic alternatives are available. 相似文献
19.
The objective of this study was to compare comorbidity, functional ability, and health care utilization in veterans with total
knee arthroplasty (TKA) or total hip arthroplasty (THA) versus matched control populations. A cohort of veterans using Veterans
Affairs (VA) healthcare system reported limitations in six activities of daily living (ADLs; bathing, dressing, eating, walking,
transferring, and using the toilet), demographics, and physician-diagnosed comorbidity. VA databases provided healthcare utilization
and International Classification of Diseases-9/Common procedure terminology codes for TKA/THA. Patients were classified as:
(1) primary TKA; (2) primary THA; (3) combination group (≥1 procedure); and (4) control veteran population (no THA/TKA). Multivariable
regression analyses compared the risk or counts of ADL limitation and in-/out-patient visits. After multivariable adjustment,
TKA, THA or combination groups had significantly higher prevalence of the following compared to veteran controls: arthritis,
diabetes, or heart disease (p < 0.0001 each), severe (≥3) ADL limitation (33%, 42%, 42% vs. 24%; p < 0.0001), and annual hospitalization rate (24%, 19%, 26% vs. 16%, p < 0.0001). Annual outpatient surgery visits were more (2.5, 2.3, 2.3 vs. 2, p = 0.01) and risk of any mental health outpatient visit was lower (12%, 11%, 12% vs. 18%, p = 0.0039). All ADLs, except eating, were significantly more limited in arthroplasty groups (p ≤ 0.0009). Severe ADL limitation was more prevalent in veterans with arthroplasty than in two age-matched US cohorts: 13.4
times in ≥65 years; and 1.2-, 1.6-, and 4-fold in ≥85, 75–84, and 65–74 years. Poorer function and higher comorbidity and
utilization in veterans with TKA/THA suggest that this group is appropriate for interventions targeted at improving function
and decreasing utilization.
Supported by NIH CTSA Award 1 KL2 RR024151-01 (Mayo Clinic Center for Clinical and Translational Research)
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the
Department of Veterans Affairs. 相似文献
20.
Fanjiang G von Glahn T Chang H Rogers WH Safran DG 《Journal of general internal medicine》2007,22(10):1463-1466
Background Despite growing emphasis on public reporting of health care quality data, available data are often ignored.
Objective To evaluate the usefulness of web-based physician-level data for patients choosing a new primary care physician (PCP).
Design Patients seeking a new PCP (n = 2225) were invited to view web-based information including PCP credentials, personal characteristics, office location and
hours, and patient experience scores. Patient experience scores included validated measures of interpersonal quality, appointment
access, care coordination, health promotion, and patient recommendations of the PCP. After viewing the website, participants
indicated their preferred PCP and completed a study questionnaire.
Results Of the invited participants, 17% visited the website (n = 382). Patient experience scores were cited most frequently as important to physician choice (51%). Among these measures,
patients’ highest priorities were interpersonal quality (37%) and patient recommendations of the PCP (41%). For patients citing
these priorities, the odds of choosing a highly scored physician after viewing the data was nearly 10 times that of choosing
such a physician by chance (odds ratio (OR) = 9.52 and 9.71, respectively).
Conclusions Targeting patients known to be making a health care decision appears to promote the use of performance data. Patients particularly
valued data concerning other patients’ experiences and, after viewing the data, made choices well-aligned with their priorities. 相似文献