Real-time EBM: From Bed Board to Keyboard and Back

Background To practice Evidence-Based Medicine (EBM), physicians must quickly retrieve evidence to inform medical decisions. Internal Medicine (IM) residents receive little formal education in electronic database searching, and have identified poor searching skills as a barrier to practicing EBM. Objective To design and implement a database searching tutorial for IM residents on inpatient rotations and to evaluate its impact on residents’ skill and comfort searching MEDLINE and filtered EBM resources. Design Randomized controlled trial. Residents randomized to the searching tutorial met for up to 6 1-hour small group sessions to search for answers to questions about current hospitalized patients. Participants Second- and 3rd-year IM residents. Measurements Residents in both groups completed an Objective Structured Searching Evaluation (OSSE), searching for primary evidence to answer 5 clinical questions. OSSE outcomes were the number of successful searches, search times, and techniques utilized. Participants also completed self-assessment surveys measuring frequency and comfort using EBM databases. Results During the OSSE, residents who participated in the intervention utilized more searching techniques overall (p < .01) and used PubMed’s Clinical Queries more often (p < .001) than control residents. Searching “success” and time per completed search did not differ between groups. Compared with controls, intervention residents reported greater comfort using MEDLINE (p < .05) and the Cochrane Library (p < .05) on post-intervention surveys. The groups did not differ in comfort using ACP Journal Club, or in self-reported frequency of use of any databases. Conclusions An inpatient EBM searching tutorial improved searching techniques of IM residents and resulted in increased comfort with MEDLINE and the Cochrane Library, but did not impact overall searching success. This paper was presented at the SGIM 29th Annual Meeting in April 2006, the SGIM 2007 Mid-Atlantic Meeting on March 9, 2007, and at the SGIM 30th Annual Meeting in April 2007.     

Factors Associated with Medical Knowledge Acquisition During Internal Medicine Residency

BACKGROUND Knowledge acquisition is a goal of residency and is measurable by in-training exams. Little is known about factors associated with medical knowledge acquisition. OBJECTIVE To examine associations of learning habits on medical knowledge acquisition. DESIGN, PARTICIPANTS Cohort study of all 195 residents who took the Internal Medicine In-Training Examination (IM-ITE) 421 times over 4 years while enrolled in the Internal Medicine Residency, Mayo Clinic, Rochester, MN. MEASUREMENTS Score (percent questions correct) on the IM-ITE adjusted for variables known or hypothesized to be associated with score using a random effects model. RESULTS When adjusting for demographic, training, and prior achievement variables, yearly advancement within residency was associated with an IM-ITE score increase of 5.1% per year (95%CI 4.1%, 6.2%; p < .001). In the year before examination, comparable increases in IM-ITE score were associated with attendance at two curricular conferences per week, score increase of 3.9% (95%CI 2.1%, 5.7%; p < .001), or self-directed reading of an electronic knowledge resource 20 minutes each day, score increase of 4.5% (95%CI 1.2%, 7.8%; p = .008). Other factors significantly associated with IM-ITE performance included: age at start of residency, score decrease per year of increasing age, −0.2% (95%CI −0.36%, −0.042%; p = .01), and graduation from a US medical school, score decrease compared to international medical school graduation, −3.4% (95%CI −6.5%, −0.36%; p = .03). CONCLUSIONS Conference attendance and self-directed reading of an electronic knowledge resource had statistically and educationally significant independent associations with knowledge acquisition that were comparable to the benefit of a year in residency training.     

Use of Multidisciplinary Rounds to Simultaneously Improve Quality Outcomes,Enhance Resident Education,and Shorten Length of Stay

BACKGROUND Hospital-based clinicians and educators face a difficult challenge trying to simultaneously improve measurable quality, educate residents in line with ACGME core competencies, while also attending to fiscal concerns such as hospital length of stay (LOS). OBJECTIVE The purpose of this study was to determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay. DESIGN Pre and post observational study assessing the impact of MDR during its first year of implementation. SETTING The Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents. METHODS Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measure performance was obtained on a monthly basis for selected heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) measures addressed on the general medical service. Resident knowledge and attitudes about MDR were determined by an anonymous questionnaire. LOS and monthly core measure performance rates were adjusted for patient characteristics and secular trends using linear spline logistic regression modeling. RESULTS Institution of MDR was associated with a significant improvement in quality core measure performance in targeted areas of CHF from 65% to 76% (p < .001), AMI from 89% to 96% (p = .004), pneumonia from 27% to 70% (p < .001), and all combined from 59% to 78% (p < .001). Adjusted overall monthly performance rates also improved during MDR (odds ratio [OR] 1.09, CI 1.06–1.12, p < .001). Residents reported substantial improvements in core measure knowledge, systems-based care, and communication after institution of MDR (p < .001). Residents also agreed that MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines. Adjusted average LOS decreased 0.5 (95% CI 0.1–0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5–0.7) days for all medicine DRGs (p < .001). CONCLUSIONS Resident-centered MDR is an effective process using no additional resources that simultaneously improves quality of care while enhancing resident education and is associated with shortened length of stay. This study was presented in part in workshop and oral format at the 27th Society of General Internal Medicine Annual Meeting, May 12–15, 2004, Chicago, IL     

Impact of the Foundations of Clinical Medicine Course on USMLE Scores

BACKGROUND  The synthesis of basic and clinical science knowledge during the clerkship years has failed to meet educational expectations. OBJECTIVES  We hypothesized that a small-group course emphasizing the basic science underpinnings of disease, Foundations of Clinical Medicine (FCM), could be integrated into third year clerkships and would not negatively impact the United States Medical Licensure Examination (USMLE) step 2 scores. DESIGN  In 2001–2002, all third year students met weekly in groups of 8–12 clustered within clerkships to discuss the clinical and basic science aspects of prescribed, discipline-specific cases. PARTICIPANTS  Students completing USMLE step 2 between 1999 and 2004 (n = 743). MEASUREMENTS  Course evaluations were compared with the overall institutional average. Bivariate analyses compared the mean USMLE steps 1 and 2 scores across pre- and post-FCM student cohorts. We used multiple linear regression to assess the association between USMLE step 2 scores and FCM cohort controlling for potential confounders. RESULTS  Students’ average course evaluation score rose from 66 to 77 (2001–2004) compared to an institutional average of 73. The unadjusted mean USMLE step 1 score was higher for the post-FCM cohort (212.9 vs 207.5, respectively, p < .001) and associated with step 2 scores (estimated coefficient = 0.70, p < .001). Post-FCM cohort (2002–2004; n = 361) mean step 2 scores topped pre-FCM (1999–2001; n = 382) scores (215.9 vs 207.7, respectively, p < .001). FCM cohort remained a significant predictor of higher step 2 scores after adjustment for USMLE step 1 and demographic characteristics (estimated coefficient = 4.3, p = .002). CONCLUSIONS  A curriculum integrating clinical and basic sciences during third year clerkships is feasible and associated with improvement in standardized testing. Electronic supplementary material  The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students,Residents, and Faculty Internists

BACKGROUND AND OBJECTIVES Little is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups’ self-confidence in and perceived utility of physical examination skills. DESIGN AND PARTICIPANTS Cross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital. MEASUREMENTS Using a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information. RESULTS The response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than “neutral” were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students’ ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001). CONCLUSIONS Self-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.     

Mortality in Peripheral Arterial Disease: A Comparison of Patients Managed by Vascular Specialists and General Practitioners

BACKGROUND Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical management is unknown. OBJECTIVE To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular specialist). DESIGN Prospective study. SETTING Primary care practice and academic vascular laboratory. PARTICIPANTS GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n = 82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrolment period of the PACE study. MEASUREMENTS All-cause and cardiovascular mortality. RESULTS After 32 months of follow-up, specialist management was associated with a lower rate of all-cause mortality (RR = 0.04; 95% CI 0.01–0.34; p = .003) and cardiovascular mortality (RR = 0.07; 95% CI 0.01–0.65; p = .020), after adjustment for patients’ characteristics. Specialists were more likely to use antiplatelet agents (93% vs 73%, p < .001), statins (62% vs 25%, p < .001) and beta blockers (28% vs 3%, p < .001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced risk of all-cause mortality (RR = 0.02; 95% CI 0.01–0.73, p = .034) and cardiovascular mortality (RR = 0.02; 95% CI 0.01–0.71, p = .033). CONCLUSIONS Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect appears to be mainly caused by the more frequent use of effective medicines by specialists.     

Part-Time Physicians…Prevalent,Connected, and Satisfied

Objective The health care workforce is evolving and part-time practice is increasing. The objective of this work is to determine the relationship between part-time status, workplace conditions, and physician outcomes. Design Minimizing error, maximizing outcome (MEMO) study surveyed generalist physicians and their patients in the upper Midwest and New York City. Measurements and Main Results Physician survey of stress, burnout, job satisfaction, work control, intent to leave, and organizational climate. Patient survey of satisfaction and trust. Responses compared by part-time and full-time physician status; 2-part regression analyses assessed outcomes associated with part-time status. Of 751 physicians contacted, 422 (56%) participated. Eighteen percent reported part-time status (n = 77, 31% of women, 8% of men, p < .001). Part-time physicians reported less burnout (p < .01), higher satisfaction (p < .001), and greater work control (p < .001) than full-time physicians. Intent to leave and assessments of organizational climate were similar between physician groups. A survey of 1,795 patients revealed no significant differences in satisfaction and trust between part-time and full-time physicians. Conclusions Part-time is a successful practice style for physicians and their patients. If favorable outcomes influence career choice, an increased demand for part-time practice is likely to occur. Other members of the MEMO investigative team include Mark Schwartz, Deborah Dowell, Perry An, and Karla Felix, New York University, NYC, NY; Julia McMurray, James Bobula, Mary Beth Plane, William Scheckler, John Frey, Jessica Sherrieb, and Jessica Grettie, University of Wisconsin, Madison; Barbara Horner-Ibler, University of Wisconsin, Milwaukee; Ann Maguire, Medical College of Wisconsin, Milwaukee; Laura Paluch, Aurora Sinai Medical Center, Milwaukee, WI; Bernice Man and Anita Varkey, Rush Medical College, Chicago IL; Elizabeth Arce, Cook County Hospital, Chicago, IL; Joseph Rabatin, Brown University, Providence, RI; Elianne Riska, University of Helsinki, Finland; JudyAnn Bigby, Brigham & Women’s Hospital, Boston, MA; Thomas R. Konrad and Peggy Leatt, University of North Carolina, Chapel Hill; Stewart Babbott, University of Kansas Medical Center, Kansas City; and Eric Williams, University of Alabama, Tuscaloosa.     

Barriers to Obtaining Waivers to Prescribe Buprenorphine for Opioid Addiction Treatment Among HIV Physicians

Background Illicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine. Objective To examine barriers to obtaining waivers to prescribe buprenorphine. Design Cross-sectional survey study. Participants 375 physicians attending HIV educational conferences in six cities in 2006. Approach Anonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression. Results 25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [95% CI] = 1.08–3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32–0.97) were significantly associated with having a buprenorphine waiver. Conclusions Among HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.     

Male sexual function and lower urinary tract symptoms after laparoscopic total mesorectal excision

Background and aims  The aim of this study was to investigate sexual function and the presence of lower urinary tract symptoms (LUTS) in male patients with rectal cancer following short-term radiotherapy and laparoscopic total mesorectal excision (LTME) by physical and psychological measurements. Materials and methods  Sexual function and LUTS were assessed by the use of questionnaires [International Index of Erectile Function (IIEF), International Prostate Symptom Score]. Sexual function was further assessed by the use of pharmaco duplex ultrasonography of the cavernous arterial blood flow and nocturnal penile tumescence and rigidity monitoring (NPTR). All investigations were performed prior to the start of preoperative radiotherapy and 15 months after surgery. Results  Nine patients (mean age 60 years) participated. Erectile function was maintained in 71% and ejaculation function in 89%. Compared with pre-operative scores on the IIEF, a significant deterioration in intercourse satisfaction was seen following radiotherapy and LTME (7.9 vs 10.3, p = 0.042), but overall satisfaction remained unchanged (8.0 vs 7.0, p = 0.246). NPTR parameters (duration of erectile episodes, duration of tip rigidity ≥60%) decreased following radiotherapy and LTME. Patients reported a deterioration in micturition frequency (2.0 vs 1.0, p = 0.034) and quality of life due to urinary symptoms (8.0 vs 1.8, p = 0.018). Conclusion  Based on these first preliminary findings, data suggest that 15 months after short-term radiotherapy and LTME in men with rectal cancer, objectively assessed sexual dysfunction was considerable, but overall sexual satisfaction had not changed.     

Development of a Web-based Resident Profiling Tool to Support Training in Practice-based Learning and Improvement

Multiple factors are driving residency programs to explicitly address practice-based learning and improvement (PBLI), yet few information systems exist to facilitate such training. We developed, implemented, and evaluated a Web-based tool that provides Internal Medicine residents at the University of Virginia Health System with population-based reports about their ambulatory clinical experiences. Residents use Systems and Practice Analysis for Resident Competencies (SPARC) to identify potential areas for practice improvement. Thirty-three (65%) of 51 residents completed a survey assessing SPARC’s usefulness, with 94% agreeing that it was a useful educational tool. Twenty-six residents (51%) completed a before–after study indicating increased agreement (5-point Likert scale, with 5=strongly agree) with statements regarding confidence in ability to access population-based data about chronic disease management (mean [SD] 2.5 [1.2] vs. 4.5 [0.5], p < .001, sign test) and information comparing their practice style to that of their peers (2.2 [1.2] vs. 4.6 [0.5], p < .001).     

PTSD in Urban Primary Care: High Prevalence and Low Physician Recognition

BACKGROUND Posttraumatic stress disorder (PTSD) is associated with medical and psychological morbidity. The prevalence of PTSD in urban primary care has not been well described. OBJECTIVE To measure the prevalence of PTSD in primary care patients overall and among those with selected conditions (chronic pain, depression, anxiety, heavy drinking, substance dependence (SD), irritable bowel syndrome (IBS), and immigrant status). DESIGN Cross-sectional study. PARTICIPANTS English-speaking patients aged 18–65 years old, awaiting primary care appointments in an urban academic medical center, were eligible for enrollment to determine PTSD prevalence (N = 509). Additional eligible participants (n = 98) with IBS or SD were subsequently enrolled. MEASUREMENTS PTSD (past year) and trauma exposure were measured with Composite International Diagnostic Interview. We calculated the prevalence of PTSD associated with depression, anxiety, heavy drinking, SD, IBS, and chronic pain. Only the analyses on heavy drinking, SD, and IBS used all 607 participants. RESULTS Among the 509 adults in primary care, 23% (95% CI, 19–26%) had PTSD, of whom 11% had it noted in the medical record. The prevalence of PTSD, adjusted for age, gender, race, and marital and socioeconomic statuses, was higher in participants with, compared to those without, the following conditions: chronic pain (23 vs 12%, p = .003), major depression (35 vs 11%, p < .0001), anxiety disorders (42 vs 14%, p < .0001), and IBS (34 vs 18%, p = .01) and lower in immigrants (13 vs 21%, p = .05). CONCLUSIONS The prevalence of PTSD in the urban primary care setting, and particularly among certain high-risk conditions, compels a critical examination of optimal approaches for screening, intervention, and referral to PTSD treatment. Portions of this work were presented at the annual meeting of the Society of General Internal Medicine, May 2005, New Orleans, LA, at the annual meeting of the College on Problems of Drug Dependence, June 2005, Orlando, FL, and at the annual meeting of the American Public Health Association, November 2004, Washington, DC.     

Community Volunteerism of US Physicians

Background  Many physicians and professional leaders agree that community participation is an important professional role for physicians. Volunteerism has also received increasing attention in the national agenda for social change. Yet little is known about physicians’ community volunteer activities. Objective  To measure levels of community volunteerism among US physicians. Design and Participants  Analysis of the 2003 Current Population Survey (CPS) Volunteer Supplement, a cross-sectional, nationally-representative, in-person and telephone survey of 84,077 adult citizens, including 316 physicians. Measurements  The primary outcome was whether the respondent had volunteered in the prior 12 months and if so the total number of hours. The level of community volunteer activity was compared between physicians, lawyers and the general public. In addition, predictors of physician volunteerism were identified. Results  According to the survey, 39% of physicians had volunteered in their community in the past 12 months compared to 30% of the general public (p = 0.002) and 57% of lawyers (p < 0.001). After multivariate adjustment, physicians were half as likely as the general public (OR = 0.52, p < 0.001) or lawyers (OR = 0.44, p < 0.001) to have volunteered. Physicians were more likely to have volunteered if they worked part-time (OR = 3.35, p = 0.03), variable hours (OR = 3.16, p = 0.03), or between 45–54 hours per week (OR = 3.15, p = 0.02) compared to a 35–44 hour work week. Conclusions  Despite highly favorable physician attitudes toward volunteerism in prior surveys, less than half of US physicians have volunteered with community organizations in the past year. Renewed attention to understanding and increasing physician engagement in community volunteer work is needed.     

Gender Differences in Aspirin use Among Adults With Coronary Heart Disease in the United States

Background Aspirin reduces mortality for men and women with coronary heart disease (CHD). Previous research suggests women with acute coronary syndromes receive less aggressive care, including less frequent early administration of aspirin. The presence of gender differences in aspirin use for secondary prevention is less clear. Objective To determine if a gender difference exists in the use of aspirin for secondary prevention among individuals with CHD. Design We analyzed data from the nationally representative 2000–2002 Medical Expenditure Panel Surveys to determine the prevalence of regular aspirin use among men and women with CHD. Participants Participants, 1,869, 40 years and older who reported CHD or prior myocardial infarction. Results Women were less likely than men to use aspirin regularly (62.4% vs 75.6%, p < .001) even after adjusting for demographic, socioeconomic and clinical characteristics (adjusted OR = 0.62, 95% CI, 0.48–0.79). This difference narrowed but remained significant when the analysis was limited to those without self-reported contraindications to aspirin (79.8% vs 86.4%, P = .002, adjusted OR = 0.68, 95% CI, 0.48–0.97). Women were more likely than men to report contraindications (20.5% vs 12.5%, P < .001). Differences in aspirin use were greater between women and men with private health insurance (61.8% vs 79.0%, P < .001, adjusted OR = 0.48, 95% CI, 0.35–0.67) than among those with public coverage (62.5% vs 70.7%, P = .04, adjusted OR = 0.74, 95% CI, 0.50–1.11) (P < .001 for gender–insurance interaction). Conclusion We found a gender difference in aspirin use among patients with CHD not fully explained by differences in patient characteristics or reported contraindications. These findings suggest a need for improved secondary prevention of cardiovascular events for women with CHD.     

Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled Trial

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.     

Effect of Training on Primary Care Residents’ Performance in Brief Alcohol Intervention: A Randomized Controlled Trial

Background Brief alcohol interventions (BAI) reduce alcohol use and related problems in primary care patients with hazardous drinking behavior. The effectiveness of teaching BAI on the performance of primary care residents has not been fully evaluated. Methods A cluster randomized controlled trial was conducted with 26 primary care residents who were randomized to either an 8-hour, interactive BAI training workshop (intervention) or a lipid management workshop (control). During the 6-month period after training (i.e., from October 1, 2003 to March 30, 2004), 506 hazardous drinkers were identified in primary care, 260 of whom were included in the study. Patients were interviewed immediately and then 3 months after meeting with each resident to evaluate their perceptions of the BAI experience and to document drinking patterns. Results Patients reported that BAI trained residents: conducted more components of BAI than did controls (2.4 vs 1.5, p = .001); were more likely to explain safe drinking limits (27% vs 10%, p = .001) and provide feedback on patients’ alcohol use (33% vs 21%, p = .03); and more often sought patient opinions on drinking limits (19% vs 6%, p = .02). No between-group differences were observed in patient drinking patterns or in use of 9 of the 12 BAI components. Conclusions The BAI-trained residents did not put a majority of BAI components into practice, thus it is difficult to evaluate the influence of BAI on the reduction of alcohol use among hazardous drinkers. Dr. Chossis died May 10, 2007. A poster on this study was presented at the 2006 RSA Annual Scientific Meeting held in Baltimore, Maryland, June 26, 2006.     

Risk factors for cardiovascular disease and endothelin-1 levels in Takayasu arteritis patients

The objective of this study was to evaluate traditional risk factors for cardiovascular disease (CVD) and endothelin-1 (ET-1) levels in Takayasu arteritis (TA) patients. Twenty-two TA patients and 37 controls were evaluated. TA patients had a higher prevalence of hypertension (63.6% vs. 21.6%, p = 0.001) and higher levels of triglycerides (129.5 mg/dL ± 70.8 vs. 88.4 mg/dL ± 60.8, p = 0.017) than controls. Mean number of CVD risk factors was 1.64 ± 1.22 in TA patients and 1.03 ± 1.44 among controls, p = 0.030. More TA patients presented at least one CVD risk factor when compared to controls (77.2% vs. 51.3%, p = 0.048). ET-1 levels were higher in patients than in controls (1.49 pg/mL ± 0.45 vs. 1.27 pg/mL ± 0.32, p = 0.034), however no significant difference was found between patients with active and inactive disease. In this study, TA patients presented a higher prevalence of hypertension, higher levels of triglycerides, and ET-1 than controls.     

The Impact of Expressions of Treatment Efficacy and Out-of-pocket Expenses on Patient and Physician Interest in Osteoporosis Treatment: Implications for Pay-for-performance Programs

BACKGROUND Clinical practice guidelines (CPGs) are increasingly used as the basis for pay-for-performance (P4P) programs. It is unclear how support for guidelines varies when treatment efficacy is expressed in varying mathematically equivalent ways. OBJECTIVES To assess: (1) how patient and provider compliance with osteoporosis CPGs varies when pharmacotherapy efficacy is presented as relative risk reduction (RRR) versus absolute risk reduction (ARR) and (2) the impact of increasing out-of-pocket drug expenditures on acceptance of guideline concordant therapy. DESIGN Cross-sectional survey of patients and physicians. SUBJECTS AND SETTING Female patients age >50 years and providers drawn from academic and community outpatient clinics. MEASUREMENTS Patient and provider acceptance of pharmacotherapy when treatment efficacy (reduction in hip fractures) was expressed alternatively in relative terms (35% RRR) versus absolute terms (1% ARR); acceptance of pharmacotherapy as patient drug copayment increased from 0% to 100% of the total drug costs. RESULTS Compliance with CPGs fell significantly when the expression of treatment benefit was switched from RRR to ARR for both patients (86% vs 57% compliance; P < .001) and physicians (97% vs 56% compliance; P < .001). Increasing drug copayment from 0% to 10% of total drug cost decreased patient compliance with CPGs from 80% to 57% (P < .001) but did not impact physician compliance. With increasing levels of copay, both patient and provider interest in treatment decreased. LIMITATIONS Respondents may not have fully understood the risks and benefits associated with osteoporosis and its treatment. CONCLUSION Patient and provider interest in CPG-recommended treatment for osteoporosis is reduced when treatment benefit is expressed as ARR rather than RRR. In addition, minimal increases in drug copayment significantly decreased patient, but not provider, interest in osteoporosis treatment. Designers of P4P programs should consider details including expressions of treatment benefit and patients’ out-of-pocket costs when developing measures to assess quality-of-care. Dr. Sinsky presented this work at the 2006 national SGIM meeting in Los Angeles.