Attitudes of US primary care physicians about HIV disease and AIDS

Telephone interviews were conducted with 500 primary care physicians, drawn from a stratified random sample of internists, family practitioners, pediatricians, general practitioners, and OB/GYN physicians. Respondents were asked to report their experience treating AIDS patients and to estimate the percentage of their patients they felt were at high risk for HIV infection. Nineteen questions designed to assess practices and attitudes towards AIDS and HIV-related issues were asked. Results suggest that physicians underestimate their patients' level of risk for HIV infection and are not taking adequate drug use and sexual histories. The level of concern for personal risk of infection was high, although a strong ethical obligation to treat HIV patients was expressed. Physicians also expressed support for mandatory reporting and contact tracing, although this diminished as contact with HIV patients increased.     

Survey of primary care physicians and home care clinicians

CONTEXT: Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients. OBJECTIVE: To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network.     

Survey of primary care physicians and home care clinicians

CONTEXT: Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients. OBJECTIVE: To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network. DESIGN: Mail survey. SETTING: Boston. PARTICIPANTS: Sixty-seven PCPs from 1 academic medical center-affiliated primary care network and 820 HCCs from 8 regional home care agencies. MEASUREMENTS: Provider responses RESULTS: Ninety percent of PCPs and 63% of HCCs responded. The majority (54%) of PCPs reported that they only "rarely" or "occasionally" read carefully the home care order forms sent to them for signature. Further, when asked to rate their prospective involvement in the decision making about home care, only 24% of PCPs and 25% of HCCs rated this as "excellent" or "very good." Although more HCCs (79%) than PCPs (47%) reported overall satisfaction with communication and collaboration, 28% of HCCs felt they provided more services to patients than clinically necessary. CONCLUSIONS: PCPs from 1 provider network and the HCCs with whom they coordinate home care were both dissatisfied with many aspects of communication and collaboration regarding home care services. Moreover, neither group felt in control of home care decision making. These findings are of concern because poor coordination of home care may adversely affect quality and contribute to inappropriate utilization of these services.     

Results of antihypertensive treatment by primary and secondary care physicians as assessed by ambulatory blood pressure monitoring

BACKGROUND: We present data from a cross-sectional study on consecutive non-randomized drug-treated mild-to-moderate essential hypertensives, whose blood pressure was ambulatorily monitored for 24 h to evaluate the presence of adequate control. DESIGN: Primary and secondary care physicians were invited to send to our clinic drug-treated patients with essential hypertension (JNC VI stages 1-2) to undergo 24-h ambulatory blood pressure monitoring (ABPM) while continuing their prescribed medications. METHODS: The 436 enrolled patients (255 males, 181 females, age 61+/-11 years) were left on their therapeutic regime: monotherapy in 208 patients (47. 7%) and combination therapy in 228 patients (52.3%). All the patients were divided into two care groups: primary care, 238 patients (54.6%) and secondary care, 198 patients (45.4%). A mean daytime blood pressure < or =135/85 mmHg was chosen as a definition of adequate blood pressure control. RESULTS: Adequate blood pressure control was found in 196/436 total patients (45%); 112/238 patients in primary care (47%) and 84/198 patients in secondary care (42.4%) (P=NS); 94/208 patients (45.2%) in monotherapy and 102/228 patients (44.7%) in combination therapy (P=NS); 125/255 male patients (49%) and 71/181 female patients (39.2%) (P=0.0428). In the logistic regression model, female sex was associated with a higher risk of inadequate blood pressure control of about 50%. CONCLUSIONS: Adequate blood pressure control, as assessed by ABPM, is not different in the two settings of family doctor's office and specialist's clinic and is predicted by male gender. The figures of adequate blood pressure control remind us of the rule of halves, regardless of treatment regimes and medications.     

Use of home blood pressure monitoring by hypertensive patients in primary care: survey of a practice-based research network cohort

Using a survey of a cohort of primary care patients, the authors determined the proportion currently using home blood pressure monitoring (HBPM) and calculated odds ratios (ORs) of factors associated with such use. Overall, 530 questionnaires were received (80% response rate); 35.2% of respondents reported that their doctor had recommended HBPM (95% confidence interval [CI], 31.1-39.3), and 43.1% reported currently using HBPM (95% CI, 38.8-47.3). Compared with patients younger than 45 years, hypertensive patients older than 65 years were more likely to be using HBPM (OR, 2.53; 95% CI, 1.20-5.33). Those with a history of stroke/transient ischemic attack were also more likely to use HBPM (OR, 2.06; 95% CI, 1.00-4.24). Compared with patients with a level of hypertension knowledge <10th percentile, those with a knowledge level >90th percentile were more likely to use HBPM (OR, 1.96; 95% CI, 1.08-3.56). The factor most strongly associated with use of HBPM was recalling a doctor's recommendation to do so (OR, 7.93; 95% CI, 4.96-12.7).     

Hypertension management in managed care: the role of home blood pressure monitoring

The interest in home blood pressure monitoring (HBPM) has grown with the widespread availability of blood pressure measurement devices, greater patient involvement in self care, and recognition of the limitations of office blood pressure monitoring (OBPM), and the expense and inconvenience of ambulatory blood pressure monitoring. HBPM is inexpensive, reproducible, and easy to learn. It can be helpful in identifying white-coat hypertension and midiagnosis, both of which may result in patients who do not have the disease being treated for hypertension and failure to maintain 24 h control of blood pressure. White-coat hypertension has been reported for about 25% and misdiagnosis for 18% of patients diagnosed with hypertension. In limited research, HBPM has been shown to reduce the number of clinic visits, the number of switches of medication, and the number of antihypertensives prescribed, and to improve control of blood pressure. Moreover, results from one large study suggest that measurements obtained via HBPM are correlated to overall mortality better than are those from OBPM. Although normal limits for blood pressure have been defined for OBPM, they have not yet been defined for HBPM. Research is now under way to confirm the clinical and economic impact of HBPM in the managed-care setting. If current data suggesting the benefit of HBPM are confirmed, the widespread adoption of this technique could improve patient care and reduce the costs of managing hypertension.     

The value of home blood pressure monitoring

Home blood pressure (BP) monitoring has become popular and acceptable. The value of home BP monitoring has been recognized, because it has some potential advantages over office BP. Home BP monitoring is more accurate and reproducible, has a better prognostic value, and increases patients’ compliance with treatment. Home BP monitoring should be performed with an adequate device, following a standardized procedure. The automated arm-cuff-oscillometric devices are recommended currently, and home BP should be measured at least twice daily, in the morning and in the evening. Home BP monitoring has revealed the phenomena ofldwhite-coat hypertension, “masked hypertension,” and “morning hypertension,” and it is useful for their management. In the future, home BP monitoring will be an essential aspect of clinical practice.     

Assessment of blood pressure in patients with Type 2 diabetes: comparison between home blood pressure monitoring, clinic blood pressure measurement and 24-h ambulatory blood pressure monitoring.

AIMS: To compare a home blood pressure (BP) monitoring device and clinic BP measurement with 24-h ambulatory BP monitoring in patients with Type 2 diabetes mellitus (DM). METHODS: Fifty-five patients with type 2 DM had BP measured at three consecutive visits to the DM clinic by nurses using a stethoscope and mercury sphygmomanometer (CBP). Twenty-four-hour ambulatory BP was measured using a Spacelabs 90207 automatic cuff-oscillometric device (ABPM). Subjects were then instructed in how to use a Boots HEM 732B semiautomatic cuff-oscillometric home BP monitoring device and measured BP at home on three specified occasions on each of 4 consecutive days at varying times (HBPM). RESULTS: Correlations between HBPM and ABPM were r = 0.88, P < 0.001 for systolic BP and r = 0.76, P < 0.001 for diastolic BP, with correlations between CBP and ABPM being systolic r = 0.59, P < 0.001, diastolic r = 0.47, P < 0.001. HBPM agreed with ABPM more closely compared with CBP (CBP +10.9/+3.8 (95% confidence intervals (CI) 6.9, 14.8/1.6, 6.1) vs. HBPM +8.2/+3.7 (95% CI 6.0, 10.3/2.0, 5.4)). The sensitivity, specificity and positive predictive value of HBPM in detecting hypertension were 100%, 79% and 90%, respectively, compared with CBP (85%, 46% and 58%, respectively). CONCLUSIONS: In patients with Type 2 DM, home BP monitoring is superior to clinic BP measurement, when compared with 24-h ambulatory BP, and allows better detection of hypertension. It would be a rational addition to the annual review process. Diabet. Med. 18, 431-437 (2001)     

Multiple clinic and home blood pressure measurements versus ambulatory blood pressure monitoring.

To compare multiple clinic and home blood pressure (BP) measurements and ambulatory BP monitoring in the clinical evaluation of hypertension, we studied 239 middle-aged pharmacologically untreated hypertensive men and women who were referred to the study from the primary healthcare provider. Ambulatory BP monitoring was successfully completed for 233 patients. Clinic BP was measured by a trained nurse with a mercury sphygmomanometer and averaged over 4 duplicate measures. Self-recorded home BP was measured with a semiautomatic oscillometric device twice every morning and twice every evening on 7 consecutive days. Ambulatory BP was recorded with an auscultatory device. Two-dimensionally controlled M-mode echocardiography was successfully performed on 232 patients. Twenty-four-hour urinary albumin was determined by nephelometry. Clinic BP was 144.5+/-12.6/94.5+/-7.4 mm Hg, home BP (the mean of 14 self-recorded measures) was 138.9+/-13.1/92.9+/-8.6 mm Hg, home morning BP (the mean of the first 4 duplicate morning measures) was 137.1+/-13.7/92.4+/-9.2 mm Hg, daytime ambulatory BP was 148.3+/-13. 9/91.9+/-7.8 mm Hg, nighttime ambulatory BP was 125.5+/-16.4/75. 6+/-8.9 mm Hg, and 24-hour ambulatory BP was 141.7+/-14.0/87.2+/-7.6 mm Hg. Pearson correlation coefficients of clinic, home, home morning, and daytime ambulatory BPs to albuminuria and to the characteristics of the left ventricle were nearly equal. In multivariate regression analyses, 36% (P<0.0001) of the cross-sectional variation in left ventricular mass index was attributed to gender and home morning systolic BP in models that originally included age, gender, and clinic, self-measured home morning, and ambulatory daytime, nighttime, and 24-hour systolic and diastolic BPs. We concluded that carefully controlled nonphysician-measured clinic and self-measured home BPs, when averaged over 4 duplicate measurements, are as reliable as ambulatory BP monitoring in the clinical evaluation of untreated hypertension.     

Ambulatory blood pressure monitoring to study white coat syndrome in patients with hypertension seen in primary care

INTRODUCTION AND OBJECTIVES: The white coat phenomenon is said to occur when the difference between systolic/diastolic blood pressure measured during visits to the doctor's office and in ambulatory recordings is greater than 20/10. These absolute differences, known as the white coat effect, may lead to normotensive patients being classified as having white coat hypertension (WCH). We used ambulatory blood pressure monitoring (ABPM) to monitor the prevalence and response (white coat effect, white coat hypertension or white coat phenomenon) in patients during pharmacological treatment for grade 1 or 2 hypertension, and 4 weeks after treatment was suspended under medical supervision. PATIENTS AND METHOD: Ambulatory blood pressure monitoring was used in 70 patients with hypertension that was well controlled with treatment. Blood pressure was recorded during treatment (phase 1) and 4 weeks after treatment was stopped (phase 2). RESULTS: 18 (26%) of the 70 patients did not participate in phase 2 because when medication was withdrawn, their blood pressure values became unacceptable and it was necessary to restart treatment. The white coat effect was significantly stronger in phase 1, and the prevalence of white coat phenomenon and white coat hypertension did not differ significantly between phases. At the end of phase 2 the prevalence of white coat hypertension was 33%. CONCLUSIONS: Withdrawal of antihypertensive medication in patients with well controlled grade 1 or grade 2 hypertension did not significantly modify the prevalence of white coat phenomenon or white coat hypertension. The white coat effect was greater while patients were on pharmacological treatment. One third of our patients were considered to have been mistakenly diagnosed as having hypertension.     

Concordance between physicians and their older and younger patients in the primary care medical encounter

To test the hypothesis that less concordance exists between older patients and their physicians than between younger patients and their physicians, we examined agreements between physicians and patients on the major goals and topics discussed during an outpatient medical encounter. Using coded audiotapes of the medical visit, patient postvisit interviews, and physician questionnaires, concordance was found to be significantly greater for younger patients and their physicians than for older patients and their physician on the major goals and major medical topics discussed during the primary care interview. This paper explores possible explanations for these findings.     

Management of high blood cholesterol by primary care physicians

Objective:To study knowledge of and adherence to National Cholesterol Education Program Adult Treatment Panel (ATP) guidelines among primary care physicians. Design:Cross-sectional telephone survey. Setting:New York State primary care practitioners; survey conducted November 1988-January 1989. Participants:Physicians in general practice, family practice, internal medicine without subspecialty, and cardiology who reported ≥10 bours/week of clinical practice (n=329; response rate = 63%). Interventions:None. Measurements and main results:While 84% of physicians bad beard of the ATP guidelines, gaps in knowledge and inconsistencies between ATP recommendations and clinical practices were found. Although the ATP guidelines recommend six months of dietary therapy before starting drug treatment, 41% of physicians would initiate drug treatment for a healthy 40-year-old man with total cbolesterol of 7.8 mmol/L (300 mg/dl) either at the initial visit or after one month of lipid-lowering diet. Multivariate analysis of a 24-item knowledge scale revealed that less knowledgeable physicians were more likely to be older, lack board certification, and have a specialty other than cardiology (p<0.01). Less knowledgeable physicians were also more likely to consider drug company literature and drug company representatives very useful sources of information about cholesterol (p=0.02). Conclusion:This study suggests that bard-to-reach physician groups may require special efforts to communicate consensus guidelines of major importance to clinical practice. Received from the Department of Medicine and the Division of Epidemiology and Sociomedical Sciences, School of Public Health, Columbia University Health Sciences Division, New York, New York. Supported in part by a Grant-in-aid from the American Heart Association, New York City Affiliate.     

Hypochondriacal patients,their physicians,and their medical care

OBJECTIVE: To examine the views hypochondriacal patients have of their physicians, and their physicians' assessments of the hypochondriacal patients. DESIGN: A sample of patients meeting DSM-III-R diagnostic criteria for hypochondriasis was obtained by screening consecutive medical outpatients. They underwent a battery of self-report questionnaires and structured interviews, their medical records were audited, and their physicians completed questionnaires about them. A random sample of nonhypochondriacal patients from the same clinic served as a comparison group. SETTING: A large general medicine outpatient clinic of an academic teaching hospital. PATIENTS: 41 DSM-III-R hypochondriacs and 71 comparison patients. MEASUREMENTS AND MAIN RESULTS: Hypochondriacal patients were more dissatisfied with their physicians than were comparison patients. Physicians rated the hypochondriacal patients as more frustrating to care for, more help-rejecting, and more demanding. Physician ratings of how hypochondriacal their patients were correlated significantly with their ratings of how frustrating they considered the patients (R2 = 0.36) and with objective measures of how hypochondriacal the patients were (incremental R2 = 0.08). Physician estimates of anxiety and depression in the hypochondriacal patients were not statistically related to patient anxiety and depression. In contrast, physician estimates of patient anxiety and depression were significantly associated with the presence of anxiety and depression in comparison patients. CONCLUSIONS: The physician's use of the term hypochondriasis is closely associated with his or her frustration with the patient and is associated with objective measures of the extent of hypochondriacal symptoms. In addition, the presence of DSM-III-R hypochondriasis impairs the physician's accuracy in assessing the levels of the patient's anxiety and depression.     

Ambulatory monitoring of blood pressure (AMBP) in patients with primary hyperparathyroidism

The purpose of our study was to evaluate the behaviour of blood pressure (BP) by ambulatory monitoring of blood pressure (AMBP) in 53 patients with primary hyperparathyroidism (PHPT) compared to 100 essential hypertensive (EH) and 31 healthy subjects (HS). The correlations between calcium-phosphorus metabolism and haemodynamic parameters in all groups are included in the study. AMBP was performed using the oscillometric technique (Space-Labs, 90207, Redmond, WA, USA) and the following AMBP parameters were evaluated: average day time systolic (S) and diastolic (D) blood pressure (BP) and heart rate (HR) (when awake), average night time SBP, DBP and HR (when asleep) and average 24-h-SBP, DBP and HR. The definition of 'dipper' or 'non-dipper' subjects was established if night time SBP and DBP fall was >10% and <10%, respectively. In total, 25 PHPT patients (47.2%) were hypertensive (HT-PHPT) and 28 PHPT (52.8%) were normotensive (NT-PHPT). Mean 24-h-SBP and DBP obtained by AMBP was higher in HT-PHPT (P < 0.05) and EH (P < 0.05) than in NT-PHPT and HS. The multiple linear regression has shown that in PHPT-HT patients ionized calcium is an independent factor for the rise of 24-h-DBP values (r: 0.497; P < 0.05) and daytime DBP values (r: 0.497; P < 0.05). In 56% of HT-PHPT patients there is an absence of physiological BP nocturnal fall ('non-dipper'), which is statistically significant (P < 0.05) compared with 'non-dipper' EH patients (30%). In conclusion, in our study the prevalence of hypertension in PHPT was 47%. AMBP revealed that the 'non-dipping 'pattern was much higher in HT-PHPT patients in respect to EH patients.     

Reproducibility of nighttime home blood pressure measured by a wrist‐type nocturnal home blood pressure monitoring device

The authors investigated the reproducibility of nighttime home blood pressure (BP) measured by a wrist‐type BP monitoring device. Forty‐six hypertensive patients (mean 69.0±11.6 years, 56.5% male) self‐measured their nighttime BP hourly using simultaneously worn wrist‐type and upper arm‐type nocturnal home BP monitoring devices at home on two consecutive nights. Using the average 7.4±1.3 measurements on the first night and the average 7.0 ± 1.8 measurements on the second night, the authors assessed the reliability and the reproducibility of nighttime BP measured on the two nights. The difference between nights in systolic BP (SBP) measured by the wrist‐device was not significant (1.6±7.0 mmHg, p = .124), while the difference in diastolic BP (DBP) was marginally significant (1.4±4.9 mmHg, p = .050). The intraclass correlation coefficients (ICCs) for agreement between nights were high both in SBP and DBP average (SBP: 0.835, DBP: 0.804). Averaging only three points of SBP resulted in lower ICC values, but still indicated good correlations (ICC > 0.6). On the other hand, the correlations of the standard deviation and average real variability of SBP between nights were low, with ICCs of 0.220 and 0.436, respectively. In conclusion, the average SBP values measured on the first night were reliable even when averaging only three readings. The reproducibility of nighttime BP variability seemed inferior to that of BP average; it might be better to measure nighttime BP over multiple nights to assess BP variability. However, this hypothesis needs verification in other study population. In addition, our study population had well‐controlled BP, which limits the generalizability of this findings to all hypertensive patients.     

Do primary care physicians screen patients about alcohol intake using the CAGE questions?

The performances of 134 primary care physicians at initial screening about alcohol use and screening with the CAGE questions were assessed using 17 standardized patients. For three-fourths of the standardized patients, more than 50% of the physicians asked an initial alcohol screening question. However, use of the CAGE questions with six patients who reported drinking more than one drink per day was less consistent; for most of these patients, few physicians asked any CAGE questions. Fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for three of four patients who drank four or more drinks per day. Methods are needed to incorporate the CAGE questions into primary care practices in a more systematic manner. Supported by grant number HS-06454-03 from the Agency for Health Care Policy and Research.