Intensity of antianginal therapy in patients referred for coronary angiography: a comparison of fee-for-service and health maintenance organization therapeutic strategies

BACKGROUND: No formal criteria have been developed to guide medical therapy for angina prior to revascularization, and no comparisons have been made between health maintenance organization (HMO) and fee-for-service (FFS) hospitals with respect to angina treatment. HYPOTHESIS: Using a literature-based measure of medical intensity, we tested the hypothesis that there is no difference in anginal medical therapeutic intensity between HMO and FFS systems. METHODS: For each antianginal drug, we developed a model from which an intensity score between 0 and 100 could be calculated. Average and maximal daily doses of drug were fit to a sigmoid curve such that they represented scores of 50 and 99, respectively. Overall intensity scores were obtained by weighted and unweighted averaging of three scores from nitrates, calcium-channel blockers, and beta blockers. This model was applied to 199 patients undergoing angiography at an FFS and an HMO hospital. RESULTS: HMO patients were taking more classes of antianginal drug (1.9 vs. 1.0, p < 0.001). Overall unweighted (17.7 vs. 11.7, p = 0.02) and weighted (27.3 vs. 16.9, p = 0.003) intensity scores for both HMO and FFS patients were low. HMO intensity scores for the use of beta blockers were greater than FFS scores (19.2 vs. 9.6, p = 0.002). The intensity scores for the use of nitrates and calcium blockers were similar. CONCLUSIONS: Models for the measurement of anginal medical therapy intensity can provide important information regarding medical therapy prior to revascularization. The overall intensity of medical therapy was low in both health care systems. These findings have important implications for patient management, guideline development, and national healthcare policy.     

Culture-bound syndrome and a culturally sensitive approach: from a viewpoint of medical anthropology

Some aspects of the culture-bound syndrome are presented for discussion. From the psychiatric and medical anthropological viewpoints, kamidaari is described as an initiatory illness for seeing a shaman, and focus on clinical realities developing between different therapeutic subcultures in the same culture and the complementary practices of two epistemological ones, namely, the shamanistic and modern psychiatric system in the shamanistic climate. It is suggested that the culture-bound syndrome that reflects cultural influences on disease patterns and renders them difficult to place in a universal classificatory system should be seen as a vernacular bricolage or as tactics used by people within the web of their own local culture of origin. Therapists who treat patients in a cross-epistemological milieu should be aware of the subcultural-epistemological issues that may affect the clinical process. It should be recognized that, depending on the nature of a particular psychiatric crisis, the clinical encounter is straddling the boundaries of multiple clinical realities. At every stage in the clinical field, there is an intersection, consonance, or interruption of rejoinders in the open dialog by all those engaged in the clinical time. Aspects of climatic, culturally sensitive psychotherapy will be described, and the concept of the culture-bound syndrome will be reconsidered. Our approach could be seen as 'situation- and fudo-bound'.     

Oculomotor impairment after 1 night of total sleep deprivation: a dissociation between measures of speed and accuracy.

OBJECTIVES: The present study examined the effects of 40 h of sleep deprivation and of time-of-day on saccadic and smooth pursuit oculomotor performance. METHODS: Nine normal subjects slept for 3 consecutive nights in the laboratory (one adaptation, one baseline, one recovery). Baseline and recovery were separated by a period of 40 h of continuous wakefulness, during which subjects were tested every 2 h. Oculomotor performance assessed at the following hours: 10:00, 12:00, 14:00, 16:00, 18:00, 20:00, 22:00, of both the days preceding and following the sleep deprivation night, as well as at 24:00, 02:00, 04:00, 06:00 and 08:00 h during the deprivation period. RESULTS: Saccade latency increased and peak velocity decreased significantly during the post-deprivation day; saccadic accuracy was unaffected. As regards smooth pursuit performance, phase (a measure of accuracy) was not affected by sleep loss, while velocity gain significantly decreased during the day that followed the sleep deprivation night. Significant time-of-day effects on the considered oculomotor variables except saccadic accuracy were also found, indicating an overall performance impairment during the night. CONCLUSIONS: It is concluded that 40 h of sleep deprivation significantly impaired diurnal performance in pursuit and saccadic tasks. This performance worsening is limited to the measures of speed, while accuracy is not affected by sleep loss. A significant operational relevance of these results is suggested, since saccadic velocity has recently been found to be negatively correlated with simulator vehicle crash rates.     

NHS services for epilepsy from the patient’s perspective: a survey of primary, secondary and tertiary care access throughout the UK

The aims of this study were to estimate the proportion of patients with epilepsy who made primary care and/or hospital outpatient medical consultations within 1 year; to formulate a model of the explanatory variables that influence whether patients consult or not; and to estimate the frequency of referral to, and waiting time for, hospital outpatient clinics in patients with new-onset seizures. Suggestions are offered for improvement of epilepsy services based on the findings. A questionnaire was distributed to 3455 unselected patients identified at population level from primary care practices in all NHS regions of the UK. There were 1652 respondents with epilepsy of all types, irrespective of aetiology, duration or severity. Fifty-two per cent of the whole sample made at least one medical consultation of any type specifically for epilepsy (42.0% primary care, 30.5% hospital, 20.4% both). Most patients with controlled epilepsy (74.5%) had no consultations. Of patients with severe epilepsy, 27.5% made no primary care consultations, 43.4% no hospital consultations and 14.1% no consultations of either type. Gender did not influence the likelihood of either GP or hospital consultations in patients with either controlled or active epilepsy. Increasing seizure frequency was associated with a greater likelihood of one or more hospital consultations for epilepsy, whereas increasing duration of epilepsy was associated with a decreased likelihood of either type of consultation. Age affected consultation rates: of those patients over the age of 65 years, only 29.9% made a medical consultation for epilepsy, compared to 53.8% of young adults. Patients under the age of 17 years were less likely to have consulted a GP and more likely to have consulted a hospital doctor. Ninety percent of new-onset patients had been referred to a hospital doctor, and the mean wait was 6.5 weeks. In conclusion, many patients with epilepsy, including severe epilepsy, are not receiving specialist input, and a significant proportion are receiving no medical supervision. The elderly are over-represented in this group. Care tends to be polarized between hospital or primary care, falling short of the ideal of shared care. It will be important to address the influences on consultation seeking in epilepsy, particularly for those patients currently under no medical supervision.     

Integrating Vocational Services on Case Management Teams: Outcomes from a Research Demonstration Project

Recent innovations to improve employment rates among persons with psychiatric disabilities include hybrid case management/employment services. Project WINS was a research/demonstration project which integrated specialized vocational services into case management teams. In this report, client outcomes of WINS involvement are evaluated, using a quasiexperimental, longitudinal design. On almost all the work-related variables, participants in the immediate and delayed treatment conditions displayed better outcomes than those in the control condition, as did individuals receiving moderate or substantial service versus no/minimal services. To address possible selection bias due to the quasiexperimental nature of the design, further analyses used baseline differences across conditions and participation levels as covariates. Results of multivariate analyses showed some anomalous findings regarding significant positive effects for the delayed, but not the immediate treatment condition versus the no-treatment control group. However, in similar analyses involving participation level as the independent variable, a moderate or substantial amount of service increased the odds of working by almost five times and also positively affected three other work-related variables. While limitations of this quasiexperimental design are noted, the results appear promising enough to support replications of WINS.     

Calcaneus Bone Mineral Density is Lower Among Men and Women with Lower Physical Performance

Fracture risk is influenced by both bone strength and by falls. Measures of physical function and performance are predictors of falls. However, the interrelationships among bone mineral density (BMD), regular physical activity, and measures of physical performance are not well known. We studied 447 community-dwelling Japanese people aged 40 years and over (96 men and 351 women) to examine the association of calcaneus BMD with measures of physical performance (grip strength, walking speed, chair stand, and functional reach) and regular physical activity. Calcaneus BMD decreased with age by approximately 25% in men and 42% in women. Measures of physical performance decreased with age by approximately 30% in both genders, however, performance on the chair stand test declined by approximately 60%. There were only minimal differences in performance measures and calcaneus BMD between people with and those without regular physical activity in both genders, and most differences were not significant. However, there were significant BMD increases of 3–6% per standard deviation (SD) increase in all performance measures for women and a 7% increase in BMD per SD increase in grip strength for men, after adjusting for age. These associations remained after additional adjustment for body mass index and regular physical activity. These findings suggest that bone density and physical function decline markedly in both men and women with age, and that low BMD and poor function tend to occur together, which would increase fracture risk more than either risk factor alone. Received: 9 August 1999 / Accepted: 4 February 2000     

Changes in left ventricular end-diastolic area, end-systolic wall stress, and fractional area change during anesthetic induction with propofol or thiamylal

Purpose. To elucidate the mechanisms of the more profound hypotensive effects of propofol relative to thiamylal, we monitored changes in left ventricular (LV) preload, afterload, and contractility during the course of anesthetic induction with propofol and thiamylal. Methods. Thirty-two patients (ASA I) were randomly assigned into two groups and injected with propofol (2 mg·kg⁻¹) or thiamylal (4 mg·kg⁻¹) as anesthetic induction agents. Transthoracic echocardiography (TTE) was used to assess LV performance before and during induction by the two anesthetics. The LV end-diastolic area (EDA) and LV end-systolic wall stress (ESWS) were used as indices of LV preload and LV afterload, respectively, while LV contractility was assessed by the fractional area change (FAC). Results. Both propofol and thiamylal significantly reduced EDA and ESWS without significant change in FAC. Propofol-induced reductions in EDA and ESWS were significantly greater than those of thiamylal. Conclusion. The more profound hypotension observed during induction of anesthesia with propofol is due to the greater decrease in preload and afterload than with thiamylal, but not to a decrease in LV contractility. Received: December 8, 1999 / Accepted: April 19, 2000     

The clinician's role in meeting patient information needs: suggested learning outcomes

BACKGROUND: Patients have always fulfilled their information needs from a variety of different sources over time. Clinician-patient consultations are one part of that process. Some patients have increasing opportunities to obtain information through new sources such as the internet, touch-screens, and patient-held records. Others remain poorly informed. OBJECTIVES: To identify learning outcomes for clinicians in meeting patient information needs and working with well-informed patients. DESIGN: Four-stage multicentre multidisciplinary qualitative study. SETTING AND SUBJECTS: (1) Semistructured interviews with 20 clinicians in Glasgow; (2) semistructured interviews with 52 clinicians in Nottingham and London; (3) testing of consensus by postal questionnaire and Delphi method amongst 37 clinicians in medicine, nursing and the professions allied to medicine, and (4) conference to discuss results. RESULTS: 46 learning outcomes were identified in the eight areas of: placing a higher priority on patient information and education; understanding the patient's information needs and environment; understanding the emotional aspects of learning; developing patient understanding; helping patients to understand about health care and health care information; learning from the patient; knowing about information sources and their use, and issues of multidisciplinary working. CONCLUSIONS: The suggested learning outcomes provide the basis for wider discussion, for possible inclusion in curricula both at undergraduate and continuing education levels, and as the basis for the development of new educational materials.     

A survey of primary care physicians' perceptions and needs regarding the precepting of medical students in their offices

OBJECTIVE: To assess the interest, perceptions, and needs of primary care physicians with regard to office-based precepting of medical students. DESIGN: Random survey. SETTING: The New England region of the United States (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut). PARTICIPANTS: Family physicians, general internists and paediatricians. MAIN OUTCOME MEASURES: These included: (1) practice and preceptor demographics; (2) Likert scale agreement or disagreement with various positive and negative perceptions about precepting students; rating (from unimportant to necessary) of potential benefits from medical schools associated with the support of precepting in the office setting, and (3) comparisons among physician groups to determine differences in perceptions and needs. RESULTS: There is a high level of interest in precepting regardless of primary care specialty, practice structure, payment mechanism, or precepting experience. Negative impacts included decreased productivity and increased length of the day by a median of 60 minutes. Positive impacts included keeping one's own knowledge up-to-date and enhanced enjoyment of practice. Benefits such as academic appointments, continuing medical education credits, faculty development, computer linkages for clinical information and medical library access are rated highly. Monetary payment, whether as a modest honorarium or as compensation for lost time/income, was felt to be important by half of our sample. CONCLUSION: A significant interest in precepting medical students on a regular basis is expressed by primary care physicians in the ambulatory medicine setting. The results of this survey can be used by medical schools to address negative perceptions and to develop appropriate benefits packages to recruit and retain these primary care preceptors.