Search

BACKGROUND: Serious illness often causes economic hardship for patients' families. However, it is not known whether this hardship is associated with a preference for the goal of care to focus on maximizing comfort instead of maximizing life expectancy or whether economic hardship might give rise to disagreement between patients and surrogates over the goal of care. METHODS: We performed a cross-sectional study of 3158 seriously ill patients (median age, 63 years; 44% women) at 5 tertiary medical centers with 1 of 9 diagnoses associated with a high risk of mortality. Two months after their index hospitalization, patients and surrogates were surveyed about patients' preferences for the primary goal of care: either care focused on extending life or care focused on maximizing comfort. Patients and surrogates were also surveyed about the financial impact of the illness on the patient's family. RESULTS: A report of economic hardship on the family as a result of the illness was associated with a preference for comfort care over life-extending care (odds ratio, 1.26; 95% confidence interval, 1.07-1.48) in an age-stratified bivariate analysis. Similarly, in a multivariable analysis controlling for patient demographics, illness severity, functional dependency, depression, anxiety, and pain, economic hardship on the family remained associated with a preference for comfort care over life-extending care (odds ratio, 1.31; 95% confidence interval, 1.10-1.57). Economic hardship on the family did not affect either the frequency or direction of patient-surrogate disagreements about the goal of care. CONCLUSIONS: In patients with serious illness, economic hardship on the family is associated with preferences for comfort care over life-extending care. However, economic hardship on the family does not appear to be a factor in patient-surrogate disagreements about the goal of care. [ABSTRACT FROM AUTHOR]

Background: We examined the patterns of nonvitamin dietary supplement (NVDS) use among adult prescription medication users in the United States., Methods: Using the 2002 National Health Interview Survey, we analyzed factors associated with NVDS use and prescription medication use in the prior 12 months with descriptive, chi(2), and logistic regression analysis., Results: In the United States, 21% of adult prescription medication users reported using NVDSs in the prior 12 months. Of the respondents who used both prescription medications and NVDSs in the prior 12 months, 69% did not discuss this use with a conventional medical practitioner. Among adults who used prescription medications in the prior 12 months, the most commonly used supplements included echinacea, ginseng, ginkgo, garlic, and glucosamine chondroitin. Prescription medication users with menopause and chronic gastrointestinal disorders had the highest rates of NVDS use (33% and 28%, respectively), and prescription medication users with coronary heart disease and history of myocardial infarction had the lowest rates of use (12% each). In the adjusted analysis, factors associated with increased use of NVDSs by prescription medication users included being female, being Hispanic, having more years of education, living in the West, lacking medical insurance, and having chronic conditions. Elderly respondents were less likely to use NVDSs., Conclusion: One in 4 prescription medication users took an NVDS in the prior 12 months, yet the majority did not share this with a conventional medical professional.

Background: Prayer is a common practice in the United States, yet little is known about the prevalence and patterns of use of prayer for health concerns., Objective: To determine the prevalence and patterns of use of prayer for health concerns., Methods: We conducted a national survey in 1998 (N = 2055, 60% weighted response rate) on use of prayer. Data were also collected on sociodemographics, use of conventional medicine, and use of complementary and alternative medical therapies. Factors associated with the use of prayer were analyzed using multivariable logistic regression., Results: We found that 35% of respondents used prayer for health concerns; 75% of these prayed for wellness, and 22% prayed for specific medical conditions. Of those praying for specific medical conditions, 69% found prayer very helpful. Factors independently associated with increased use of prayer (P<.05) included age older than 33 years (age 34-53 years: odds ratio [OR], 1.6 [95% confidence interval (CI), 1.3-2.1]; age > or =54 years: OR, 1.5 [95% CI, 1.1-2.0]); female sex (OR, 1.4 [95% CI, 1.1-1.7]); education beyond high school (OR, 1.5 [95% CI, 1.2-1.8]); and having depression, chronic headaches, back and/or neck pain, digestive problems, or allergies. Only 11% of respondents using prayer discussed it with their physicians., Conclusions: An estimated one third of adults used prayer for health concerns in 1998. Most respondents did not discuss prayer with their physicians. Prayer was used frequently for common medical conditions, and users reported high levels of perceived helpfulness.

Background: Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care., Methods: We calculated the override rate among 3481 consecutive alerts generated at 5 adult primary care practices that use a common computerized physician order entry system for prescription writing. For detailed review, we selected a random sample of 67 alerts in which physicians did not prescribe an alerted medication and 122 alerts that resulted in a written prescription. We identified factors associated with the physicians' decisions to override a medication alert, and determined whether an adverse drug event (ADE) occurred., Results: Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts. In the multivariable analysis using the medical chart review sample (n = 189), physicians were less likely to prescribe an alerted medication if the prescriber was a house officer (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.84) and if the patient had many drug allergies (OR, 0.70; 95% CI, 0.53-0.93). They were more likely to override alerts for renewals compared with new prescriptions (OR, 17.74; 95% CI, 5.60-56.18). We found no ADEs in cases where physicians observed the alert and 3 ADEs among patients with alert overrides, a nonsignificant difference (P =.55). Physician reviewers judged that 36.5% of the alerts were inappropriate., Conclusions: Few physicians changed their prescription in response to a drug allergy or interaction alert, and there were few ADEs, suggesting that the threshold for alerting was set too low. Computerized physician order entry systems should suppress alerts for renewals of medication combinations that patients currently tolerate.

Objective: To determine whether internists' attitudes toward the hospitalist model change after implementation of a new inpatient service., Design: Cross-sectional surveys performed in 1998 and 2000., Setting: Tertiary care hospital in Boston, Mass., Subjects: A total of 236 internal medicine board-certified physicians affiliated with Beth Israel Deaconess Medical Center., Main Outcome Measures: Responses to survey items regarding attitude toward inpatient care and the hospitalist model. We used multivariable models to determine factors associated with physician responses., Results: Of physicians surveyed in 2000, 236 (69%) responded; 145 (61%) had also responded in 1998. The mean (SD) age of respondents was 46.4 (10.8) years; 157 (66.5%) were male; and 146 (61.9%) were primary care providers. In 2000, more physicians agreed that "caring for inpatients is an inefficient use of my time" (P<.001), and that "use of a hospitalist service improves quality of care" (P =.002). In 2000, more physicians disagreed that "use of a hospitalist service diminishes physician career satisfaction" (P<.001), and that "use of the hospitalist service adversely affects the physician-patient relationship" (P<.001). No differences were detected in responses to questions regarding patient satisfaction or overall career satisfaction. In multivariable models, older physicians were more likely to favor the hospitalist model; those with busier inpatient practices were more negative (P<.05 for each). Physician specialty or being a primary care provider was not associated with attitudes toward the hospitalist model., Conclusions: Following experience with a hospitalist system, physician attitude, including concerns regarding career satisfaction and relationships with patients, toward a voluntary hospitalist model improved. Future research should investigate whether the hospitalist model affects patient satisfaction and quality of care.

Background: In 1997, patients made an estimated 629 million visits to complementary and alternative medicine (CAM) providers; however, little is known about factors associated with visits to CAM providers., Objective: To examine the effect of insurance coverage on frequency of use of CAM providers., Methods: We conducted a nationally representative, random household telephone survey of 2055 adults., Main Outcome Measure: The number of visits made to CAM providers., Results: An estimated 44% of the US population used at least 1 CAM therapy in 1997. Of those using CAM, 52% had seen at least 1 CAM provider in the last year. Among those who used a CAM therapy, factors independently associated with seeing a provider were having been in the upper quartile of visits to conventional providers in the last year (adjusted odds ratio [AOR], 2.00; 95% confidence interval [CI], 1.33-3.01), female sex (AOR, 1.67; 95% CI, 1.17-2.38), and having used the therapy to treat diabetes (AOR, 5.20; 95% CI, 1.40-19.40), cancer (AOR, 2.99; 95% CI, 1.04-8.62), or back or neck problems (AOR, 1.51; 95% CI, 1.02-2.23). Factors independently associated with frequent use (. or = 8 visits per year) of a CAM provider were full insurance coverage of the CAM provider (AOR, 5.06; 95% CI, 2.45-10.47), partial insurance coverage (AOR, 3.26; 95% CI, 1.72-6.19), having used the therapy for wellness (AOR, 2.85; 95% CI, 1.63-4.98), and having seen the provider for back or neck problems (AOR, 2.26; 95% CI, 1.29-3.94). Conservative extrapolation to national estimates suggests that 8.9% of the population (17.5 million adults) accounted for more than 75% of the 629 million visits made to CAM providers in 1997., Conclusions: A small minority of persons accounted for more than 75% of visits to CAM providers. Extent of insurance coverage for CAM providers and use for wellness are strong correlates of frequent use of CAM providers.

Background: The effect of weight control concerns on smoking among adults is unclear. We examined the association between smoking behavior and weight control efforts among US adults., Methods: A total of 17 317 adults responded to the Year 2000 Supplement of the 1995 National Health Interview Survey (83% combined response rate). Respondents provided sociodemographic and health information, including their smoking history and whether they were trying to lose weight, maintain weight, or gain weight., Results: Rates of smoking were lower among adults who were trying to lose or maintain weight than among those not trying to control weight (25% vs 31%; P<.001). After adjustment for sex, race, education, income, marital status, region of the country, and body mass index, the relationship between trying to lose weight and current smoking varied according to age. Among adults younger than 30 years, those trying to lose weight were more likely to smoke currently (odds ratio, 1.36 [95% confidence interval, 1.09-1.70]), whereas older adults trying to lose weight were as likely or less likely to smoke compared with adults not trying to control weight. After adjustment, smokers of all ages who were trying to lose weight were more likely to express a desire to quit smoking. Results were similar after stratification by sex and body mass index., Conclusions: Adults younger than 30 years are more likely to smoke if they are trying to lose weight. However, smokers of all ages who are trying to lose weight are more likely to want to stop smoking. Patients' weight control efforts should not discourage clinicians from counseling about smoking cessation. Education about smoking and healthy weight control methods should target young adults.

Background: The quality of discharge planning is an important determinant of patient outcomes following hospital discharge. Patients often report inadequate discussion prior to discharge regarding major elements of the postdischarge treatment plan, including medication and daily activities., Objective: To determine whether this apparent lack of communication might be the result of differing perceptions on the part of patients and physicians regarding the patients' understanding of the treatment plan., Methods: We surveyed 99 patients and their attending physicians. All patients had been discharged recently from an academic medical center with the diagnosis of acute myocardial infarction or pneumonia. We asked both patients and physicians about time spent prior to discharge discussing the postdischarge treatment plan and the patients' understanding of this plan. McNemar test was used to determine whether responses of patients and physicians differed., Results: Physicians reported spending more time discussing postdischarge care than did patients (P = .10). Physicians believed that 89% of patients understood the potential side effects of their medications, but only 57% of patients reported that they understood (P < .001). Similarly, physicians believed that 95% of patients understood when to resume normal activities, while only 58% of patients reported that they understood (P < .001)., Conclusions: Physicians overestimate patients' understanding of the postdischarge treatment plan. Steps should be taken to improve communication about postdischarge treatment.