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Background: Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments. Objective: To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments. Design: Retrospective cohort study. Participants: Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018. Main Measures: Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments. Key Results: The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5–1.8) for outpatient appointments, 1.9 (1.7–2.1) for gastroenterology appointments, and 3.1 (2.9–3.4) for adherence with bowel preparation kits, respectively. Conclusions: Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available. [ABSTRACT FROM AUTHOR]

Background: Burnout among clinicians is common and can undermine quality of care, patient outcomes, and workforce preservation, but sources of burnout or protective factors unique to clinicians working in safety-net settings are less well understood. Understanding these clinician experiences may inform interventions to reduce burnout. Objective: To describe clinician perspectives on sources of burnout in a safety-net healthcare system. Design: Semi-structured interviews were conducted with clinicians from multiple disciplines who provided care at a safety-net healthcare system from October 2018 to January 2019. Transcripts were analyzed using thematic analysis. Participants: Forty clinicians (25 female and 15 male; mean [SD] age, 41 [9.1]) participated, including physicians, social workers, advanced practice providers, nurses, psychologists, physical and occupational therapists, and other healthcare professionals. Main Outcomes and Measures: Themes and subthemes that reflected clinician experiences, burnout, and workload expectations. Key Results: Five themes emerged: limited resources (entrenched social injustices, brokenness of the US healthcare system, precarious discharge options, and "revolving door" readmissions), barriers to building trust with patients (chasm of communication, addressing fear and mistrust, and being exposed to threats), administrative requirements (criticism hampering meaningful care, assuming extra workloads, bureaucratic burden), compassion fatigue (confronting traumatic situations, persistent worry about patient safety and welfare, witnessing mistreatment and stigmatization, overextending and overinvesting, withdrawing and shutting down, blaming self and career crisis), and advocacy as a counterbalance to burnout (solidarity when helping underserved communities, fervent advocacy, and patient gratitude). Conclusions: Among clinicians who provide care in a safety-net healthcare system, sources of burnout included limited resources, barriers to building trust with patients, administrative requirements, and compassion fatigue, but clinicians remained driven by their desire to advocate for patients. Policy-level interventions which increase funding to safety-net healthcare systems to bolster existing resources and staffing, create peer-support and wellness programs, and support advocacy efforts may mitigate burnout. [ABSTRACT FROM AUTHOR]

In the United States, hypertension is more common among individuals from racial and ethnic minority groups. Hypertension control rates are also lower for minority group members compared with White Americans. However, little research has employed well-established theoretical perspectives on health behavior, such as the Theory of Planned Behavior (TPB) and the Model of Goal-Directed Behavior (MGB), to better understand racial differences in rates of hypertension control. The present study examines the psychological processes involved in efforts to control blood pressure, through the lens of the TPB augmented by the MGB, in hypertensive patients of three racial groups: American Indian/Alaska Native, Black/African American, and White. Participants completed measures of past efforts to control blood pressure, attitudes, norms, perceived behavioral control, intentions, and anticipated emotions. Analyses employed confirmatory factor analysis and cross-groups path analysis. Measurement of the theoretical constructs and core putative mediators of blood pressure control intentions were largely similar across racial groups. With regard to the patterns of relationships among the constructs, differences among the groups were most apparent in pathways from past efforts to both cognitive and affective theoretical antecedents of intentions. These findings contribute to the sparse literature on factors involved in racial differences in hypertension control rates and may inform future interventions aimed at increasing hypertension control behaviors. Trial Registration ClinicalTrials.gov, NCT03028597, registered 23 January 2017, https://clinicaltrials.gov/ct2/show/NCT03028597; ClinicalTrials.gov, NCT04414982, registered 4 June 2020 (retrospectively registered), https://www.clinicaltrials.gov/ct2/show/NCT04414982 [ABSTRACT FROM AUTHOR]

Objectives: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. Methods: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. Results: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia. [ABSTRACT FROM AUTHOR]

Background: Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare.Objective: Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety DESIGN: Longitudinal observational study PARTICIPANTS: Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate) MAIN MEASURES: Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion.Key Results: Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18).Conclusions: Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care. [ABSTRACT FROM AUTHOR]

We then assessed how many additional risk factors were present when each individual risk factor was absent, in order to determine the information that would be lost if screening were limited to a single risk factor. Relationships Between Social Risk Factors Participants most often reported lacking money to pay utility bills (53.6%), and least often reported lacking a decent place to live (16.9%). Increasingly, healthcare systems are screening for social risk factors and connecting patients with programs to mitigate their social needs and improve health outcomes.[1]-[4] A recent national survey demonstrated substantial variability in the selection of social risk factors for screening.[1] Many clinics appear to rely on practitioner opinion rather than patient-derived data to choose risk factor domains.[2]-[4] During a randomized controlled trial (RCT) in a federally qualified health center, we collected information about seven social risk factors from study participants.[5], [6] In this report, we present an analytic approach that such a clinic might use to guide the selection of social risk factors for screening. [Extracted from the article]

Background: Both hyperkalemia and hypokalemia can lead to cardiac arrhythmias and are associated with increased mortality. Information on the predictors of potassium in individuals with diabetes in routine clinical practice is lacking. Objective: To identify predictors of hyperkalemia and hypokalemia in adults with diabetes. Design: Retrospective cohort study, with classification and regression tree (CART) analysis. Participants: 321,856 individuals with diabetes enrolled in four large integrated health care systems from 2012 to 2013. Main Measures: We used a single serum potassium result collected in 2012 or 2013. Hyperkalemia was defined as a serum potassium ≥ 5.5 mEq/L and hypokalemia as < 3.5 mEq/L. Predictors included demographic factors, laboratory measurements, comorbidities, medication use, and health care utilization. Key Results: There were 2556 hypokalemia events (0.8%) and 1517 hyperkalemia events (0.5%). In univariate analyses, we identified concordant predictors (associated with increased probability of both hyperkalemia and hypokalemia), discordant predictors, and predictors of only hyperkalemia or hypokalemia. In CART models, the hyperkalemia "tree" had 5 nodes and a c-statistic of 0.76. The nodes were defined by prior potassium results and eGFRs, and the 5 terminal "leaves" had hyperkalemia probabilities of 0.2 to 7.2%. The hypokalemia tree had 4 nodes and a c-statistic of 0.76. The hypokalemia tree included nodes defined by prior potassium results, and the 4 terminal leaves had hypokalemia probabilities of 0.3 to 17.6%. Individuals with a recent potassium between 4.0 and 5.0 mEq/L, eGFR ≥ 45 mL/min/1.73m2, and no hypokalemia in the previous year had a < 1% rate of either hypokalemia or hyperkalemia. Conclusions: The yield of routine serum potassium testing may be low in individuals with a recent serum potassium between 4.0 and 5.0 mEq/L, eGFR ≥ 45 mL/min/1.73m2, and no recent history of hypokalemia. We did not examine the effect of recent changes in clinical condition or medications on acute potassium changes. [ABSTRACT FROM AUTHOR]

Background: Undocumented immigrants with end-stage kidney disease (ESKD) who rely on emergency-only hemodialysis (dialysis only after an emergency department evaluation) face psychosocial distress. Emergency-only hemodialysis (EOHD) is likely burdensome for primary caregivers as well. Objective: To understand the experience of primary caregivers of undocumented immigrants with ESKD who rely on emergency-only hemodialysis. Design, Setting, and Participants: A qualitative, semi-structured interview study to assess the experiences of primary caregivers of undocumented immigrants with ESKD at a safety-net hospital in Denver, Colorado from June 28 to November 15, 2018. Applied thematic analysis was used to analyze interviews. Main Outcomes and Measures: Themes and subthemes. Results: Twenty primary caregiver participants had a mean (SD) age of 46 (17), 13 (65%) were female, 7 (35%) were in an adult child caregiver role, and 13 (65%) were spouses. Five themes and 17 subthemes (in parentheses) were identified: (1) Caregiver role (providing emotional, physical, and economic support, advocacy and care navigation), (2) Caregiver burden (anxiety related to patient and personal death, emotional exhaustion and personal illness, struggle with finances, self-care and redefining relationship), (3) Unpredictable EOHD (acute episodes of illness that trigger emergency, stress when patient is denied dialysis, impact on work and sleep, and emotional relief after a session of EOHD), (4) Effect on children (dropping out or missing school, psychosocial distress, children assuming caregiver responsibilities, and juggling multi-generational caregiving of children), (5) Faith and appreciation (comfort in God and appreciation of healthcare). Conclusions and Relevance: Caregivers of undocumented immigrants with ESKD who rely upon EOHD experience caregiver burden and distress. The impact of EOHD on caregivers should be considered when assessing the consequences of excluding undocumented immigrants from public insurance programs. [ABSTRACT FROM AUTHOR]

Depression prevalence is known to vary by individual factors (gender, age, race, medical comorbidities) and by neighborhood factors (neighborhood deprivation). However, the combination of individual- and neighborhood-level data is rarely available to assess their relative contribution to variation in depression across neighborhoods. We geocoded depression diagnosis and demographic data from electronic health records for 165,600 patients seen in two large health systems serving the Denver population (Kaiser Permanente and Denver Health) to Denver's 144 census tracts, and combined these data with indices of neighborhood deprivation obtained from the American Community Survey. Non-linear mixed models examined the relationships between depression rates and individual and census tract variables, stratified by health system. We found higher depression rates associated with greater age, female gender, white race, medical comorbidities, and with lower rates of home owner occupancy, residential stability, and higher educational attainment, but not with economic disadvantage. Among the Denver Health cohort, higher depression rates were associated with higher crime rates and a lower percent of foreign born residents and single mother households. Our findings suggest that individual factors had the strongest associations with depression. Neighborhood risk factors associated with depression point to low community cohesion, while the role of education is more complex. Among the Denver Health cohort, language and cultural barriers and competing priorities may attenuate the recognition and treatment of depression. [ABSTRACT FROM AUTHOR]

Background: Pneumococcal vaccine (PPV) is recommended for adults >or=65 years and those with chronic illness, but there are potential advantages of universal vaccination of adults age 50-64 years.Objective: To assess reported (1) recommendations and administration practices of general internists for PPV, (2) barriers to vaccination, and (3) willingness to expand vaccination to all adults >or=50 years.Methods: National survey of general internists representative of the American College of Physicians.Results: Response rate was 74% (N = 326). Although 99% reported giving PPV, less than 20% used a computerized database to identify eligible patients by age or diagnoses and only 6% recalled patients. Major barriers included acute problems taking precedence over preventive care (39%), difficulty determining vaccination history (30%), not thinking of it/not a priority (20%), and inadequate reimbursement for vaccine (19%). If ACIP expanded recommendations, 60% would definitely and 37% would probably institute this change.Conclusions: Most general internists reported giving PPV, but delivery was hindered by competing demands, lack of systems to identify patients needing vaccination, and reimbursement issues. Barriers might be decreased by a policy of universal vaccination of adults >or=50 years, and the majority of physicians reported they would follow such a recommendation if it were made. [ABSTRACT FROM AUTHOR]

Background: Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes.Methods: We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n = 27,954), and systolic blood pressure (SBP) >130 mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator.Results: We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6 % of blacks versus 39.7 % of whites were not highly adherent (i.e., MRA <80 %) to HbA1c oral medication(s); 58.4 % of blacks and 46.7 % of whites were not highly adherent to lipid medication(s); and 33.4 % of blacks and 23.7 % of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5 % of blacks and 45.8 % of whites achieved HbA1c <8 %; 52.6 % of blacks and 60.8 % of whites achieved LDL-C <100; and 45.7 % of blacks and 53.6 % of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics.Conclusions: Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Few studies have directly investigated the association of clinicians' implicit (unconscious) bias with health care disparities in clinical settings. OBJECTIVE: To determine if clinicians' implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients. RESEARCH DESIGN AND PARTICIPANTS: Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians' black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians' implicit biases and ethnic or racial differences in hypertension care and outcomes. MAIN MEASURES: Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits. KEY RESULTS: One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients ( P = 0.85, P = 0.06 and P = 0.31, respectively) and for Latino patients ( P = 0.55, P = 0.40 and P = 0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients. CONCLUSIONS: Implicit bias did not affect clinicians' provision of care to their minority patients, nor did it affect the patients' outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership. [ABSTRACT FROM AUTHOR]

Although racial and ethnic minorities are more likely to be involved with the criminal justice system than whites in the USA, critical scientific gaps exist in our understanding of the relationship between the criminal justice system and the persistence of racial/ethnic health disparities. Individuals engaged with the criminal justice system are at risk for poor health outcomes. Furthermore, criminal justice involvement may have direct or indirect effects on health and health care. Racial/ethnic health disparities may be exacerbated or mitigated at several stages of the criminal justice system. Understanding and addressing the health of individuals involved in the criminal justice system is one component of a comprehensive strategy to reduce population health disparities and improve the health of our urban communities. [ABSTRACT FROM AUTHOR]

BACKGROUND Information comparing characteristics of patients who do and do not pick up their prescriptions is sparse, in part because adherence measured using pharmacy claims databases does not include information on patients who never pick up their first prescription, that is, patients with primary non-adherence. Electronic health record medication order entry enhances the potential to identify patients with primary non-adherence, and in organizations with medication order entry and pharmacy information systems, orders can be linked to dispensings to identify primarily non-adherent patients. OBJECTIVE This study aims to use database information from an integrated system to compare patient, prescriber, and payment characteristics of patients with primary non-adherence and patients with ongoing dispensings of newly initiated medications for hypertension, diabetes, and/or hyperlipidemia. DESIGN This is a retrospective observational cohort study. PARTICIPANTS (OR PATIENTS OR SUBJECTS) Participants of this study include patients with a newly initiated order for an antihypertensive, antidiabetic, and/or antihyperlipidemic within an 18-month period. MAIN MEASURES Proportion of patients with primary non-adherence overall and by therapeutic class subgroup. Multivariable logistic regression modeling was used to investigate characteristics associated with primary non-adherence relative to ongoing dispensings. KEY RESULTS The proportion of primarily non-adherent patients varied by therapeutic class, including 7% of patients ordered an antihypertensive, 11% ordered an antidiabetic, 13% ordered an antihyperlipidemic, and 5% ordered medications from more than one of these therapeutic classes within the study period. Characteristics of patients with primary non-adherence varied across therapeutic classes, but these characteristics had poor ability to explain or predict primary non-adherence (models c-statistics = 0.61-0.63). CONCLUSIONS Primary non-adherence varies by therapeutic class. Healthcare delivery systems should pursue linking medication orders with dispensings to identify primarily non-adherent patients. We encourage conduct of research to determine interventions successful at decreasing primary non-adherence, as characteristics available from databases provide little assistance in predicting primary non-adherence. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about how the development of a new chronic health condition affects management of existing chronic conditions over time. New conditions might worsen management of existing conditions because of competing demands or improve management of existing conditions because of increased engagement with heath care. We assessed the effect of incident stage 0, 1, 2 or 3 breast, colon or prostate cancer; incident depression; or an exacerbation of chronic pulmonary disease on control of type 2 diabetes (DM2).Methods: We conducted a longitudinal, historical cohort study within an integrated, not-for-profit HMO. Of a cohort of persons with diagnoses of DM2 between 1998 and 2008, 582, 2,959 and 2,332 developed incident cancer, depression or pulmonary disease exacerbation, respectively. We assessed change in hemoglobin A1c (A1c) as a function of the occurrence of the incident comorbidity in each subcohort for a period of 1 to 5 years after the occurrence of the incident comorbidity. Secondary outcomes were systolic blood pressure (SBP) and low density lipoprotein (LDL) levels. Multivariate linear regression was adjusted for demographics, morbidity level, BMI, numbers of primary and specialty visits, and continuity of primary care. Latent class analyses assessed post-comorbidity outcome trajectories. All time-varying covariates were calculated for a 24-month pre-diagnosis period and 0 to 24- and 24 to 60-month post-diagnosis periods.Results: For each condition, A1c did not change significantly from before to after the incident comorbidity. This was confirmed by latent class growth curve analyses that grouped patients by their A1c trajectories. SBP and LDL were also not significantly changed pre- and post-diagnosis of the incident comorbidities.Discussion: Although incident comorbidities inevitably will affect patients' and clinicians' care priorities, we did not observe changes in these particular outcomes. Additional investigation of interactions between diseases will inform changes in care that benefit complex patient populations. [ABSTRACT FROM AUTHOR]

The effect of acculturation with cardiovascular disease (CVD) risk factors is poorly understood. We assessed the association of three acculturation measures (English language, US country of birth and a combination of the two) with CVD risk factors and co-morbid medical and behavioral conditions in a registry of 6,793 Latinos with hypertension. Greater acculturation was associated with higher adherence to medication ( P < 0.05) and a higher prevalence of behavioral conditions ( P < 0.01) but not with differences in prevalence of CVD risk factors, greater levels of CVD risk factor control or outcomes. Our study demonstrates that our proxies for acculturation were associated with behavioral risk factors, but not with the level of control of biomedical CVD risk factors. While more work is needed to develop proxies that can predict risk factor control and CVD outcomes, our simple measures can facilitate regular assessment of the cultural component of behavioral risk. [ABSTRACT FROM AUTHOR]

Patient knowledge about lower endoscopy might have beneficial effects on satisfaction outcomes, pre-procedure anxiety, and adherence, although this is poorly understood. Methods Searching the national and international literature, we reviewed 20 years of observational studies and randomized trials that examine possible relationships between educating patients about lower endoscopy and clinical outcomes. Twenty-three publications were included but their heterogeneity precluded meta-analyses. Standard and modified informed consent procedures and enhanced educational interventions were associated most often with levels of patient knowledge, satisfaction, anxiety, and adherence. Regardless of the approach, a large proportion of patients have poor comprehension of lower endoscopy's risks, benefits, and alternatives; patient satisfaction with information and procedures manifests ceiling effects; only a subset of patients have clinically significant pre-procedure anxiety; and providing written information and reminders may improve procedure adherence. Future work should focus on strategies for improving patient knowledge in the setting of initial screening colonoscopy within open access systems. Patient knowledge of lower endoscopy is often inadequate even though greater knowledge might be associated with better clinical outcomes for certain patient subgroups. Professional societies have an important role to play in endorsing educational strategies and in clarifying and assessing the adequacy of patient knowledge. [ABSTRACT FROM AUTHOR]

The article discusses how representative stories can help disseminate research effectively. Five attributes of representative stories are being suggested including expression of important themes in research, explicit location in the distribution of stories, verifiability, acknowledgement of uncertainty and compelling narration. Researchers who want to enhance dissemination of their work should gather more stories during the research process to identify stories which are credible.

OBJECTIVE: To study the educational contributions of attending physicians in an internal medicine house staff ambulatory clinic. DESIGN: Cross-sectional, self-administered survey. SETTING: University-affiliated general internal medicine practice. PATIENTS/PARTICIPANTS: Internal medicine residents and attendings. MEASUREMENTS AND MA/N RESULTS: Attending and resident perceptions of whether attendings made contributions to teaching points, diagnosis (DX), therapy (RX), and health care maintenance (HCM) were assessed in 428 patient encounters. Resident assessments significantly exceeded attending self-assessments of contributions to teaching points (82% vs 74%, P=.001), DX (44% vs 34%, P=.001), RX (61% vs 55%, P=.02), and HCM (19% vs 15%, P=.04). Both residents and attendings perceived that contributions declined progressively with increasing resident year (P<.05). Primary care and categorical residents assessed attending contributions comparably. However, attendings perceived contributing more to RX and HCM for categorical residents than primary care (P<.05). Male and female residents assessed attending contributions comparably. However, attendings perceived contributing generally more to DX in male residents than female (P=.003). In 8% of encounters, either residents or attendings felt that patient evaluation by the attending was needed. In these encounters with personal patient evaluation by attendings, both residents and attendings felt that attendings made more contributions to DX (P=.001) and teaching points than in other encounters. CONCLUSIONS: Attending physicians consistently underestimate their perceived contributions to house officer ambulatory teaching. Their personal patient evaluation increases assistance with DX and teaching points. Given perceived declining contributions by training year, attendings may need to identify other teaching strategies for interactions with senior residents. [ABSTRACT FROM AUTHOR]

Background: Timeliness of care is 1 of 6 dimensions of quality identified in Crossing the Quality Chasm. We compared patient and physician perceptions of appropriate timing of visits for common medical problems.Methods: This study was conducted at 2 internal medicine clinics at the University of Colorado Health Sciences Center. Adult patients and companions, and outpatient General Internists were surveyed. The survey contained 11 clinical scenarios of varying urgency. Respondents indicated how soon the patient in each scenario should be seen. Responses ranged from that day to 1 to 3 months. Responses were analyzed using the Mann-Whitney U test.Results: Two hundred and sixty-two patients and 46 of 61 physicians responded. For 8 of the 11 scenarios patients felt they should be seen significantly earlier than physicians. Scenarios involving chronic knee and stomach pain, routine diabetes care, and hyperlipidemia generated the greatest differences. Patients and physicians agreed on the urgency of scenarios concerning wheezing in an asthmatic, an ankle injury, and acute pharyngitis.Conclusions: Patients expected to be seen sooner than physicians thought necessary for many common chronic medical conditions, but are in agreement about timeliness for some acute problems. Understanding patient expectations may help physicians respond to requests for urgent evaluation of chronic conditions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Colonoscopy has become a preferred cob rectal cancer (CRC) screening modality. Little is known about why patients who are referred for colonoscopy do not complete the recommended procedures. Prior adherence studies have evaluated colonoscopy only in combination with flexible sigmoidoscopy, failed to differentiate between screening and diagnostic procedures, and have examined cancellations/no-shows, but not nonscheduling, as mechanisms of nonadherence. METHODS: Sociodemographic predictors of screening completion were assessed in a retrospective cohort of 647 patients referred for colonoscopy at a major university hospital. Then, using a qualitative study design, a convenience sample of patients who never completed screening after referral (n=52) was interviewed by telephone, and comparisons in reported reasons for nonadherence were made by gender. RESULTS: Half of all patients referred for colonoscopy failed to complete the procedure, overwhelmingly because of nonscheduling. In multivariable analysis, female sex, younger age, and insurance type predicted poorer adherence. Patient-reported barriers to screening completion included cognitive-emotional factors (e.g., lack of perceived risk for CRC. fear of pain, and concerns about modesty and the bowel preparation), logistic obstacles (e.g., cost, other health problems, and competing demands), and health system barriers (e.g., scheduling challenges, long waiting times). Women reported more concerns about modesty and other aspects of the procedure than men. Only 40% of patients were aware of alternative screening options. CONCLUSIONS: Adherence to screening colonoscopy referrals is sub-optimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in colonoscopy referral and scheduling mechanisms. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Little is known about the impact of fellowship training in primary care on subsequent research productivity. Our goal was to identify characteristics of research fellows and their training associated with subsequent publications and research funding. DESIGN: Mail survey in 1998. SETTING AND PARTICIPANTS: 1988–1997 graduates of 25 National Research Service Award primary care research fellowships in the United States. OUTCOME MEASURES: 1) Publishing 1 or more papers per year since the beginning of fellowship, or 2) serving as principal investigator (PI) on a federal or non-federal grant. RESULTS: One hundred forty-six of two hundred fifteen program graduates (68%) completed the survey. The median age was 38 years, and 51% were male. Thirty-two percent had published 1 or more papers per year, and 44% were PIs. Male gender (odds ratio [OR], 3.6; 95% confidence interval [95% CI], 1.4 to 9.2), self-reported allocation of 40% or more of fellowship time to research (OR, 4.4; 95% CI, 1.8 to 11.2), and having an influential mentor during fellowship (OR, 5.0; 95% CI, 1.5 to 17.2) were independently associated with publishing 1 or more papers per year. Fellows with funding as a PI were also more likely to have an influential mentor (OR, 3.0; 95% CI, 1.3 to 7.2). CONCLUSION: Primary care fellows who had influential mentors were more productive in research early after fellowship. Awareness of the indicators of early research success can inform the policies of agencies that fund research training and the curricula of training programs themselves. [ABSTRACT FROM AUTHOR]

This study traces the origins and development of the crime of genocide using the Holocaust and its absolutist ideology and racist myth systems--as developed by Nazi geneticists and sociologists--which has lead to euthanasia, killing squads and extermination camps such as Auschwitz-Birkenau, as a frame of reference. This inquiry further investigates how seemingly "ordinary," indoctrinated and often intimidated people acted upon biddings of an unscrupulous leader assisted by cohorts who uncritically assumed assigned roles and externalized discretion in a totalitarian system. Individual discretion was externalized and delegated to the leader. Adolf Hitler, or to their immediate superiors. Following the orders of these leaders gradually paved the process of an escalation of violence into genocide. Reasons for this process are not merely politically and/or economically motivated, but are also to be sought in the society's pool and level of moral and social intelligence, as well as in frustrated expectations experienced by large segments of the populous. Individual and group response to powerful situational forces are examined. Human behavior is found to be represented on a broad spectrum ranging from altruism on one hand of the scale to authoritarianism and extreme destructiveness on the other. Special attention is given to moral integrity and accountability, its development and application. [ABSTRACT FROM AUTHOR]

Objective: To describe the clinical features of patients diagnosed with upper respiratory tract infections (URIs), and determine which clinical features are associated with antibiotic use.Design: Prospective cohort study.Setting: Three ambulatory care practices at a group-model HMO in the Denver metropolitan area.Patients: Adults (aged 18 years or older) seeking care for acute respiratory illnesses.Measurements: Clinical features were documented on standardized encounter forms. Clinician type, secondary diagnoses, and antibiotic treatment were extracted from administrative databases. Results are presented as adjusted odds ratios (ORs) with 95% confidence intervals (CIs).Main Results: Antibiotics were prescribed to 33% (95% CI 28%, 38%) of patients diagnosed with URI, after excluding patients with coexisting antibiotic-responsive conditions (e.g., sinusitis, pharyngitis) or a history of cardiopulmonary disease. Multivariate logistic regression analysis identified tobacco use (OR 2.8; 95% CI 1.5, 5.1), history of purulent nasal discharge (OR 2.0; 95% CI 1.1, 3.6) or green phlegm (OR 4.8; 95% CI 2.1, 11.1), and examination findings of purulent nasal discharge (OR 5.2; 95% CI 2.4, 11.2) or tonsillar exudate (OR 3.7; 95% CI 1.1, 12.1) to be independently associated with antibiotic use. The majority of patients treated with antibiotics (82%) had at least one of these factors present.Conclusions: Antibiotic treatment of URIs is most common when purulent manifestations are present. Efforts to reduce antibiotic treatment of URIs should educate clinicians about the limited value of purulent manifestations in predicting antibiotic-responsive disease. [ABSTRACT FROM AUTHOR]

A personal narrative is presented which explores the author's experiences of caring for his father and supervising his funeral.

The article presents the results of a study conducted by I. M. Kronish and colleagues on the clinical implementation of electronic adherence monitors in the U.S. It finds the study important as it prompts others to think deeply on integrating adherence assessment into clinical practice and designing research studies that test clinical interventions. The barriers to such implementation are cited, including the concern on adherence information integration into decision making.

Objectives: To describe the clinical features of adults diagnosed with acute bronchitis, and to identify clinical variables associated with antibiotic treatment of acute bronchitis.Design: Prospective, cohort study.Setting: Primary care office practices at a group-model HMO in the Denver metropolitan area.Patients/participants: Patients were adults seeking care for acute respiratory illnesses. Participating clinicians included internists, family medicine physicians, nurse practitioners, physician assistants, and registered nurses.Measurements and Main Results: Clinicians voluntarily completed encounter forms for patients presenting with acute respiratory illnesses between February and May, 1996. Acute bronchitis was the primary diagnosis in 16% of acute respiratory illness visits (n = 1,525). The most frequent symptoms of acute bronchitis were cough (92%), phlegm production (63%), "runny nose" (50%), and throat pain (50%). The most frequent physical examination findings were pharyngeal erythema (45%), cervical lymphadenopathy (19%), wheezes (18%), and rhonchi (17%). Antibiotics were prescribed to 85% of patients diagnosed with acute bronchitis. Purulent nasal discharge by patient report, and sinus tenderness on physical examination were moderately associated with antibiotic treatment (p = .06 and .08, respectively). Antibiotic prescription rates did not vary by patient age or gender, duration of illness, days of work lost due to illness, or clinician type.Conclusions: Acute bronchitis is frequently treated with antibiotics in ambulatory practice. The clinical factors we identified to be associated with antibiotic use for acute bronchitis appear to play a minor role in explaining the excessive use of antibiotics for this condition. These findings suggest that clinicians use the diagnosis of acute bronchitis as an indication for antibiotic treatment, despite clinical trials and expert recommendations to the contrary. [ABSTRACT FROM AUTHOR]

Objective: Hypothyroidism often remains undetected because of the difficulty associating symptoms with disease. To determine the relation between symptoms and biochemical disease, we assessed symptoms and serum thyroid function tests, concurrently, for patients with and without hypothyroidism.Design: Cross-sectional study.Setting/patients: Seventy-six newly diagnosed case patients with overt hypothyroidism and 147 matched control patients identified through outpatient laboratories in Michigan and Colorado.Measurements and Main Results: Patient symptoms were assessed by questionnaire. Case patients reported a higher proportion of hypothyroid symptoms than did control patients (30.2% vs 16.5%, p < .0001). Univariate analysis identified three significant predictors of an elevated level of thyroid-stimulating hormone (TSH) (p < .05), and 13 symptoms which, when they had changed in the past year, were reported more often by case patients with hypothyroidism than by control patients (p < .005). Individuals reporting changes in 7 or more symptoms were significantly more likely to have hypothyroidism (likelihood ratio [LR] = 8.7, 95% confidence interval [CI] 3.8, 20.2); those reporting changes in 2 or fewer symptoms were less likely to have hypothyroidism (LR = 0.5, 95% CI 0.4, 0.7).Conclusions: In this sample, the number of hypothyroid symptoms reported was directly related to the level of TSH. The association was stronger when more symptoms were reported. Symptoms that had changed in the past year were more powerful than symptoms reported present at the time of testing. This suggests that traditional symptoms are valuable when deciding which patients to test for hypothyroidism. [ABSTRACT FROM AUTHOR]

Objective: To determine whether large prescriptions (> or = 90 days' supplies) enhance the acquisition of maintenance medications by patients.Design: Study 1: multisite, retrospective cohort study evaluating outpatient digoxin use. Study 2: single-site, retrospective cohort study to confirm Study 1.Setting: Study 1: Ten Veterans Affairs Medical Centers in the Rocky Mountain region. Study 2: The only facility from Study 1 (site C) that dispensed large prescriptions of maintenance medications.Patients: Randomly selected outpatients receiving two or more digoxin prescriptions (n = 176 in Study 1, n = 114 in Study 2).Intervention: None.Results: The main outcome measure was the proportion of prescribed doses of maintenance medications obtained. In Study 1, patients who received at least one large digoxin prescription obtained a mean of 137.2% of their prescribed digoxin doses over a mean of nine months, compared with 91.3% for patients who received only small prescriptions of < 90 days' supplies (p = 0.02). Patients receiving large prescriptions were more likely to obtain at least 100% of their prescribed amounts of digoxin (adjusted OR = 11.4, 95% CI = 1.3-96.8, p = 0.03). At site C, patients in Study 1 obtained a mean of 129.0% of all maintenance drugs given in large supplies, compared with 95.2% of drugs prescribed only in small supplies (p = 0.006). In Study 2, acquisition of digoxin increased progressively from 89.7% among individuals who received only small digoxin prescriptions to 113.0% for those who received only large supplies (p = 0.002), over a mean of 14 months.Conclusions: Large prescriptions facilitate the acquisition of maintenance medications but may lead to oversupplies, while small prescriptions impose a barrier to obtaining these drugs. [ABSTRACT FROM AUTHOR]

Objectives: 1) To describe the prevalence of eight injury-prone behaviors (IPBs) and the associations of these behaviors with ten standard chronic disease and sociodemographic risk factors (CDSRFs) among internal medicine patients and 2) to identify a subset of patients with multiple IPBs who might be at particularly high risk of injury.Design: Cross-sectional survey.Setting: The University of Colorado Health Sciences Center general internal medicine clinic.Patients: Four hundred ninety-two consecutive continuity care patients were eligible. The response rate was 94.3% (464/492).Instrument: A validated, self-administered questionnaire.Main Results: Thirty-four percent of patients did not wear safety belts regularly and 32% had no smoke detector in their homes. Nearly 26% of patients had firearms at home and 6% had a loaded and unlocked gun at home. Fourteen percent of patients had seriously thought about suicide and 6% had attempted suicide. In the prior month, 10% had ridden with a drunk driver, and 4% had driven after drinking too much. Of patients aged 65 years or older, 50% had had recent falls. After adjustment for other CDSRFs, problem drinking was the CDSRF most frequently associated with IPBs. Among men, problem drinking was significantly associated with drinking and driving (OR = 35.3), safety belt non-use (OR = 4.3), and previous thoughts of or attempts at suicide (OR = 6.2). Among women, problem drinking was significantly associated with drinking and driving (OR = 8.7). Among men, being unmarried was the demographic risk factor associated with the most IPBs. Of all IPBs, safety belt non-use was most frequently associated with CDSRFs (ORs ranged from 2.8 to 4.4). Men with three or more IPBs were more likely to be problem drinkers (OR = 9.6), smokers (OR = 15.8), obese (OR = 6.3), and unmarried (OR = 67.1).Conclusions: 1) Injury-prone behaviors are common among patients attending a university-based internal medicine clinic; 2) men and women have substantially different patterns of risk factor associations; 3) CDSRFs, such as problem drinking smoking, and being unmarried, are associated with many IPBs; 4) safety belt non-use is the IPB associated with the most CDSRFs; and 5) CDSRFs appear to cluster in men with multiple IPBs, suggesting that screening for high-risk individuals may be feasible in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction.Design: Observational study with 11-month follow-up.Setting: Outpatient hypertension clinic at the Seattle Veterans Administration Hospital.Patients: 59 males (51% of those eligible) with diastolic BP less than 95 mm Hg for greater than or equal to 6 months; 57 patients (97%) completed the study.Intervention: Gradual reduction of medications unless diastolic BP rose above 95 mm Hg.Measurements and Main Results: Intensity of treatment with BP medications was assessed using a scale of their comparative "vigors." 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2 +/- 12.3 mm Hg (mean +/- SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7 +/- 1.7 vs. 1.3 +/- 0.5 "vigor units," p = 0.0001), and they had been enrolled in the clinic longer (5.5 +/- 3.0 vs. 3.1 +/- 2.3 years, p = 0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age less than or equal to 65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more "vigor units" had the highest specificity (79%) and likelihood ratio (3.3).Conclusions: Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully. [ABSTRACT FROM AUTHOR]

Focuses on health related issues. Symptoms of hypothyroidism; Use of lumbar spine imaging test for medical procedures of physicians; Prevalence of thyroid deficiency in women.