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Objective: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use.Design: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996.Measurements: Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART.Results: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08).Conclusions: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the educational strategies and experiences of residency programs regarding the training of primary care providers in the care of patients who have AIDS.Design: Cross-sectional, self-administered questionnaire survey.Setting: Survey conducted November 1988-April 1989.Participants: All 771 non-military U.S. internal medicine and family medicine program directors were surveyed; 80% responded.Interventions: None.Measurements and Main Results: While 91% of the directors felt that primary care of AIDS patients was an important educational experience and 94% reported that their programs usually had AIDS inpatients, only 16% reported that the majority of trainees cared for AIDS patients in their continuity clinics. Even at programs that typically had six or more AIDS inpatients, only 26% of directors reported that most residents had cared for an AIDS patient in their continuity clinics. Among the 57% who did not believe or were unsure whether their residents were adequately trained in AIDS ambulatory care, only 38% reported improving resident education in this area to be a high priority. Among the 39% who did not encourage residents' assumption of primary care, 60% had at least one of the following concerns: AIDS care too stressful for residents (24%), AIDS care too complicated for generalists (31%), or clinic faculty not qualified to supervise residents' caring for AIDS patients (39%).Conclusion: Although program directors view education in AIDS ambulatory care as important, most do not believe that residents are adequately trained, many do not encourage residents' assumption of primary care of AIDS patients, and residents usually have not provided such care in their programs. Strategies to augment residents' ambulatory experience in AIDS care are needed. [ABSTRACT FROM AUTHOR]

Funding for medical care research in the interrelated fields of health services research, clinical decision-making, clinical epidemiology, the medical humanities and social sciences, and medical education has been unstable, and relatively little is available in the form of investigator-initiated grants. Stable funding for these fields is important to society and critical to the healthy development of academic general internal medicine. Strategies to augment funding can include political interventions to increase support for the National Center for Health Services Research and Health Care Technology Assessment and to secure designated funds within the National Institutes of Health. Public funding is also needed for career development awards in these fields. Research support also could be enhanced by establishing a consortium of foundations interested in funding investigator-initiated grants through open competition, by developing a mechanism for reviewing proposals from small foundations, by developing consortia in the private sector to support focused research, and by developing endowments to support research. [ABSTRACT FROM AUTHOR]

Objective: To assess both the accuracy of scientific data presented in print pharmaceutical advertisements and the compliance of these advertisements with current Food and Drug Administration (FDA) standards.Design: Cross-sectional survey.Measurements: Each full-page pharmaceutical advertisement (n = 109) appearing in 10 leading medical journals, along with all available references cited in the advertisement (82% of the references cited were available) were sent to three reviewers: two physicians in the relevant clinical area who were experienced in peer review and one academic clinical pharmacist. Reviewers, 95% of whom responded, were asked to evaluate the advertisements using criteria based on FDA guidelines, to judge the educational value and overall quality of the advertisements, and to make a recommendation regarding publication.Results: In 30% of cases, two or more reviewers disagreed with the advertisers' claim that the drug was the "drug of choice." Reviewers felt that information on efficacy was balanced with that on side effects and contraindications in 49% of advertisements but was not balanced in 40%. Reviewers agreed with advertisements' claims that the drug was safe in 86% of the cases but judged that headlines in 32% of the advertisements containing headlines misled the reader about efficacy. In 44% of cases, reviewers felt that the advertisement would lead to improper prescribing if a physician had no other information about the drug other than that contained in the advertisement. Fifty-seven percent of advertisements were judged by two or more reviewers to have little or no educational value. Overall, reviewers would not have recommended publication of 28% of the advertisements and would have required major revisions in 34% before publication.Conclusion: In the opinion of the reviewers, many advertisements contained deficiencies in areas in which the FDA has established explicit standards of quality. New strategies are needed to ensure that advertisements comply with standards intended to promote proper use of the products and to protect the consumer. [ABSTRACT FROM AUTHOR]

Objective: To evaluate U.S. and Canadian resident physicians' views about their health care systems.Design: Self-administered questionnaire survey in 1989.Participants: Senior family medicine and internal medicine residents in Canada and in ten geographically representative American states.Main Results: American and Canadian residents had similar levels of professional satisfaction and almost universally agreed on the ethical obligation to provide care to persons of all social circumstances, but U.S. residents were more likely to perceive a serious access problem in their country (75% compared with 18%) and to think that current controls on the medical profession interfere with patient care (81% compared with 58%; P less than 0.001). In addition, U.S. residents were more likely than Canadian residents to believe that primary care salaries were too low (78% compared with 38%) and that salaries of medical subspecialists (57% compared with 17%) and surgeons (85% compared with 28%) were too high. In general, residents preferred their own country's predominant health care system. Whereas 87% of U.S. physicians supported private fee-for-service health care, 85% of Canadian physicians supported government-funded national health insurance. Nonetheless, 42% of U.S. physicians supported and only 17% strongly opposed national health insurance as an alternative approach. About two thirds of respondents from both countries opposed a salaried national health service.Conclusions: American residents perceived greater problems with access, overall intrusions into medical practice, and fee disparities than did their Canadian counterparts. They preferred private fee-for-service health care, but few strongly opposed government-funded national health insurance as an alternative approach to the health care needs of the United States. [ABSTRACT FROM AUTHOR]

Objective: To examine residents' experiences in the care of patients with the acquired immunodeficiency syndrome (AIDS), and to examine factors that may influence their attitudes about such care.Design: Cross-sectional, self-administered questionnaire survey conducted in 1989.Participants: All senior internal medicine and family medicine residents in ten geographically representative states who were identified through the 1986 National Residency Matching Program.Measurements and Main Results: Seventy-four percent of residents reported that patients with AIDS accounted for 5% or more of general medicine admissions, and 50% of residents reported that they were currently following one or more human immunodeficiency virus (HIV)-infected patients in their continuity clinics. Among residents who had provided ambulatory care to patients with AIDS, 77% felt that it was an excellent educational experience, and among those who planned to do general primary care in their future practices, 74% planned on providing primary care to patients with AIDS. However, 61% expressed concerns about the adequacy of their training in AIDS ambulatory care. A greater amount of contact with outpatients who had AIDS, but not with inpatients who had AIDS, was associated with residents' intending to provide AIDS primary care in their future practices. Among all residents, 23% reported that, if given a choice, they would not provide care to any patients with AIDS, and 23% reported that they would not work in an area with a high prevalence of AIDS because of concern about contracting the syndrome. Nine percent of residents reported that they had been exposed to a blood-contaminated needlestick from an HIV-seropositive patient.Conclusions: Although most residents have substantial contact with inpatients and outpatients with AIDS, most still find their education in AIDS ambulatory care to be deficient. A minority of residents would prefer not to care for patients with AIDS. Residency curricula should include training and experience in ambulatory AIDS care, explicitly address negative attitudes toward caring for patients with AIDS, and include programs to reduce needlestick exposures. [ABSTRACT FROM AUTHOR]