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Background: Prior to the COVID‐19 pandemic there were many barriers to telemedicine primary care for adults ≥65 years including insurance coverage restrictions and having lower digital access and literacy. With the pandemic, insurance coverage broadened and many older adults utilized telemedicine creating an opportunity to learn from their experiences to inform future policy. Methods: Between April 2020 and June 2021, we conducted a cross‐sectional multimethod study of English‐speaking, cognitively‐intact, adults ≥65, who had a phone‐only and/or video telemedicine visit with their primary care physician within one large Massachusetts health system (10 different practices) since March 2020. The study questionnaire asked participants their overall satisfaction with telemedicine (7‐point scale) and to compare telemedicine with in‐person care. We used linear regression to examine the association between participants' demographics, Charlson comorbidity score, and survey completion date with their satisfaction score. The questionnaire also included open‐ended questions on perceptions of telemedicine; which were analyzed using qualitative methods. Results: Of 278 eligible patients reached, 208 completed the questionnaire; mean age was 74.4 years (±4.4), 61.5% were female, 91.4% were non‐Hispanic White, 64.4% had ≥1 comorbidity, and 47.2% had a phone‐only visit. Regardless of their age, participants reported being satisfied with telemedicine; median score was 6.0 on the 7‐point scale (25th percentile = 5.0 and 75th percentile = 7.0). Non‐Whites satisfaction scores were on average 1 point lower than those of non‐Hispanic Whites (p = 0.02). Those with comorbidity reported scores that on average were 0.5 points lower than those without comorbidity (p = 0.07). Overall, 39.5% felt their telemedicine visit was worse than in‐person care; 4.9% thought it was better. Participants appreciated telemedicine's convenience but described frustrating technical challenges. While participants preferred in‐person care, most wanted telemedicine to remain available. Conclusions: Adults ≥65 reported being satisfied with primary care telemedicine during the pandemic's first 14 months and wanted telemedicine to remain available. See related Editorial by Biese et al. in this issue. [ABSTRACT FROM AUTHOR]

The article discusses a survey focusing on the perspectives of primary care physicians (PCPs) who provided telemedicine to older adults since March 2020. Results from the email survey, sent out to PCPs from September 2020 to January 2021, are presented and discussed. Self-efficacy and attitudes towards the use of telemedicine are also mentioned.

Introduction: Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk.Study Design: Pretest-Posttest trial.Setting/participants: Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019.Intervention: Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest.Main Outcome Measures: Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020.Results: Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician).Conclusions: Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians.Trial Registration: This study is registered at www.clinicaltrials.govNCT03180086. [ABSTRACT FROM AUTHOR]

Background: The diagnostic framework and clinical reasoning process of Chinese medicine are central to the practice of acupuncture and other related disciplines. There is growing interest in integrating it into clinical trials of acupuncture and Chinese herbal medicine to guide individualized treatment protocols and evaluate outcomes. Strategies that enhance diagnostic reliability may contribute to this integration. Objectives: (1) To evaluate inter-rater reliability among practitioners of Traditional Chinese Medicine (TCM) when assessing women with dysmenorrhea using a structured assessment questionnaire (Traditional East Asian Medicine Structure Interview [TEAMSI]-TCM) compared to using a TCM questionnaire from routine clinical practice, not developed for research purposes (CONTROL); and (2) To evaluate the impact of training in the use of each approach on reliability. Design: Thirty-eight acupuncturists were asked to complete assessments of 10 subjects based on the viewing of a videotape of the initial assessment interview, a picture of the tongue, and a description of the pulse. Acupuncturists were randomized into one of four groups comparing the use of two questionnaires, TEAMSI-TCM versus CONTROL, and comparing training in the use of each versus no training. Analysis: The authors used Cohen's kappa to estimate agreement on TCM diagnostic categories relevant to dysmenorrhea between 2 practitioners with respect to questionnaires and training over all 10 patients and all 10 TCM diagnostic categories. For all analyses, the authors estimated kappa values for questionnaire, training, and experience level. Analysis of variance was used to test agreement among various groupings. Results: Regardless of the questionnaire used or training, analysis of inter-rater reliability indicated overall agreement to be low among practitioners (median 0.26). Kappa varied slightly by questionnaire and training, among 38 practitioners, but the difference was not statistically significant (p = 0.227 and p = 0.126, respectively). Conclusions: A structured assessment interview instrument designed for research purposes with or without training did not significantly improve reliability of TCM diagnosis of dysmenorrhea compared to a commonly used instrument. Challenges in assessing reliability in TCM remain. [ABSTRACT FROM AUTHOR]

Background. Standardized tests and outcome measures (STOM) have not been consistently implemented as part of most physical therapists' practice. Incidence of STOM use among physical therapists at Beth Israel Deaconess Medical Center was similar to low levels cited nationally among acute care physical therapists. Targeted knowledge translation (KT) strategies have been suggested to promote the application of research evidence into clinical decision making. Purpose. The purpose of this quality improvement (QI) effort was to implement a series of interventions aimed at increasing both use and interpretation of STOM by physical therapists practicing in acute care. Design. This study used an observational longitudinal design. Methods. A literature review identified current barriers and facilitators to the use of STOM by physical therapists. KT strategies were tailored to the practice setting in order to target barriers and promote facilitators to the use of STOM. Data were collected through retrospective chart review at baseline and then subsequently at 4 periods following the implementation of the QI project. Results. A statistically significant increase in both the use (primary outcome) and interpretation (secondary outcome) of STOM was observed following the implementation of KT strategies. The increase was sustained at all subsequent measurement periods. Limitations. Limitations include the lack of a control group and the small number of setting- and diagnosis-specific STOM available for use by physical therapists practicing in acute care. Conclusions. Implementation of KT strategies was associated with an increase in the frequency of use and interpretation of STOM. Similar QI efforts are feasible in any acute care physical therapy department and potentially other settings. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about Traditional Vietnamese Medicine (TVM) and its use among Vietnamese immigrants in the United States. This study aimed to characterize TVM and improve understanding of its use among Vietnamese outpatients attending an urban clinic. Methods: This cross-sectional observation study was performed by mailing bilingual surveys to a stratified random sample of 400 Vietnamese adult patients (≥18 years of age) who had visited a community health center in Boston, Massachusetts, at least once in the prior 12 months. The data were analyzed by using descriptive and multivariable regression statistics. The use of TVM and the factors influencing their use were reported. Results: Among the 216 respondents, 68% reported using TVM. Of those users, the median age was 56 years and 68% were female, 51% had lived in the United States for less than 13 years, and 91% spoke English 'not well or not at all.' Among the 89% who reported using TVM of indigenous origin, 62% used 'wind scraping,' 35% used herbal pills/products, and 30% used 'wind snatching.' Sixty-one percent used therapies of foreign origin; of those, 51% used Asian-originated TVM (herbs, 25%; Eastern massage, 23%) and 38% used Western-influenced TVM (diet supplements, 28%; Western massage, 8%). TVM was mostly used for pain conditions (57%), 'staying well' (38%), and cough/colds (27%). Forty-five percent ignored the question on revealing TVM use to providers; of those who answered, 57% said 'no.' Fifty-one percent of TVM users reported using Western medicine for the same problem, while 46% used TVM and Western medicine within 2 days of each other. Self-rated health (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.34-5.06), household size (OR, 2.09; 95% CI, 1.04-4.22), and education (OR, 2.65; 95% CI, 1.03-6.80) were associated with TVM use. Conclusion: TVM is an important component of the healthcare of urban Vietnamese and needs to be further investigated. Healthcare providers need to encourage open discussion to better care for this population. [ABSTRACT FROM AUTHOR]

Structural Integration (SI) is an alternative method of manipulation and movement education. To obtain preliminary data on feasibility, effectiveness, and adverse events (AE), 46 outpatients from Boston area with chronic nonspecific low back pain (CNSLBP) were randomized to parallel treatment groups of SI plus outpatient rehabilitation (OR) versus OR alone. Feasibility data were acceptable except for low compliance with OR and lengthy recruitment time. Intent-to-treat data on effectiveness were analyzed by Wilcoxon rank sum, n=23 per group. Median reductions in VAS Pain, the primary outcome, of -26 mm in SI + OR versus 0 in OR alone were not significantly different (P=0.075). Median reductions in RMDQ, the secondary outcome, of -2 points in SI + OR versus 0 in OR alone were significantly different (P=0.007). Neither the proportions of participants with nor the seriousness of AE were significantly different. SI as an adjunct to OR for CNSLBP is not likely to provide additional reductions in pain but is likely to augment short term improvements in disability with a low additional burden of AE. A more definitive trial is feasible, but OR compliance and recruitment might be challenging. This trial is registered with ClinicalTrials.gov (NCT01322399). [ABSTRACT FROM AUTHOR]

Objectives To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications. Design Pre-post interventional trial. Setting Large academic medical center. Participants Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls. Intervention The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults. Measurements Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous ( IV) morphine in excess of 2 mg, and discharge disposition. Results Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio ( OR) for the difference of differences = 1.23 (95% confidence interval ( CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol ( OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine ( OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities ( OR = 1.18, 95% CI = 1.04-1.35, P = .01). Conclusion An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care. [ABSTRACT FROM AUTHOR]

Objectives: The study objectives were to determine the feasibility and effects of providing therapeutic massage at home for patients with metastatic cancer. Design: This was a randomized controlled trial. Settings/location: Patients were enrolled at Oncology Clinics at a large urban academic medical center; massage therapy was provided in patients' homes. Subjects: Subjects were patients with metastatic cancer. Interventions: There were three interventions: massage therapy, no-touch intervention, and usual care. Outcome measures: Primary outcomes were pain, anxiety, and alertness; secondary outcomes were quality of life and sleep. Results: In this study, it was possible to provide interventions for all patients at home by professional massage therapists. The mean number of massage therapy sessions per patient was 2.8. A significant improvement was found in the quality of life of the patients who received massage therapy after 1-week follow-up, which was not observed in either the No Touch control or the Usual Care control groups, but the difference was not sustained at 1 month. There were trends toward improvement in pain and sleep of the patients after therapeutic massage but not in patients in the control groups. There were no serious adverse events related to the interventions. Conclusions: The study results showed that it is feasible to provide therapeutic massage at home for patients with advanced cancer, and to randomize patients to a no-touch intervention. Providing therapeutic massage improves the quality of life at the end of life for patients and may be associated with further beneficial effects, such as improvement in pain and sleep quality. Larger randomized controlled trials are needed to substantiate these findings. [ABSTRACT FROM AUTHOR]

Background: Extreme temperatures have been associated with hospitalization and death among individuals with heart failure, but few studies have explored the underlying mechanisms. Objectives: We hypothesized that outdoor temperature in the Boston, Massachusetts, area (1- to 4-day moving averages) would be associated with higher levels of biomarkers of inflammation and myocyte injury in a repeated-measures study of individuals with stable heart failure. Methods: We analyzed data from a completed clinical trial that randomized 100 patients to 12 weeks of tai chi classes or to time-matched education control. B-type natriuretic peptide (BNP), C-reactive protein (CRP), and tumor necrosis factor (TNF) were measured at baseline, 6 weeks, and 12 weeks. Endothelin-1 was measured at baseline and 12 weeks. We used fixed effects models to evaluate associations with measures of temperature that were adjusted for time-varying covariates. Results: Higher apparent temperature was associated with higher levels of BNP beginning with 2-day moving averages and reached statistical significance for 3-and 4-day moving averages. CRP results followed a similar pattern but were delayed by 1 day. A 5°C change in 3-and 4-day moving averages of apparent temperature was associated with 11.3% [95% confidence interval (CI): 1.1, 22.5; p = 0.03) and 11.4% (95% CI: 1.2, 22.5; p = 0.03) higher BNP. A 5°C change in the 4-day moving average of apparent temperature was associated with 21.6% (95% CI: 2.5, 44.2; p = 0.03) higher CRP. No clear associations with TNF or endothelin-1 were observed. Conclusions: Among patients undergoing treatment for heart failure, we observed positive associations between temperature and both BNP and CRP-predictors of heart failure prognosis and severity. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the feasibility of a randomized controlled trial of the effect of a tai chi program on quality of life and exercise capacity in patients with COPD. METHODS: We randomized 10 patients with moderate to severe COPD to 12 weeks of tai chi plus usual care (n = 5) or usual care alone (n = 5). The tai chi training consisted of a 1-hour class, twice weekly, that emphasized gentle movement, relaxation, meditation, and breathing techniques. Exploratory outcomes included disease-specific symptoms and quality-of-life, exercise capacity, pulmonary function tests, mood, and self-efficacy. We also conducted qualitative interviews to capture patient narratives regarding their experience with tai chi. RESULTS: The patients were willing to be randomized. Among 4 of the 5 patients in the intervention group, adherence to the study protocol was excellent. The cohort's baseline mean ± SD age, percent-of-predicted FEV1, and ratio of FEV1 to forced vital capacity were 66 ± 6 y, 50 ± 12%, and 0.63 ± 0.14, respectively. At 12 weeks there was significant improvement in Chronic Respiratory Questionnaire score among the tai chi participants (1.4 ± 1.1), compared to the usual-care group (−0.1 ± 0.4) (P = .03). There were nonsignificant trends toward improvement in 6-min walk distance (55 ± 47 vs -13 ± 64 m, P = .09), Center for Epidemiologic Studies Depression Scale (−9.0 ± 9.1 vs −2.8 ± 4.3, P = .20), and University of California, San Diego Shortness of Breath score (−7.8 ± 3.5 vs −1.2 ± 11, P = .40). There were no significant changes in either group's peak oxygen uptake. CONCLUSIONS: A randomized controlled trial of tai chi is feasible in patients with moderate to severe COPD. Tai chi exercise as an adjunct to standard care warrants further investigation. (ClinicalTrials.gov registration NCT01007903) [ABSTRACT FROM AUTHOR]

The article presents the study on the impact of medication safety alerts particularly the electronic drug alerts on patient safety, health care utilization, and cost in ambulatory care. The study employs 279 476 e-prescriptions written by 2321 Massachusetts clinicians who used the PocketScript e-prescribing system from January 1 through June 30, 2006. It mentions that electronics prescribing alerts in ambulatory care have the potential to prevent harm and reduce health care costs.

The article presents a study which examines the overrides of medication safety alerts in ambulatory care. The study conducted a retrospective analysis of medication safety alerts that are generated by clinicians who used a common electronic prescribing system in Massachusetts, New Jersey and Pennsylvania. Multivariate techniques were also used to analyze the factors associated with the acceptance of medication alerts. Results of the study show that clinicians override most of these alerts because they may be inadequate to protect patient safety.

Purpose: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.Subjects: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital.Methods: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about "problems,""mistakes," and "injuries" that occurred. Physician investigators classified patients' reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events.Results: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4).Conclusion: Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety. [ABSTRACT FROM AUTHOR]

Context: Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality.Objective: To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills.Design: Qualitative study using focus groups and content analysis to determine domains of quality of care.Setting: Four community health centers in Massachusetts.Participants: A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide.Main Outcome Measures: Domains of quality of care mentioned by patients in verbatim transcripts.Results: In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services.Conclusions: Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services. [ABSTRACT FROM AUTHOR]

We surveyed 241 board-certified internists affiliated with a large teaching hospital (Boston, Mass) before implementing a hospitalist service to determine attitudes towards providing inpatient care and the hospitalist model. Of physicians surveyed, 66% responded. Most disagreed that inpatient care is "an inefficient use of my time," only 10% felt a hospitalist service would improve patient satisfaction, and 54% felt it would hurt patient-doctor relationships. Multivariable analyses suggest that physicians physically furthest from their inpatient site were had more favorable attitudes toward the hospitalist model; more experienced and busier physicians were more negative. Future investigations should determine strategies for implementing the hospitalist model which address physicians' concerns. [ABSTRACT FROM AUTHOR]

Investigates the effect of lack in patient-physician communication in the quality of discharge planning in Beth Israel Hospital, Boston, Massachusetts. Specific inclusion criteria for patients; Patient and physician interviews; Discussion of post-discharge plans; Overestimation of patients' understanding of post-discharge plans.

Timely use of necessary follow-up services is an im portant dimension of ambulatory care quality. Using a hospital-based walk-in center, this study identified pa tients who were referred for follow-up care and exam ined factors related to compliance with these referrals. The participants were 696 adults seen in a hospital- based walk-in unit between June 1, 1992, and December 1, 1992. Patients completed a self-administered ques tionnaire including questions about sociodemographic characteristics, prior use of health services, and the Medical Outcomes Study (MOS) 36-Item Health Survey. Medical findings, follow-up recommendations, insur ance status, and compliance with follow-up referrals were ascertained using chart review, the hospital's com puting system, and clinic records. Fifty percent of the patients were referred for follow-up medical care; 55% of these complied with follow-up referrals. Factors asso ciated with referral for follow-up care included older age, inability to afford a physician, longer duration of chief complaint, the patient's belief that follow-up care would be needed, and worse MOS pain score. The most important factor associated with compliance with fol low-up referral was scheduling appointments while pa tients were still in the walk-in unit. Patients with such scheduled appointments were almost 10 times more likely than others to receive follow-up (adjusted odds ratio = 9.6, 95% confidence interval = 4.4-21.2). The most important step a provider can take to improve compliance with follow-up referral is to schedule ap pointments before patients are sent home. This should presumably improve quality of ambulatory care. [ABSTRACT FROM PUBLISHER]

An abstract of the study "Use of Meditation and Breathing Exercises in Mind-Body Exercise in the U.S.," by Sara A. Chacko, Christina C. Wee, Roger B. Davis and Gloria Y. Yeh is presented.

Few complementary and alternative medicine (CAM) institutions require their students to undergo substantive training in research literacy and conduct, and well-developed programs to train CAM institution faculty in research are virtually non-existent. As part of a National Center for Complementary and Alternative Medicine (NCCAM) initiative to increase research capacity at CAM institutions, the New England School of Acupuncture (NESA), in collaboration with the Harvard Medical School (HMS) Osher Institute, was awarded a Developmental Center for Research on Complementary and Alternative Medicine (DCRC) grant. This article discusses a number of initiatives that we designed and implemented to train NESA students, faculty members, and alumni ha the foundations of clinical research and to stimulate interest in both participating in research and receiving additional research training. Specific initiatives included a 30-hour faculty "Foundations of Research" course; a year-long course entitled, "How to Write a Publishable Case Report"; institution of a monthly research seminar series; revision of an already required student research course; and the addition of 2 new student-mentored independent research electives. We discuss successes and challenges encountered in developing and administering these initiatives and the overall impact they have had on research culture and productivity at NESA. [ABSTRACT FROM AUTHOR]

Purpose: The prevalence and severity of pain have not been well described among oncology patients in ambulatory care. To better understand the burden of pain among patients with advanced cancer, we examined the prevalence of pain reported during office and treatment visits. Methods: A retrospective study of 4,014 patients with advanced disease (stage 4 at diagnosis or metastatic progression) who completed an ambulatory visit between 2004 and 2006 was conducted at a comprehensive cancer center in Boston, Massachusetts. Results: At their first visit during the study period, 74% of patients reported no pain (0 score); 12%, low pain (1 to 3 score); 9%, moderate pain (4 to 6 score); and 5%, severe pain (7 to 10 score). The prevalence of pain was highest among patients who were younger than 60 years of age, were nonwhite, did not speak English as their primary language, or were covered by Medicaid, received free care, or paid their own health care costs. Patients with thoracic, breast, and head and neck cancers had higher pain scores than those with other diseases. Pain was reported more frequently among patients whose diagnosis or metastatic progression occurred less than 3 months before the reported pain score. In multivariable regression analysis, age, race, cancer type, and time since diagnosis/progression were identified as important factors associated with severe pain. Conclusion: Younger age, minority race, and recent onset of advanced disease are associated with severe pain among patients with cancer. Recognizing these high-risk groups could inform targeted interventions to address pain care in ambulatory patients with advanced cancer. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Resident physicians learn to perform inpatient bedside procedures in a manner that is neither standardized nor rigorous. As a result, residents may be unskilled and uncomfortable performing procedures. This study characterizes residents’ comfort performing medical procedures and identifies factors associated with lack of comfort. Subjects: Study subjects were internal medicine resident physicians who performed one of four medical procedures (central line, lumbar puncture, paracentesis, or thoracentesis) on adult medical inpatients between July 1, 2003, and June 30, 2004. Methods: This prospective cohort study was conducted at a 556-bed Boston teaching hospital. Resident physicians evaluated their comfort with 9 aspects of 4 medical procedures, recording this information in an electronic log. We also abstracted operator characteristics and patient demographic data. We analyzed residents’ comfort with each aspect of the procedure and defined “overall comfort” as comfort with each of the 9 aspects. Results: A majority of resident physicians reported lack of comfort with at least one aspect of the procedure. Residents reported lack of comfort with 37% of unsupervised procedures. They also reported lack of comfort with the prospect of managing complications in 35% of procedures. In the multivariable analysis, overall comfort was associated with the use of a dedicated medical procedure service (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4) and inversely associated with postgraduate year 1 status (OR 0.3, CI 0.1-0.5), first time performing the procedure (OR 0.4, CI 0.2-0.8), thoracenteses (OR 0.4, CI 0.2-0.8), and emergent procedures (OR 0.6, CI 0.3-1.0). Conclusions: Many resident physicians are uncomfortable performing common bedside procedures. Experience and supervision mitigate some, but not all, discomfort. [Copyright &y& Elsevier]

Background: Bariatric or weight loss surgery (WLS) may alter alcohol metabolism resulting in a higher prevalence of problem drinking postoperatively. Few studies distinguish those who report improvements in drinking from those who report worsening behavior after surgery. The objective of this study was to characterize high-risk alcohol use before and after WLS and according to surgery type., Methods: We interviewed patients before and annually after WLS. High-risk alcohol use as assessed via a modified version of the Alcohol Use Disorders Identification Test-Consumption., Results: Of 541 participants who underwent WLS, 375 (69% retention) completed the 1-year interview and 328 (63% retention) completed the 2-year interview. At 1 year, 13% reported high-risk drinking compared to 17% at baseline, P = .10; at year 2, 13% reported high-risk drinking compared to 15% at baseline, P = .39; 7% and 6% of patients, respectively, reported new high-risk drinking at 1- and 2-year follow-up. At both follow-up time points, more than half of those who reported high-risk drinking at baseline no longer did so. A larger proportion of gastric bypass patients (71%) reported amelioration in high-risk drinking than gastric banding (48%) at year 1, but this difference did not reach statistical significance (P = .07); the difference largely dissipated by year 2 (50% versus 57%) ., Conclusion: Although 7% of patients report new high-risk alcohol use 1 year after WLS, more than half who reported high-risk alcohol use before surgery discontinued high-risk drinking., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery is one of few obesity treatments to produce substantial weight loss but only a small proportion of medically-eligible patients, especially men and racial minorities, undergo bariatric surgery., Objective: To describe primary care patients' consideration of bariatric surgery, potential variation by sex and race, and factors that underlie any variation., Design, Setting, and Patients: Telephone interview of 337 patients with a body mass index or BMI > 35 kg/m(2) seen at four diverse primary care practices in Greater-Boston., Measurements: Patients' consideration of bariatric surgery., Results: Of 325 patients who had heard of bariatric surgery, 34 % had seriously considered surgery. Men were less likely than women and African Americans were less likely than Caucasian patients to have considered surgery after adjustment for sociodemographics and BMI. Comorbid conditions did not explain sex and racial differences but racial differences dissipated after adjustment for quality of life (QOL), which tended to be higher among African American than Caucasian patients. Physician recommendation of bariatric surgery was independently associated with serious consideration for surgery [OR 4.95 (95 % CI 2.81-8.70)], but did not explain variation in consideration of surgery across sex and race. However, if recommended by their doctor, men were as willing and African American and Hispanic patients were more willing to consider bariatric surgery than their respective counterparts after adjustment. Nevertheless, only 20 % of patients reported being recommended bariatric surgery by their doctor and African Americans and men were less likely to receive this recommendation; racial differences in being recommended surgery were also largely explained by differences in QOL. High perceived risk to bariatric surgery was the most commonly cited barrier; financial concerns were uncommonly cited., Limitations: Single geographic region; examined consideration and not who eventually proceeded with bariatric surgery., Conclusion: African Americans and men were less likely to have considered bariatric surgery and were less likely to have been recommended surgery by their doctors. Differences in how obesity affects QOL appear to account for some of these variations. High perceived risk rather than financial barrier was the major deterrent for patients.

The authors developed a computer-based general medical history to be taken by patients in their homes over the internet before their first visit with their primary care doctor, and asked six doctors and their participating patients to assess this history and its effect on their subsequent visit. Forty patients began the history; 32 completed the history and post-history assessment questionnaire and were for the most part positive in their assessment; and 23 continued on to complete their post-visit assessment questionnaire and were for the most part positive about the helpfulness of the history and its summary at the time of their visit with the doctor. The doctors in turn strongly favored the immediate, routine use of two modules of the history--the family and social histories--for all their new patients. The doctors suggested further that the summaries of the other modules of the history be revised and shortened to make it easier for them to focus on clinical issues in the order of their preference.

Background: Several studies suggest yoga may be effective for chronic low back pain; however, trials targeting minorities have not been conducted. PRIMARY STUDY OBJECTIVES: Assess the feasibility of studying yoga in a predominantly minority population with chronic low back pain. Collect preliminary data to plan a larger powered study., Study Design: Pilot randomized controlled trial., Setting: Two community health centers in a racially diverse neighborhood of Boston, Massachusetts., Participants: Thirty English-speaking adults (mean age 44 years, 83% female, 83% racial/ethnic minorities; 48% with incomes < or = $30,000) with moderate-to-severe chronic low back pain., Interventions: Standardized series of weekly hatha yoga classes for 12 weeks compared to a waitlist usual care control., Outcome Measures: Feasibility measured by time to complete enrollment, proportion of racial/ethnic minorities enrolled, retention rates, and adverse events. Primary efficacy outcomes were changes from baseline to 12 weeks in pain score (0=no pain to 10=worst possible pain) and back-related function using the modified Roland-Morris Disability Questionnaire (0-23 point scale, higher scores reflect poorer function). Secondary efficacy outcomes were analgesic use, global improvement, and quality of life (SF-36)., Results: Recruitment took 2 months. Retention rates were 97% at 12 weeks and 77% at 26 weeks. Mean pain scores for yoga decreased from baseline to 12 weeks (6.7 to 4.4) compared to usual care, which decreased from 7.5 to 7.1 (P=.02). Mean Roland scores for yoga decreased from 14.5 to 8.2 compared to usual care, which decreased from 16.1 to 12.5 (P=.28). At 12 weeks, yoga compared to usual care participants reported less analgesic use (13% vs 73%, P=.003), less opiate use (0% vs 33%, P=.04), and greater overall improvement (73% vs 27%, P=.03). There were no differences in SF-36 scores and no serious adverse events., Conclusion: A yoga study intervention in a predominantly minority population with chronic low back pain was moderately feasible and may be more effective than usual care for reducing pain and pain medication use.

Background: While electronic prescribing (e-prescribing) systems with drug interaction and allergy alerts promise to improve medication safety in ambulatory care, clinicians often override these safety features. We undertook a study of respondents' satisfaction with e-prescribing systems, their perceptions of alerts, and their perceptions of behavior changes resulting from alerts., Methods: Random sample survey of 300 Massachusetts ambulatory care clinicians who used a commercial e-prescribing system., Results: A total of 184 respondents completed the survey (61%). Respondents indicated that e-prescribing improved the quality of care delivered (78%), prevented medical errors (83%), and enhanced patient satisfaction (71%) and clinician efficiency (75%). In addition, 35% of prescribers said that electronic alerts caused them to modify a potentially dangerous prescription in the last 30 days. They suggested that alerts also led to other changes in clinical care: counseling patients about potential reactions (49% of respondents), looking up information in medical references (44%), and changing the way a patient was monitored (33%). Altogether, 63% of clinicians reported taking action other than discontinuing or modifying an alerted prescription in the previous month in response to alerts. Despite these benefits, fewer than half of respondents were satisfied with drug interaction and allergy alerts (47%). Problems included alerts triggered by discontinued medications (58%), alerts that failed to account for appropriate drug combinations (46%), and excessive volume of alerts (37%)., Conclusion: Although clinicians were critical of the quality of e-prescribing alerts, alerts may lead to clinically significant modifications in patient management not readily apparent based on "acceptance" rates.

A significant practical, yet perhaps under-appreciated, barrier to a more active role of complementary and alternative medicine (CAM) institutions in research is the organizational infrastructure required for submitting and managing research grants. In this article, we discuss how the New England School of Acupuncture, in collaboration with the Harvard Medical School Osher Institute and with the support of a Developmental Center for Research on Complementary and Alternative Medicine grant awarded by the National Center for Complementary and Alternative Medicine of the National Institutes of Health, developed its grants management infrastructure and increased its research capacity. We highlight initiatives that have been successful, challenges we have encountered, and lessons we learned that may be relevant to other CAM institutions that may wish to develop a research program.

Background: A culture of safety survey was used to study features of the safety culture and their relationship with patient safety indicators., Study Design: Anonymous written surveys were collected from 455 of 1,027 (44%) workers at four Massachusetts hospitals. Respondents characterized their organizations' patient safety, workplace safety, and features of a safety culture, such as leadership commitment, professional salience, presence of a nonpunitive environment, error reporting, and communication., Results: Employees universally regarded patient safety as an essential part of their job. Two-thirds of workers worried at least once a day about making a mistake that could injure a patient; 43% said that the work load hindered their ability to keep patients safe. Workers' overall assessment of patient safety was associated with their perceptions of workplace safety (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.02-3.43, p = .044) and leadership commitment to patient safety (OR 3.20, 95% CI 1.97-5.19, p < .001). Incident reporting rates correlated with survey results, while adoption of best practices and expert opinion did not., Discussion: Patient safety is salient to workers, who universally embraced patient safety as an essential part of their job. Independent indicators of patient safety did not line up neatly with safety culture survey results. Incident reporting rates correlated directly, while adoption of best practices and expert opinion varied inversely with survey results. The safety culture is a complex phenomenon that requires further study.