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Background: Transient human immunodeficiency virus (HIV) viremia, a common phenomenon among patients taking antiretroviral therapy, is often attributed to lapses in adherence to the medication regimen. We investigated this relationship in a prospective observational cohort of 128 patients initiating a new regimen., Methods: A case of transient viremia was defined as an HIV RNA level of 40-1000 copies/mL ("blip") sandwiched between 2 months of HIV RNA levels <40 copies/mL ("pre" and "post"). Adherence was most often measured with a composite adherence score (CAS), which is primarily based on electronically measured adherence. Case subjects' adherence and dose-timing was compared with (1) that of other patients (control subjects), who had undetectable virus loads for 3 consecutive months, and (2) that during periods of sustained undetectable virus loads among the case subjects themselves, if available., Results: Among the 28 case subjects, mean CAS-measured adherence did not decrease before transient viremia; adherence during the pre, blip, and post periods were 86%, 84%, and 80%, respectively. Control subjects had lower adherence levels during the corresponding 3 months (77%, 79%, and 75%, respectively; P = .046). Among the 19 patients able to serve as their own controls, CAS-measured adherence was higher during the period of transient viremia than during control periods (P = .01). Similar relationships were found when comparing only electronically measured adherence on a week-wise basis. There were no significant differences in dose-timing error between case subjects and control subjects., Conclusions: We found no evidence that transient HIV viremia is associated with decreases in adherence or differences in dose-timing. Other etiologies for transient viremia should be evaluated.

Background: Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care., Objectives: To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes., Design: Prospective cohort study., Patients and Setting: A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1717 patients eligible for PI treatment and the 367 providers who cared for them., Measurements: Providers' attitude toward prescribing PIs to nonadherent patients, time until patients' first receipt of PIs, mortality, and physical health status., Main Results: Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P =.05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers' prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P =.04), after controlling for baseline physical health status and other patient and provider covariates., Conclusions: Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.

Clinicians in primary care settings are well positioned to participate in the prevention and management of visual disability. They can have a significant impact on their patients' visual health by screening for vision problems, aggressively controlling known risk factors for visual loss, ensuring adherence to ophthalmologic treatment and continuity of eye care, and by timely referral of specific patient populations to qualified eye care professionals (eg, ophthalmologists and optometrists). Using their knowledge about common ophthalmic medications, clinicians can detect adverse effects of these agents, including exacerbations of heart or lung disease. They can ensure that appropriate patients are screened for common serious eye diseases, such as glaucoma, and that patients with disabilities related to vision problems are assessed for treatable conditions, such as cataracts or refractive error. Finally, clinicians can direct patients with low vision from any cause to resources designed to help enhance patient function and emotional support.

The need for cross-cultural training (CCT) increases as physicians encounter more culturally diverse patients. However, most medical schools relegate this topic to non-clinical years, hindering skills development. Some residency programs have successfully addressed this deficit by teaching cross-cultural communication skills in a teaching objective structured clinical examination (tOSCE) context. The authors developed and evaluated a CCT workshop designed to teach cross-cultural communication skills to third-year medical students using a tOSCE approach. A 1 and 1/2-day workshop incorporating didactic, group discussion and tOSCE components taught medical students cross-cultural awareness, interviewing skills, working with an interpreter, attention to complementary treatments, and consideration of culture in treatment and prevention. Six standardized patient cases introduced various clinical scenarios and the practical and ethical aspects of cross-cultural care. Student evaluation of the workshop was positive concerning educational value, skills advancement and pertinence to their clinical activities. Survey of students before and after the workshop demonstrated improvement in students' abilities to assess the culture and health beliefs of patients and negotiate issues regarding treatment. CCT in the context of medical student clinical training can be carried out effectively and efficiently using a dedicated multi-modal workshop including standardized patients.

Background: Many people 65 years of age and older are at risk for functional decline and death. However, the resource-intensive medical care provided to this group has received little evaluation. Previous studies have focused on general medical conditions aimed at prolonging life, not on geriatric issues important for quality of life., Objective: To measure the quality of medical care provided to vulnerable elders by evaluating the process of care using Assessing Care of Vulnerable Elders quality indicators (QIs)., Design: Observational cohort study., Setting: Managed care organizations in the northeastern and southwestern United States., Patients: Vulnerable older patients identified by a brief interview from a random sample of community-dwelling adults 65 years of age or older who were enrolled in 2 managed care organizations and received care between July 1998 and July 1999., Measurements: Percentage of 207 QIs passed, overall and for 22 target conditions; by domain of care (prevention, diagnosis, treatment, and follow-up); and by general medical condition (for example, diabetes and heart failure) or geriatric condition (for example, falls and incontinence)., Results: Patients were eligible for 10 711 QIs, of which 55% were passed. There was no overall difference between managed care organizations. Wide variation in adherence was found among conditions, ranging from 9% for end-of-life care to 82% for stroke care. More treatment QIs were completed (81%) compared with other domains (follow-up, 63%; diagnosis, 46%; and prevention, 43%). Adherence to QIs was lower for geriatric conditions than for general medical conditions (31% vs. 52%; P < 0.001)., Conclusions: Care for vulnerable elders falls short of acceptable levels for a wide variety of conditions. Care for geriatric conditions is much less optimal than care for general medical conditions.

Objectives: To evaluate the applicability of process-of-care quality indicators (QIs) to vulnerable elders and to measure the effect of excluding indicators based on patients' preferences and for advanced dementia and poor prognosis., Design: The Assessing Care of Vulnerable Elders (ACOVE) project employed 203 QIs for care of 22 conditions (including six geriatric syndromes and 11 age-associated diseases) for community-based persons aged 65 and older at increased risk of functional decline or death. Relevant QIs were excluded for persons deciding against hospitalization or surgery. A 12-member clinical committee (CC) of geriatric experts rated whether each QI should be applied in scoring quality of care for persons with advanced dementia (AdvDem) or poor prognosis (PoorProg). Using content analysis, CC ratings were formulated into a model of QI exclusion. Quality scores with and without excluded QIs were compared., Setting: Enrollees in two senior managed care plans, one in the northeast United States and the other in the southwest., Participants: CC members evaluated applicability of QIs. QIs were applied to 372 vulnerable elders in two senior managed care plans., Measurements: Frequency and type of QIs excluded and the effect of excluding QIs on quality of care scores., Results: Of the 203 QIs, a patient's preference against hospitalization or surgery excluded 10 and eight QIs, respectively. The CC voted to exclude 81.5 QIs (40%) for patients with AdvDem and 70 QIs (34%) for patients with PoorProg. Content analysis of the CC votes revealed that QIs aimed at care coordination, safety or prevention of decline, or short-term clinical improvement or prevention with nonburdensome interventions were usually voted for inclusion (90% and 98% included for AdvDem and PoorProg, respectively), but QIs directed at long-term benefit or requiring interventions of moderate to heavy burden were usually excluded (16% and 19% included, respectively). About half of QIs aimed at age-associated diseases were voted for exclusion, whereas fewer than one-quarter of QIs for geriatric syndromes were excluded. Thirty-nine patients (10%) in our field trial held preferences or had clinical conditions that would have excluded 68 QIs. This accounted for 5% of all QIs triggered by these 39 patients and 0.6% of QIs overall. The quality score without exclusion was 0.57 and with exclusion was 0.58 (P =.89)., Conclusion: Caution is required in applying QIs to vulnerable elders. QIs for geriatric syndromes are more likely to be applicable to these individuals than are QIs for age-associated diseases. The objectives of care, intervention burdens, and interval before anticipated benefit affect QI applicability. At least for patients with AdvDem and PoorProg, identification of applicable or inapplicable QIs is feasible. In a community-based sample of vulnerable elders, few QIs are excluded.

During the past quarter century, researchers, providers, insurers, and governmental agencies have devoted considerable effort to improving and standardizing the quality of health care provided to older persons. Because older persons differ from younger persons as a result of their life expectancy, disease prevalence and comorbidity, social resources, goals of treatment, and preferences for care, defining and measuring quality of care has been more difficult for this age group. Nevertheless, several decades of research have led to reliable, although imperfect, methods of measuring quality, including those for geriatric conditions. Using these measurement approaches, a variety of studies using different patient populations and sampling strategies have consistently identified deficiencies in quality of care provided to older persons. Moreover, efforts to improve quality of care for older persons have been difficult to design, implement, and sustain. Some have been successful, including having effects on outcome measures, but have not made the transition from research to clinical settings. Others have used quality improvement methods to improve the care of diseases (e.g., diabetes mellitus, congestive heart failure) that commonly affect older persons. However, the lack of alignment of incentives between providers and insurers for most older persons is a major barrier to this approach. In addition, there is no concerted effort among providers, regulatory agencies, and insurers to move the quality-of-care agenda for most Medicare recipients. Despite substantial progress in defining and measuring high-quality care for older persons, the goal of ensuring that older persons receiving such care remains a distant hope.

Symptom recognition is critical for patient care but has been little studied in older HIV-infected individuals. The authors examined differences in symptom expression between younger (younger than age 50 years) and older (older than age 50 years) HIV-infected individuals. The authors analyzed data from two cross-sectional studies of HIV-infected individuals: 2864 individuals from the HIV Cost and Service Utilization Study (HCSUS) and 881 individuals from the Veterans Aging Cohort 3 Site Study (VACS 3). The authors compared the prevalence of eight symptoms common to both studies and 10 symptoms examined only in the VACS 3 population, stratified by age and race. Disease severity was assessed by CD4 count and 18 HIV-related diseases reported. Multivariate logistic regression models were used to account for demographics and severity differences. VACS 3 versus HCSUS participants were more likely nonwhite and older. In unadjusted comparisons, older nonwhites were less likely to report experiencing symptoms than younger whites. They reported the fewest total number of symptoms and the fewest individual symptoms common to both studies (headache, fever, nausea/vomiting, and diarrhea) or in the VACS 3 only (dizziness, sleeping difficulty, fatigue, rashes, bloating, and myalgias/arthalgias). Multivariate regression estimates suggest older age predicts a greater likelihood of reporting peripheral neuropathy, weight loss, or hair loss, but a lower likelihood of reporting headaches, depressed mood, white oral patches, or diarrhea. Nonwhites appeared less likely to report symptoms. Age is a determinant of reporting certain symptoms in HIV disease but may be masked or accentuated by other factors such as race.

Background: HIV-infected patients commonly use complementary and alternative medicine (CAM), but it is not known how often CAM is used as a complement or as a substitute for conventional HIV therapy., Objectives: To evaluate the prevalence and factors associated with CAM use with potential for adverse effects and CAM substitution for conventional HIV medication., Design and Participants: Cross-sectional survey of U.S. national probability sample of HIV-infected patients (2,466 adults) in care from December 1996 to July 1997., Main Outcome Variables: Any CAM use, CAM use with potential for adverse effects, and use of CAM as a substitute for conventional HIV therapy. Substitution was defined as replacement of some or all conventional HIV medications with CAM., Results: Fifty-three percent of patients had recently used at least one type of CAM. One quarter of patients used CAM with the potential for adverse effects, and one-third had not discussed such use with their health care provider. Patients with a greater desire for medical information and involvement in medical decision making and with a negative attitude toward antiretrovirals were more likely to use CAM. Three percent of patients substituted CAM for conventional HIV therapy. They were more likely to desire involvement in medical decision-making (odds ratio, 1.8; 95% confidence interval, 1.0-3.2) and to have a negative attitude toward antiretrovirals (odds ratio, 7.8; 95% confidence interval, 3.0-19.0)., Conclusions: Physicians should openly ask HIV-infected patients about CAM use to prevent adverse effects and to identify CAM substitution for conventional HIV therapy.

Background: Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection., Objective: To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART)., Design: Observational cohort study of patients under care for HIV infection and their physicians., Patients and Setting: This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians., Measurements: Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor., Results: Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations., Conclusions: Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.

In a cohort of 128 human immunodeficiency virus-infected patients, we found that patients' knowledge of antiretroviral dosing was suboptimal at regimen initiation but improved with time. Poor medication knowledge 8 weeks after regimen initiation was associated with lower adherence and with a lower level of literacy in a multivariate model (P=.03). Because knowledge deficits are common after antiretroviral regimen initiation, clinicians should assess patients' understanding of medication dosing soon after regimen initiation or change.

Purpose: Didactic teaching conferences are a cornerstone of residents' training in internal medicine, yet these programs have received little formal evaluation. This study determines the factors associated with residents' attendance at didactic teaching conferences and the relationship of attendance to residents' scores on medical certification examinations., Method: The attendance of 81 residents was recorded at 199 conferences at one university hospital's internal medicine residency program during the 1996-97 academic year. Characteristics of the conferences were recorded, including the date, whether lunch was provided, the daily census on the medicine general wards, daily ambient temperature, and conference type. Residents' scores on the United States Medical Licensing Examination (USMLE) Step 2 and American Board of Internal Medicine (ABIM) certification examination were collected., Results: Residents' attendance at conferences was 34% overall or 54% excluding excused absences. Adjusting for the conferences' and residents' characteristics, attendance declined by one third as the year progressed. Providing lunch at noon conferences enhanced residents' attendance (odds ratio [OR] 1.26 overall and OR 1.64 for residents on inpatient rotations). Higher attendance was not associated with improvement in standardized medical knowledge test scores., Conclusions: Absenteeism and waning attendance through the year have important implications for structuring didactic internal medicine teaching. Providing lunch improves attendance, but this incentive should be weighed against the potential burdens of the pharmaceutical industry's funding of these lunches. The lack of relationship between attendance and residents' adjusted board scores calls for a better understanding of the value of this high-intensity medical education intervention.

Objective: Adherence to complex antiretroviral therapy (ART) is critical for HIV treatment but difficult to achieve. The development of interventions to improve adherence requires detailed information regarding barriers to adherence. However, short follow-up and inadequate adherence measures have hampered such determinations. We sought to assess predictors of long-term (up to 1 year) adherence to newly initiated combination ART using an accurate, objective adherence measure., Design: A prospective cohort study of 140 HIV-infected patients at a county hospital HIV clinic during the year following initiation of a new highly active ART regimen., Measures and Main Results: We measured adherence every 4 weeks, computing a composite score from electronic medication bottle caps, pill count and self-report. We evaluated patient demographic, biomedical, and psychosocial characteristics, features of the regimen, and relationship with one's HIV provider as predictors of adherence over 48 weeks. On average, subjects took 71% of prescribed doses with over 95% of patients achieving suboptimal (<95%) adherence. In multivariate analyses, African-American ethnicity, lower income and education, alcohol use, higher dose frequency, and fewer adherence aids (e.g., pillboxes, timers) were independently associated with worse adherence. After adjusting for demographic and clinical factors, those actively using drugs took 59% of doses versus 72% for nonusers, and those drinking alcohol took 66% of doses versus 74% for nondrinkers. Patients with more antiretroviral doses per day adhered less well. Participants using no adherence aids took 68% of doses versus 76% for those in the upper quartile of number of adherence aids used., Conclusions: Nearly all patients' adherence levels were suboptimal, demonstrating the critical need for programs to assist patients with medication taking. Interventions that assess and treat substance abuse and incorporate adherence aids may be particularly helpful and warrant further study.

Purpose: An understanding of the situations in which adherence lapses occur is critical to the design of effective interventions to enhance adherence. We investigated whether a switch in antiretroviral medications affected adherence by examining a prospective observational cohort of 128 patients who began a new antiretroviral regimen., Method: Adherence was measured using electronic devices, pill counts, and self-reports, which were combined into a composite adherence measure and expressed as the proportion of prescribed medication taken., Results: During 1,056 person-months of follow-up, 129 medication regimen changes occurred among 84 patients (66% of participants). Among the 89 analyzable switches (representing 66 patients), the most common reasons for switch included pill to liquid ritonavir (n = 26), gastrointestinal intolerance (n = 11), virologic failure (n = 8), and peripheral neuropathy (n = 7). Overall, mean adherence prior to regimen switch exceeded mean adherence after regimen switch (0.75 vs. 0.70; p =.035). Among subgroups of switches, adherence decreased significantly after switching from pill to liquid ritonavir (0.83 vs. 0.68; p <.001). When this group was excluded, there was no change in adherence after switches (0.72 vs. 0.71; p =.74)., Conclusion: Antiretroviral regimen changes are not associated with adherence improvement and may be associated with declining adherence when a new regimen is unpalatable. Antiretroviral regimen changes should trigger reassessment of adherence and, when appropriate, adherence intervention.

Objective: To assess the association of specialty training and experience in the care of HIV disease with HIV-specific knowledge, referral patterns, and HIV-related education activities., Design: Cross-sectional survey., Setting: The United States., Participants: Physicians caring for patients in the HIV Costs and Service Utilization Study, a study of a probability sample of HIV-infected individuals in the United States., Measurements and Main Results: Measures included physicians' reports of specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities. Approximately 72% (379) of the eligible physicians completed a survey. Of these, 152 (40%) had infectious disease (ID) training, and 213 (56%) were generalists; 4% of ID-trained physicians and 37% of generalist physicians did not consider themselves HIV experts. The median current caseloads were 150 and 200 patients for ID experts and generalist experts, respectively. In contrast, the median caseload for non-expert generalists was 5. Mean scores on the knowledge scale were similar for ID and generalist experts (9.0 items correct out of 11 vs 8.5; P=not significant), but lower for generalist non-experts (6.5 items correct; P <.01). Experts had attended more local and national HIV meetings than non-experts (9.3 vs 2.7; P <.01, and 2.3 vs.40; P <.01, respectively) in the past year. Fewer ID experts ever referred than generalist experts (13.0% vs 27.3%; P=.01). In multivariable models that included specialty training and caseload, physicians with caseloads of 20 to 49 and >50 were more likely to have a high knowledge score (defined as 80% or more correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P <.001, respectively), and the effect of specialty was attenuated (OR, 2.7; P=.02 decreased from OR, 7.8; P <.001 in a model without caseload). In the models predicting referral practices, both experience (OR,.25; P <.01 and OR,.17; P <.01 for caseloads of 20 to 49 and >50, respectively) and specialty (OR,.19; P <.01 and OR,.09; P <.01 for generalist and ID experts, respectively) were significant., Conclusions: In a national sample of physicians, HIV-specific knowledge was more strongly associated with HIV caseload than with specialty training. In addition, although referral practices were related to both experience and specialty, generalist experts and ID physicians reported similar behaviors. This suggests that generalist physicians, through clinical experience and self-education, can develop specialized knowledge in HIV care.

Objective: Adherence to combination antiretroviral therapy is critical for clinical and virologic success in HIV-infected patients. To combat poor adherence, clinicians must identify nonadherent patients so they can implement interventions. However, little is known about the accuracy of these assessments. We sought to describe the accuracy of clinicians' estimates of patients' adherence to combination antiretroviral therapy., Setting: Public HIV clinic., Design: Prospective cohort study. During visits, we asked clinicians (nurse practitioners, residents and fellows, and their supervising attending physicians) to estimate the percentage of antiretroviral medication taken by patients over the last 4 weeks and predicted adherence over the next 4 weeks. Adherence was measured using electronic monitoring devices, pill counts, and self-reports, which were combined into a composite adherence measure., Patients and Participants: Clinicians estimated 464 episodes of adherence in 82 patients., Results: Among the 464 adherence estimates, 264 (57%) were made by principal care providers (31% by nurse practitioners, 15% by fellows, 6% by residents, and 5% by staff physicians) and 200 (43%) by supervising attending physicians. Clinicians' overestimated measured adherence by 8.9% on average (86.2% vs 77.3%). Greater clinician inaccuracy in adherence prediction was independently associated with higher CD4 count nadir (1.8% greater inaccuracy for every 100 CD4 cells, P=.005), younger patient age (3.7% greater inaccuracy for each decade of age, P=.02), and visit number (P=.02). Sensitivity of detecting nonadherent patients was poor (24% to 62%, depending on nonadherence cutoff). The positive predictive value of identifying a patient as nonadherent was 76% to 83%., Conclusions: Clinicians tend to overestimate medication adherence, inadequately detect poor adherence, and may therefore miss important opportunities to intervene to improve antiretroviral adherence.

Objectives: To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey., Design: Analysis of longitudinal survey data., Setting: A nationally representative community-based survey., Participants: Six thousand two hundred five Medicare beneficiaries age 65 and older., Measurements: Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline., Results: A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of >or=3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of.78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system., Conclusions: A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

Diet, exercise, smoking, and substance use patterns affect the course of illness and quality of life for people with HIV. In interviews with a national probability sample of 2,864 persons receiving HIV care, it was found that most had made health-promoting changes in one or more of these behaviors since diagnosis. Many reported increased physical activity (43%) and improved diet (59%). Forty-nine percent of cigarette smokers quit or cut down; 80% of substance users did so. Desire for involvement in one's HIV care and information seeking-positive coping were the most consistent correlates of change. Other correlates varied by health practice but included health status, emotional well-being, demographics, and attitudes toward other aspects of HIV care. Most people with HIV improve their health behavior following diagnosis, but more might be helped to do so by targeting these behaviors in future interventions.

Context: Deficits in advance care planning leave many patients and their physicians unprepared for decisions about end-of-life care. Even though the prognosis has improved for many persons with human immunodeficiency virus (HIV) infection, a need for planning remains., Objective: To evaluate prevalence of end-of-life discussions, use of advance directives, and preferences concerning end-of-life care and their relationship with patient demographics, clinical status, psychosocial variables, and practitioner characteristics among HIV-infected persons., Design, Setting, and Patients: Cross-sectional survey of a US probability sample of 2864, which represents 231 400 adults receiving care for HIV, conducted from January 1996 to April 1997., Main Outcome Measures: Communication with physician regarding end-of-life issues, completion of an advance directive, preference for aggressiveness of care, and willingness to tolerate future permanent adverse health states., Results: A total of 1432 patients (50%) discussed some aspect of end-of-life care with their practitioner and 1088 (38%) completed an advance directive. Patients were more likely to complete an advance directive after a physician discussion (odds ratio [OR], 5.82; 95% confidence interval [CI], 4.50-7.52). Practitioners discussed end-of-life care less with blacks (OR, 0.57; 95% CI, 0.39-0.83) and Latinos (OR, 0.74; 95% CI, 0.55-0.98) than with whites. Women (OR, 1.39; 95% CI, 1.05-1.84) and patients with children in the household (OR, 1.53; 95% CI, 1.12-2.10) communicated the most with practitioners about end-of-life issues. Patients infected with HIV via injection drug use (OR, 0.64; 95% CI, 0.45-0.89) and those with less education communicated the least with physicians about end-of-life issues. Less denial, greater trust in one's practitioner, and longer patient-practitioner relationship were associated with more advance care planning., Conclusions: Half of all persons infected with HIV are at risk of making end-of-life decisions without prior discussions with their health care practitioners. Blacks, Latinos, intravenous drug users, and less educated individuals need advance care planning interventions in clinical HIV programs.

Background: Poor adherence to HIV protease inhibitors may compromise the effectiveness of treatment. Few studies have compared methods for measuring adherence or have related adherence measures to a clinical outcome., Objective: To examine the relationship among a composite score of adherence, the three primary measures of adherence, and HIV virologic response., Design: Longitudinal cohort study., Setting: Public HIV clinic., Patients: 108 HIV-infected adults receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors who were monitored for 666 monthly intervals., Measurements: Medication Event Monitoring System (MEMS), pill count, and interview combined into a composite adherence score (CAS), and HIV viral load., Results: Mean antiretroviral adherence differed by adherence measure (MEMS, 0.63; pill count, 0.83; interview, 0.93; and CAS, 0.76). Composite adherence score decreased significantly over time. Composite adherence score, MEMS values, pill values, and interview values were statistically significantly associated with achievement of an undetectable viral load within 6 months of initiating therapy. Composite adherence score showed the strongest predictive relationship (odds ratios for a 10% increase in adherence for CAS, MEMS, pill count, and interview, respectively, were 1.26 [95% CI, 1.16 to 1.37], 1.13 [CI, 1.06 to 1.21], 1.10 [CI, 1.02 to 1.19], and 1.35 [CI, 0.94 to 1.94])., Conclusions: Different measures applied to the same patient suggest different levels of adherence. Adherence may be underestimated by MEMS and overestimated by pill count and interview. A summary measure combining several measures is more strongly related to a clinical response, but more practical measurement methods are needed for clinical use.

Background: Left ventricular assist devices (LVADs) are a relatively new technology that is increasingly used to preserve cardiac function. These devices work by a mechanism that may complicate ethical decision-making for patients who subsequently lose decision-making capacity and are no longer considered transplant candidates., Methods: Using a clinical case from our medical center, we explored the complex ethical issues associated with the discontinuation of LVAD therapy by discussing how this device is distinct from the withdrawal of other treatments., Results: While halting an implanted LVAD may permit a patient to die, the deactivated device itself may contribute to patient death due to the potential for blood backflow and pooling, as well as the disruption of heart contractility. Inadequate informed consent and failure to appoint a surrogate decision-maker in advance of the implant procedure resulted in a complex ethical dilemma for the patient's family and the medical team., Conclusions: Clinicians and families must consider the benefits and burdens of LVAD therapy as they do when considering removal of other life-sustaining treatment. The informed consent process associated with LVADs as bridging technology should include extensive consideration of the purpose of the device, future circumstances in which it may be halted, and how such situations would be recognized and handled. Appointment of a surrogate decision-maker before the surgical procedure is essential.

Objectives: The goal of this study was to determine factors associated with receiving cardiologist care among patients with an acute exacerbation of congestive heart failure., Background: Because cardiologist care for acute cardiovascular illness may improve care, barriers to specialty care could impact patient outcomes., Methods: We studied 1,298 patients hospitalized with acute exacerbation of congestive heart failure who were cared for by cardiologists or generalist physicians. Using multivariable logistic models we determined factors independently associated with attending cardiologist care., Results: Patients were less likely to receive care from a cardiologist if they were black (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.35, 0.80), had an income of less than $11,000 (AOR 0.65, 95% CI 0.45, 0.93) or were older than 80 years of age (AOR 0.23, 95% CI 0.12, 0.46). Patients were more likely to receive cardiologist care if they had college level education (AOR 1.89, 95% CI 1.02, 3.51), a history of myocardial infarction (AOR 1.59, 95% CI 1.17, 2.16), a serum sodium less than 133 on admission (AOR 1.96, 95% CI 1.30, 2.95) or a systolic blood pressure less than 90 on admission (AOR 1.97, 95% CI 1.20, 3.24). Patients who stated a desire for life extending care were also more likely to receive care from a cardiologist (AOR 1.40, 95% CI 1.04, 1.90)., Conclusions: After adjusting for severity of illness and patient preferences for care, patient sociodemographic factors were strongly associated with receiving care from a cardiologist. Future investigations are required to determine whether these associations represent unmeasured preferences for care or inequities in our health care system.

Background: Highly active antiretroviral therapy (HAART) became standard for HIV in 1996. Studies at that time showed that most people infected with HIV had initiated HAART, but that members of minority groups and poor people had lower HAART use. It is not known whether high levels of HAART use have been sustained or whether socioeconomic and racial disparities have diminished over time., Objectives: To determine the proportion of patients who had received and were receiving HAART by January 1998, and to evaluate predictors of HAART receipt., Design and Participants: Prospective cohort study of a national probability sample of 2267 adults receiving HIV care who completed baseline, first follow-up, and second follow-up interviews from January 1996 to January 1998., Main Outcome Variables: Proportion currently using HAART at second follow-up (August 1997 to January 1998), contrasted with the cumulative proportions using HAART at any time before January 1998 and before December 1996., Analyses: Bivariate and multiple logistic regression analysis of population characteristics predicting current use of HAART at the time of the second follow-up interview., Results: The proportion of patients ever having received HAART increased from 37% in December 1996 to 71% by January 1998, but only 53% of people were receiving HAART at the time of the second follow-up interview. Differences between sociodemographic groups in ever using HAART narrowed after 1996. In bivariate analysis, several groups remained significantly less likely to be using HAART at the time of the second follow-up interview: blacks, male and female drug users, female heterosexuals, people with less education, those uninsured and insured by Medicaid, those in the Northeast, and those with CD4 counts of >/=500 cells/microl (all p <.05). Using multiple logistic regression analysis, low CD4 count (for CD4 <50 cells/microl: odds ratio [OR], 3.20; p <.001) remained a significant predictor of current HAART use at the time of the second follow-up interview, but lack of insurance (OR, 0.71; p <.05) predicted not receiving HAART., Conclusions: The proportion of persons under HIV care in the United States who had ever received HAART increased to over 70% of the affected population by January 1998 and the disparities in use between groups narrowed but did not disappear. However, nearly half of those eligible for HAART according to the U.S. Department of Health and Human Services guidelines were not actually receiving it nearly 2 years after these medications were first introduced. Strategies to promote the initiation and continuation of HAART are needed for those without contraindications and those who can tolerate it.

Physicians may receive various gifts and incentives from companies that make pharmaceuticals and medical devices. Although such incentives may benefit patients and physicians, they often pose serious conflicts of interest that violate a physician's professional responsibility. The physician-patient relationship is predicated on the physician acting in the best interest of the patient. The application of medical knowledge to complex clinical circumstances is difficult, even without biased sources of information and internal conflicts attributable to financial incentives. Yet, industry resources often are dedicated to the dissemination of information and incentives aimed to influence decisions not necessarily aimed at the goals of the patient. Physicians often are unaware of the nature of the incentives and commonly deny their demonstrated impact. Any incentive that is designed to impede, rather than enhance, the clinician's ability to make optimal patient care decisions is unethical for a physician to accept. These incentives should play no role in the practice of orthopaedic surgery.

Objective: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals., Design: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective., Setting: A senior center and a multilevel retirement community in Los Angeles., Participants: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with end-of-life decision making., Main Results: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of having lived a "full life." Decision-making authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient's interests), and shifted from physician to family as the patient's prognosis for functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors to end-of-life treatment decisions., Conclusions: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and valued life activities may be better suited to patients' end-of-life care goals than those that focus on specific medical interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients' and families' goals for care.

Obtaining informed consent is a frequent and important part of the practice of orthopaedic surgery. However, the process can be complicated, especially when there are impediments to communication and unusual decisions. An approach that considers each of the elements of informed consent permits the clinician to enhance the role of autonomy in patient decisions while maximizing the probability of achieving successful informed consent. Attending to (and testing when necessary) a patient's capacity to make decisions, ensuring comprehension of the clinical circumstances and proposed intervention and it's risks and benefits, and evaluating the decision-making mechanism are essential steps. A patient's capacity to participate in informed consent at times may be enhanced by selected interventions and may require serial reevaluation to identify the optimal time to discuss the issues. Implied consent has an important but delimited role in emergent circumstances. Prospective elicitation of patient preferences and delineation of surrogate decision makers can substantially enhance the ease and efficiency of informed consent while matching care with patient goals.

In this paper, we empirically explore some manifestations of norms for the conduct of science. We focus on scientific research ethics and report survey results from 606 scientists who received funding in 1993 and 1994 from the Division of Molecular and Cellular Biology of the Biology Directorate of the National Science Foundation. We also report results for 91 administrators charged with overseeing research integrity at the scientists' research institutions. Both groups of respondents were presented with a set of scenarios, designed by fractional factorial methods, describing different kinds of scientific conduct that in the eyes of some would likely be unethical. Respondents then were asked to evaluate each of these scenarios for how unethical the behavior might be and what kinds of sanctions might be appropriate. We use the responses to consider the nature of consensus around norms related to the practice of science and in particular, similarities and differences between scientists and science administrators. Implications for policy are also discussed.

Objective: To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older., Design: A prospective cohort study with mortality follow-up using the National Death Index., Setting: Four teaching hospitals in the US., Participants: Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery., Measurements: A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care., Results: A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly., Conclusions: Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.

Objective: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in-hospital CPR., Design: We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician-patient communication with physician understanding of patient CPR preferences. Among patients preferring to forego CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician., Patients/setting: Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments. GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forego CPR. Younger patient age, higher physician-estimated quality of life, and higher physician prediction of 6-month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forego CPR. Physicians who spoke with patients about resuscitation and had longer physician-patient relationships understood patients' preferences to forego CPR more often. Patients whose physicians understood their preference to forego CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation., Conclusions: Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forego CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forego CPR but whose wishes are not understood by their physician may receive unwanted treatment.

Objective: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn., Design: Prospective cohort study., Setting: Five teaching hospitals., Patients: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure., Main Outcome Measures: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued., Results: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn., Conclusions: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

Objective: To evaluate prospectively seriously ill patients' characteristics, perceptions, and preferences associated with discussing resuscitation (CPR) with their physicians., Design: Prospective cohort., Setting: Five academic medical centers., Participants: Patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who had not communicated with their physicians about CPR at admission to a hospital for life-threatening illness (n = 1288)., Measurements: Baseline surveys of patients' characteristics, health status, desires for participation in medical decision making, and cardiopulmonary resuscitation. Two month follow-up surveys of patients' communication of resuscitation preference. Chart reviews for clinical indicators., Results: Thirty percent of patients communicated their resuscitation preference to their physician during a 2 month-period following hospital admission. Patients whose preference was to forego CPR (odds ratio (OR) 2.9;(95% CI, 1.9-4.2)) and whose preference had changed from desiring to foregoing CPR (OR 1.6; (95% CI, 1.1-2.4)) were more likely to communicate their preference than patients who continued to prefer to receive CPR. However, only 50% of patients who maintained a preference to forego CPR communicated this over a 2-month period. Having an advance directive and remaining in the hospital at 2-month follow-up were also independently associated with communication, whereas patients' preference for participation in decision-making, health status, and prognostic estimate were not., Conclusions: Communication about resuscitation preferences occurred infrequently after hospital admission for a serious illness, even among patients wishing to forego resuscitation. Factors such as declining quality of life, which were expected to be associated with communication, were not. An invitation to communicate about CPR preference is important after hospital admission for a serious illness. Novel approaches are needed to promote physician-patient discussions about resuscitation.

Objective: To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)., Design: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making., Setting: Five teaching hospitals in the United States., Participants: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died., Measurements: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making., Results: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8)., Conclusions: Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.

Scrutiny of the quality of medical care near the end of life is increasing. Experts have begun to define and conceptualize quality of care for dying patients and are developing measurement tools to assess quality of care in this population. Definitions and conceptual models of quality of care at the end of life are reviewed. Approaches for measuring the processes and outcomes of end-of-life care are discussed. Approaches for initiating quality assessment of end-of-life care among geriatric patients are suggested.

Objective: To identify age group differences in care practices and outcomes for seriously ill hospitalized patients with malignancy., Design: Prospective cohort study (SUPPORT project)., Setting: Five United States teaching hospitals; data was gathered between 1989 and 1994., Subjects: Nine hundred twenty five older (age > or = 65 years), 983 middle aged (age = 45-64 years), and 274 younger (age = 18-44 years) hospitalized patients receiving care for non-small cell lung cancer, colon cancer metastasized to the liver, or multi-organ system failure associated with malignancy., Measurements: Care practices and patient outcomes were determined from hospital records. Length of survival was identified using the National Death Index. After adjusting for important variables, including severity of illness (i.e., SUPPORT model estimate for 2-month survival, cancer condition), hospital site, selection to intervention and sociodemographic variables, age group differences in care practices and outcomes were identified using general linear models., Results: Older patients with cancer had lower resource utilization during hospitalization (P < .04) and were less likely to receive cancer-related treatments (i.e., chemotherapy, platelet infusions, scheduled intravenous medications) than middle-aged and young-adult patients in the first week of hospitalization (P < or = .01). More care topics were discussed with older patients and their families then with younger patients and their families (P < .001). Length of stay and total hospital costs were lower for older and middle-aged patients than for younger patients. Although more older patients had discussions about transfer to hospice (P < .001), older patients were no more likely to be discharged with supportive care (inpatient hospice or home with home/ hospice care). Older patients died sooner than middle-aged patients (P < .01)., Conclusions: Patient age influenced care decisions and outcomes. Older patients (age > or = 65 years) received less aggressive care, had more discussions about care decisions, and died sooner than younger patients with cancer. Younger patients had longer stays, higher hospital costs, and greater probability of rehospitalization. Although well over half of patients died within 6 months of hospitalization, few patients in any age group were discharged with supportive care. Future studies should examine age differences in palliation, as well as acute care of cancer patients across inpatient and ambulatory care settings and should assess quality of care at the end of life.

Background: Despite concern about the high costs and the uncertain benefit of prolonged treatment in the intensive care unit (ICU), there has been little research examining decision-making and outcomes for patients with prolonged ICU stays., Objectives: To evaluate decision-making and outcomes for seriously ill patients with an ICU stay of at least 14 days., Design: A prospective cohort study., Setting: Five teaching hospitals., Participants: Seriously ill patients enrolled in the Study To Understand Prognoses and Preferences for Risks and Outcomes of Treatments (SUPPORT)., Measurement: Patients, their surrogate decision-makers, and their physicians were interviewed about prognosis, communication, and goals of medical care. Based on age, diagnoses, comorbid illnesses, and acute physiology data, the SUPPORT Prognostic Model provided estimates of 6-month survival on study days 1, 3, 7, and 14. Hospital costs were estimated from hospital billing data., Results: Of the 9105 patients enrolled in SUPPORT, 1494 (16%) had ICU stays of 14 days or longer. The median length of stay in an ICU was 4 days for the entire SUPPORT cohort and 35 days for patients who were treated in an ICU for 14 days or longer. Median hospital costs were $76,501 for patients who had ICU stays 14 days or longer and $10,916 for patients who did not have long ICU stays. Fifty-five percent of patients with long ICU stays had died by 6 months, and an additional 19% had substantial functional impairment. Among patients with ICU stays of at least 14 days, only 20% had estimates of 6-month survival that fell below 10% at any time during their hospitalization. For patients with long ICU stays, the mean predicted probability of 6-month survival was 0.46 on study Day 3 and 0.47 on study Day 14. Fewer than 40% of patients (or their surrogates) reported that their physicians had talked with them about their prognoses or preferences for life-sustaining treatment. Among the patients who preferred a palliative approach to care, only 29% thought that their care was consistent with that aim. Those who discussed their preferences for care with a physician were 1.9 times more likely to believe that treatment was in accord with their preferences for palliation (95% CI, 1.4-2.5), Conclusions: Prolonged ICU stays were expensive and were often followed by death or disability. Patients reported low rates of discussions with their physicians about their prognoses and preferences for life-sustaining treatments. Many preferred that care focus on palliation and believed that care was inconsistent with their preferences. Patients were more likely to receive care consistent with their preferences if they had discussed their care preferences with their physicians.

Objective: To develop a model estimating the probability of a patient aged 80 years or older having functional limitations 2 months and 12 months after being hospitalized., Design: A prospective cohort study., Setting: Four teaching hospitals in the US., Participants: Enrolled patients were nonelective hospital admissions aged 80 years or older who stayed in hospital at least 48 hours. The 804 patients who survived and completed an interview at 2 months and the 450 who completed an interview at 12 months were from the 1266 patients in the Hospitalized Elderly Longitudinal Project (HELP) (76% and 47% of survivors, respectively). Median age of the 2-month survivors was 84.7 years., Measurements and Main Outcomes: Patient function 2 and 12 months after enrollment was defined by the number of dependencies in Activities of Daily Living (ADLs). Ordinal logistic regression models were constructed to predict functional status. Predictors included demographic characteristics, disease category, geriatric conditions, severity of physiologic imbalance, current quality of life, and exercise capacity and ADLs 2 weeks before study admission., Results: Before admission, 39% of patients were functionally independent in ADLs. Of patients who survived and were interviewed at 2 months, 32% were functionally independent, and at 12 months, 36% were independent. Among patients with no baseline dependencies, 42% had developed one or more limitations 2 months later, and 41 % had limitations 12 months later. The patient's ability to perform activities of daily living at baseline was the most important predictor of functional status at both 2 and 12 months. In a multivariable predictive model, independent predictors of poorer functional status at 2 months included: worse baseline functional status and quality of life; depth of coma, if any; lower serum albumin level; presence of dementia, depression, or incontinence; being bedridden; medical record documentation of need for nursing home; and older age. Model performance, assessed using Somers' D, was 0.61 for 2 months and 0.57 for 12 months (Receiver Operating Characteristic (ROC) area = 0.81 and .79, respectively.) Bootstrap validation of the month 2 model also yielded a Somers' D = 0.60. The models were well calibrated over the entire risk range. The ROC area for prediction of the loss of independence was 0.76 for 2 months and 0.68 for 12 months., Conclusions: Many older patients are functionally impaired at the time of hospitalization, and many develop new functional limitations. A limited amount of readily available clinical information can yield satisfactory predictions of functional status 2 months after hospitalization. Models like this may prove to be useful in clinical care. This work illuminates a potential method for risk adjustment in research studies and for monitoring quality of care.

Objective: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults., Design: Discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews., Methods: A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community-dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions., Results: The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end-of-life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community-dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end-of-life care) are not recorded as diagnoses., Conclusions: Twenty-one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings.

Context: The epidemiology of do-not-resuscitate (DNR) orders for hospitalized patients has been reported, but little is known about factors associated with the use of cardiopulmonary resuscitation (CPR)., Objective: To identify factors associated with an attempt at CPR for patients who experienced cardiopulmonary arrest., Design: Secondary analysis of data collected in 2 prospective cohort studies: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT, 1989-1994) and the Hospitalized Elderly Longitudinal Project (HELP, 1994). Setting Five teaching hospitals across the United States., Participants: A total of 2505 seriously ill hospitalized patients and nonelectively admitted persons aged 80 years or older who experienced cardiopulmonary arrest., Main Outcome Measures: Medical records data on CPR efforts, DNR orders, disease severity, age, race, sex, length of stay, and survival; functional status and preferences concerning CPR obtained by interviews with patients or surrogates; and 2-month survival estimates provided by physicians., Results: Five hundred fourteen study subjects (21 %) received CPR during their index hospitalization. Among them, 327 (63.6%) had CPR within 2 days of death and 93 (18.1 %) had resuscitation and survived their index hospitalization. Use of CPR was more likely in men (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.12-1.73), younger patients (OR per 10-year increase, 0.90; 95% CI, 0.84-0.96), African Americans (OR, 1.76; 95% CI, 1.33-2.34), patients whose reported preferences were for CPR (OR, 2.60; 95% CI, 1.91-3.55), who reported better quality of life (OR, 1.49; 95% CI, 1.10-2.03), or who had higher physician estimates for 2-month survival (OR per 10% increase, 1.14; 95% CI, 1.09-1.19). Rates varied significantly with geographic location and diagnosis; the adjusted OR for patients with congestive heart failure was 3.31 (95% CI, 2.12-5.15) compared with patients with acute respiratory failure or multiple organ system failure., Conclusions: Our data suggest that a resuscitation attempt is more likely when preferred by patients and when death is least expected. Further study is required to understand variation in use of CPR among sites and for patients with different diagnoses, race, sex, or age.

Scientists, as professionals, have a responsibility to self-regulate. However, whistleblowing is rare. We investigated scientists' infrequent disclosure of unethical behavior by studying their responses to scenarios describing unethical research acts and compared their responses to those of research administrators. A cross-sectional survey was administered to National Science Foundation-funded principal investigators and their institutions' representatives (IRs) to the Office of Research Integrity. Both scientists and IRs proposed to respond to nearly all research behaviors that they rated as unethical. Scientists more often proposed responses limited to the research team (58% vs. 25% of cases, p < .001) whereas IRs more often proposed to inform an administrator or dean, journal editor, funding agency, professional society, or reporter. The prior behavior and academic rank of the scenario protagonist were associated with responses, but consequences of the unethical behavior were not. Scientists appear to perceive that they uphold their responsibility to respond to unethical behavior by disclosures within the research team, whereas administrators propose to report to externally accountable individuals, raising the question of whether scientists' behavior constitutes professional self-regulation or cover up.

We studied symptom burden and associated factors in a cohort of 1582 seriously ill patients admitted at five tertiary care academic centers in the U.S. between June 1989 and June 1991 in the SUPPORT Study. Logistic regression was used to test the independent association of symptoms with demographic, psychological, chronic, and acute illness measures. Pain, dyspnea, anxiety, and depression caused the greatest symptom burden. The following symptoms accounted for 67.3% of all symptoms that were at least moderately severe at least half of the time: dyspnea (19.2%), pain (17.6%), pain/dyspnea (7.6%), anxiety (5.9%), depression (5.0%), anxiety/depression (4.4%), anxiety/depression/pain/dyspnea (3.9%), and nausea (3.7%). Hospital, male gender, disease category, more comorbidities, more dependencies in activities of daily living prior to illness, and poorer quality of life were associated with greater symptom burden. Seriously ill patients have a high symptom burden. Better strategies will be needed to control symptoms in these patients.

Objective: To evaluate whether nursing home residents and their families reported discussions about life-sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician-patient communication about life-sustaining treatment., Design: Cross-sectional interviews and retrospective chart abstraction., Setting: Three regions: West Coast, New England, Western., Sample: A total of 413 nursing home residents, 363 family/surrogate interviews, and 192 resident interviews., Main Outcome Measures: Measured were (1) physician-resident communication about life-sustaining treatment and (2) presence of an advance directive or do not resuscitate (DNR) order in resident's chart., Results: Seventy-four percent of residents had DNR orders, and 32% had advance directives; only 29% of residents reported discussions about life-sustaining treatment. Of residents with DNR orders who could have participated in discussions about life-sustaining treatment, nearly half reported they had not discussed CPR with their caregivers. Older age, longer duration of time living in nursing home, location in a New England nursing home, physician-family member discussion, and the presence of an advance directive in the medical chart were positively associated with having DNR orders. Physician-resident discussion was not associated with having a DNR order. For the subsample of interviewed residents, age and a diagnosis of cognitive impairment were negatively associated with a physician-resident discussion about life-sustaining treatment, whereas the likelihood of having a discussion increased with increasing numbers of medical diagnoses., Conclusions: Chart orders to limit therapy are common, but physician-resident discussions about life-sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.

Purpose: To investigate the perceptions of scientists and institutional representatives (IRs) to the National Institutes of Health's Office of Research Integrity concerning appropriate punishment for unethical research behavior., Method: In 1994-95, 606 scientists and 91 IRs rated the ethical behaviors of and suggested appropriate punishments for protagonists in randomly generated scenarios describing scientific research behaviors. The authors evaluated the relationships of the suggested punishments to the protagonists' behaviors and characteristics, and compared recommendations of the scientists and IRs., Results: The respondents suggested punishments for 80% of the scenarios that were rated unethical. Punishments were more often prescribed for behaviors rated more unethical and for repeat offenders. The type of punishment was related to the protagonist's academic status and the nature of the unethical behavior. IRs proposed more and different punishments than did scientists., Conclusion: Scientists and IRs proposed that most unethical research behaviors be punished. The decision to punish depended on the unethical level of the behavior. The type of punishment depended on the aims: correcting the wrong, rehabilitation, or sanction. Variation in the respondents' selections of punishments and the IRs' greater propensity to punish suggest that scientists committing similar ethical violations may receive different punishments. Explicit consideration of which punishment is merited under what circumstances should be undertaken by the scientific community.

Lack of timely HIV testing leads to missed prevention opportunities and poor prevention counselling may be related to further disease spread. We examined the association of self-reported access to medical care with receiving HIV testing and preventive counselling services among a sample of patients with HIV disease prior to hospitalization. We conducted a cross-sectional interview of 217 Los Angeles patients hospitalized with HIV-related illness between 1992 and 1993 and abstracted clinical data from the medical record. Eighty-four per cent of patients received HIV testing prior to hospitalization, but only 33% received preventive counselling services. Only 48% of all patients rated outpatient medical care as somewhat or very easy to obtain. Controlling for severity of illness, better access to outpatient medical care (OR = 1.48; 95% CI = 1.02-2.15), having a regular source of care (OR = 3.40; 95% CI = 1.29-8.97) and non-homosexual mode of HIV transmission (OR = 0.31; 0.12-0.83) were associated with receiving HIV testing services prior to hospitalization. Having a regular source of care (OR = 3.55; 95% CI = 1.37-9.22), being VA (Veterans' Administration) insured (OR = 6.16; 1.46-26.05), older age (OR = 0.95; 95% CI = 0.90-0.99) and having a CD4 count between 101-200 (OR = 0.19; 95% CI = 0.06-0.63) were associated with receiving HIV counselling. Limited self-reported access to medical care is associated with fewer patients receiving HIV testing and counselling. Improving timeliness of HIV testing may require removing the barriers to medical care.

Orthopaedic surgery residents will be faced with a variety of ethical issues when they enter clinical practice. A previous survey suggested that they lack knowledge about how to approach several types of medical ethics dilemmas. We developed a medical ethics curriculum for orthopaedic surgery residents and presented it over a one-year period to the residents in one training program. The effect of the educational intervention on the residents' knowledge of medical ethics and their ability to handle hypothetical situations was measured by comparing their responses to a questionnaire, administered before and after the intervention, with those of residents in a training program in which the intervention was not provided. The twenty-five residents at the site of the educational intervention had a mean improvement of 0.10 in the overall score, from a mean score of 0.71 on the baseline survey to a mean score of 0.81 on the follow-up survey. This improvement was significantly greater than the mean improvement of 0.02 for the thirty residents at the control site, who had a mean score of 0.72 on the baseline survey and a mean score of 0.74 on the follow-up survey (p = 0.002). Six residents who participated in the medical ethics curriculum rated it as very useful; seventeen, as somewhat useful; one, as slightly useful; and one, as not at all useful. A medical ethics curriculum can increase orthopaedic residents' knowledge of medical ethics. Whether this curriculum also will lead to behavioral changes requires additional evaluation.

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources. Patients' pain was determined from hospital interviews with patients and surrogates. Pain 2 and 6 months later or after death and satisfaction with its control at all time periods were also assessed. All analyses were adjusted for baseline risk of being in pain and propensity to be in the intervention group. Overall, 50.9% of patients reported some pain. After adjustment for other variables associated with pain, comparing the intervention to the control group, there was not a statistically significant difference in level of pain (OR for higher levels of pain 1.15; CI 1.00-1.32) or satisfaction with control of pain during the hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2 or 6 months after discharge, or during the last 3 days of life. A multifaceted intervention using information, empowerment, advocacy, counseling and feedback was ineffective in ameliorating pain in seriously ill patients. Control of pain in these patients remains an important problem. More intensive pain treatment strategies addressing the needs of seriously ill hospitalized adults must be evaluated.

We developed a survey instrument to evaluate knowledge of ethical issues among orthopaedic surgeons and to assess their ability to handle ethical dilemmas. The twenty-six-item survey evaluates seven areas of medical practice: confidentiality, informed consent, truth-telling, the physician-patient relationship, economic aspects of care, end-of-life decision-making, and the approach to an incompetent colleague. It was administered to 117 attending orthopaedic surgeons and residents in two orthopaedic surgery training programs. One hundred and two orthopaedic surgeons (87 per cent) completed the survey. Overall, they correctly answered a mean of nineteen (73 per cent) of the twenty-six questions. The respondents appropriately handled questions involving economic aspects, truth-telling, confidentiality, and an incompetent colleague. However, there was poorer understanding of proper ethical conduct with regard to informed consent (58 per cent of the responses were correct), the physician-patient relationship (72 per cent of the responses were correct), and end-of-life decision-making (78 per cent of the responses were correct). No significant differences were found, with the numbers available, in overall performance according to site, attending compared with resident status, age, gender, or whether the physician had had training in ethics. Economic, social, and professional forces have increased the medical ethical issues facing orthopaedic surgeons. Medical ethics now must be taught in training programs in orthopaedic surgery. Our survey of two orthopaedic surgery training programs demonstrated that orthopaedic surgeons approach most medical ethical problems appropriately. However, improvement is needed in selected areas.