Showing papers by "Carol E. Golin published in 2002"

A prospective study of predictors of adherence to combination antiretroviral medication.

Abstract: 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.

How Well Do Clinicians Estimate Patients' Adherence to Combination Antiretroviral Therapy?

Abstract: 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 fellow, 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.

Impoverished diabetic patients whose doctors facilitate their participation in medical decision making are more satisfied with their care.

Abstract: OBJECTIVE: Greater participation in medical decision making is generally advocated for patients, and often advocated for those with diabetes. Although some studies suggest that diabetic patients prefer to participate less in decision making than do healthy patients, the empirical relationship between such participation and diabetic patients’ satisfaction with their care is currently unknown. We sought to characterize the relationship between aspects of diabetic patients’ participation in medical decision making and their satisfaction with care. DESIGN: Cross-sectional observational study. SETTING: A general medical county hospital-affiliated clinic. PARTICIPANTS: One hundred ninety-eight patients with type 2 diabetes. MAIN MEASURES: Interviews conducted prior to the doctor visit assessed patients’ desire to participate in medical decision making, baseline satisfaction (using a standardized measure), and sociodemographic and clinical characteristics. Postvisit interviews of those patients assessed their visit satisfaction and perception of their doctor’s facilitation of patient involvement in care. A discrepancy score was computed for each subject to reflect the difference between the previsit stated desire regarding participation and the postvisit report of their experience of participation. RESULTS: Overall, patients reported low postvisit satisfaction relative to national standards (mean of 70 on a 98-point scale). Patients perceived a high level of facilitation of participation (mean 88 on a 100-point scale). Facilitation of participation and the discrepancy score both independently predicted greater visit satisfaction. In particular, a 13-point (1 SD) increase in the perceived facilitation score resulted in a 12-point (0.87 SD) increase in patient satisfaction, and a 1.22 point increase (1 SD) in the discrepancy score (the extent to which the patient was allowed more participation than, at previsit, he or she desired) resulted in a 6-point (0.5 SD) increase in the satisfaction score, even after controlling for initial desire to participate. For women, but not for men, physician facilitation of participation was a positive predictor of satisfaction; for men, but not women, desire to participate was a significant positive predictor of visit satisfaction. CONCLUSION: Clinicians may feel reassured that encouraging even initially reluctant patients with diabetes to participate in medical decision making may be associated with increased patient satisfaction. Greater patient participation has the potential to improve diabetic self-care because of the likely positive effect of patient satisfaction on adherence to treatment. Further research to assess the prospective effects of enhancing physician facilitation of patient participation is likely to yield important information for the effective treatment of chronically ill patients.

Secret pills: HIV-positive patients' experiences taking antiretroviral therapy in North Carolina.

Abstract: Understanding the barriers to antiretroviral adherence is a critical step in improving the effectiveness of HIV treatment and saving lives. We sought to assess, qualitatively, the experiences of HIV-positive persons taking antiretroviral therapy (ART) in North Carolina. Twenty-four people participated in one of six focus groups. A structured interview script included three questions (two open-ended) and eight probes. Each discussion was taped, transcribed, and content-analyzed. Three distinct themes emerged. First, many participants believed that taking ART was lifesaving but missed doses because they feared that taking them in public would reveal their HIV status. Second, as a result, participants often found it difficult to integrate their regimens into the most basic daily activities. Finally, participants stressed the importance of having open, ongoing dialogues about their treatment plans and privacy needs with a wide range of health care workers. Multidimensional, tailored interventions may help persons living with HIV overcome the stigma and other complex barriers they face in taking antiretroviral therapy.

Impact of antiretroviral regimen switches on adherence.

Abstract: 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....

Characteristics of general internists who practice only outpatient medicine: results from the physician worklife study

Abstract: • Purpose: Several recent articles have focused on the emerging new career path of hospitalists, yet little attention has been paid to the concomitant development of outpatient-focused internists. The purpose of this study was to learn more about the characteristics of outpatient-focused internists. • Design: Analysis of data from the Physician Worklife Study, a national random stratified survey of primary care and specialty physicians conducted from 1996 to 1997. • Method: The analysis focused on self-identified general internists who worked greater than or equal to 30 hours per week (n = 353). Respondents were categorized into two groups: “exclusively outpatient internists” (0% inpatient time; n = 59); and “any inpatient internists” (inpatient time greater than 0%; n = 294), which was a combination of “mixed internists” (0% to 50% inpatient time; n = 286) and “primarily inpatient internists” (inpatient time greater than 50%; n = 8). The demographic, practice, and patient case mix characteristics of these two groups were compared. • Results: Of general internal medicine respondents, 17% were “exclusively outpatient internists” whereas 83% were “any inpatient internists” (of this group, 2% were “primarily inpatient internists”). Exclusively outpatient internists earned less in salary, worked fewer hours per week, were more likely to work part-time or in an emergency department or urgent care setting, and were more likely to intend to change their specialty within 5 years. A greater proportion of exclusively outpatient internists were women and unmarried. Compared with their male counterparts, female exclusively outpatient internists treated a greater percentage of female patients, were more likely to be salaried, and were less likely to intend to leave direct patient care within 5 years. • Conclusions: As of the 1996‐1997 Physician Worklife Study, approximately 17% of internists worked exclusively outside the hospital. Important differences were found between these general internists and internists who maintain or favor an inpatient practice. These differences show that the practice of internal medicine is changing and that substantial heterogeneity in the career paths and practice patterns of general internists can be expected in the near and distant future.