Showing papers by "Michael J. Fine published in 2003"

Testing Strategies in the Initial Management of Patients with Community-Acquired Pneumonia

Abstract: The initial management of patients suspected of having community-acquired pneumonia is challenging because of the broad range of clinical presentations, potential life-threatening nature of the illness, and associated high costs of care. The initial testing strategies should accurately establish a diagnosis and prognosis in order to determine the optimal treatment strategy. The diagnosis is important in determining the need for antibiotic therapy, and the prognosis is important in determining the site of care. This paper reviews the test characteristics of the history, physical examination, and laboratory findings, individually and in combination, in diagnosing community-acquired pneumonia and predicting short-term risk for death from the infection. In addition, we consider the implications of these test characteristics from the perspective of decision thresholds. The history and physical examination cannot provide a high level of certainty in the diagnosis of community-acquired pneumonia, but the absence of vital sign abnormalities substantially reduces the probability of the infection. Chest radiography is considered the gold standard for pneumonia diagnosis; however, we do not know its sensitivity and specificity, and we have limited data on the costs of false-positive and false-negative results. In the absence of empirical evidence, the decision to order a chest radiograph needs to rely on expert opinion in seeking strategies to optimize the balance between harms and benefits. Once community-acquired pneumonia is diagnosed, a combination of history, physical examination, and laboratory items can help estimate the short-term risk for death and, along with the patient's psychosocial characteristics, determine the appropriate site of treatment.

Assessment of Mortality after Long-Term Follow-Up of Patients with Community-Acquired Pneumonia

Abstract: Although studies have assessed short-term mortality among patients with community-acquired pneumonia, there is limited data on prognosis and risk factors that affect long-term mortality. The mortality among patients enrolled at 4 sites of the Pneumonia Patient Outcome Research Team cohort study who survived at least 90 days after presentation to the hospital was compared with that among age-matched control subjects. Overall, 1419 of 1555 patients survived for >90 days, with a mean follow-up period of 5.9 years. There was significantly higher long-term mortality among patients with pneumonia than among age-matched controls. Factors significantly associated with long-term mortality were age (stratified by decade), do-not-resuscitate status, poor nutritional status, pleural effusion, glucocorticoid use, nursing home residence, high school graduation level or less, male sex, preexisting comorbid illnesses, and the lack of feverishness. This study demonstrates that there is significantly higher long-term mortality among patients with pneumonia than among age-matched controls and that long-term mortality largely is not affected by acute physiologic derangements.

Understanding Racial Disparities in HIV Using Data From the Veterans Aging Cohort 3-Site Study and VA Administrative Data

Abstract: Objectives. We identified race-associated differences in survival among HIV-positive US veterans to examine possible etiologies for these differences. Methods. We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients’ health status, clinical management, and adherence to medication by race. Results. Nationally, minority veterans had higher mortality rates than did white veterans with HIV. Minority veterans had poorer health than white veterans with HIV. No significant differences were found in clinical management or adherence. Conclusions. HIV-positive minority veterans experience poorer survival than white veterans. This difference may derive from differences in comorbidities and in the severity of illness of HIV-related disease.

Health Care of Homeless Veterans: Why Are Some Individuals Falling Through the Safety Net?

Abstract: It is important to understand the needs of those veterans who are homeless. We describe characteristics of homeless male veterans and factors associated with needing VA benefits from a two-city, community survey of 531 homeless adults. Overall, 425 were male, of whom 127 were veterans (29.9%). Significantly more veterans had a chronic medical condition and two or more mental health conditions. Only 35.1% identified a community clinic for care compared with 66.8% of non-veterans (P <.01); 47.7% identified a shelter-based clinic and 59.1% reported needing VA benefits. Those reporting this need were less likely to report a medical comorbidity (58.7% vs 76.9%; P =.04), although 66.7% had a mental health comorbidity and 82.7% met Diagnosic Screening Manual (DSM)-IIIR criteria for substance abuse/dependence. They were also significantly more likely to access shelter clinics compared with veterans without this need. Homeless veterans continue to have substantial health issues. Active outreach is needed for those lacking access to VA services.

Physician awareness and self-reported use of local and national guidelines for community-acquired pneumonia

Abstract: OBJECTIVES: To assess physician awareness and reported use of medical guidelines for community-acquired pneumonia (CAP), and to identify factors associated with variations in awareness and use of these guidelines. DESIGN: A questionnaire was administered during the preintervention phase of a randomized clinical trial of a pneumonia guideline implementation strategy. PARTICIPANTS: Three hundred and fifty-two physicians who managed CAP patients at 7 Pittsburgh, PA hospitals completed the questionnaire. Physician and practice setting characteristics, and physician awareness and reported use of national American Thoracic Society (ATS) and local (hospital-developed) guidelines for CAP were assessed. RESULTS: Overall, 48% reported being influenced by ATS guidelines and 20% reported using these guidelines; 48% were uncertain whether a local pneumonia guideline existed. Only 28% of physicians who knew a local guideline existed reported frequently using the guideline. Use of national ATS guidelines was independently associated with practice as an infectious disease or pulmonary medicine specialist, nonpatient care-related professional activities, and intellect personality score. Use of local guidelines was independently negatively associated with practice as an infectious disease or pulmonary medicine specialist, and positively associated with positive attitudes toward practice guidelines. CONCLUSIONS: Results indicate low levels of awareness and use of guidelines for the management of CAP. Key indicators (e.g., medical specialty, fewer clinical duties, and positive attitudes about guidelines) were associated with greater use of national and local guidelines. If replicated with data on actual physician management practices, more effective guideline implementation strategies will be necessary to encourage compliance with practice guidelines for the management of CAP.

Achieving Health Equity: An Incremental Journey

Abstract: Racial and ethnic disparities in health and health care have been well documented in a broad range of medical conditions and health care services in numerous settings. These disparities are not trivial. For example, African Americans suffer shorter life expectancy and higher rates of cancer, stroke, heart disease, HIV and mental illness than do Whites. American Indians and Alaskan Natives also experienc shorter life expectancy than that of Whites. Puerto Ricans, a subset of Hispanic ethnicity, have a significantly higher infant mortality rate than do Whites. Racial and ethnic disparities also exist in the utilization of specialist care, preventive services, renal and bone marrow transplants, and orthopedic procedures such as knee and hip replacements. There are several reasons why identifying and understanding health disparities and marshaling the "political will" needed to eliminate them are essential for all Americans.

The Veterans Health Administration’s Promotion of Health Equity for Racial and Ethnic Minorities

Abstract: The Department of Veterans Affairs(VA) Health Services Research and Development Service( HSRD) is proud to collaborate with the Journal to publish this special edition highlighting the Third Annual National Minority Health Leadership Summit. The summit, held in Pittsburgh, Pa, in January 2003, was titled “Eliminating Racial and Ethnic Health Disparities: The Role of Community- Based Participatory Research.” It was organized by the Center for Minority Health at the University of Pittsburgh Graduate School of Public Health and was cosponsored by the US Department of Health and Human Services Office for Civil Rights (Region III) and the VA Center for Health Equity Research and Promotion. During a special VA panel session at the summit, we described the VA’s comprehensive response to the national initiative to eliminate disparities in health and health care among racial and ethnic minorities. The audience, a diverse group of health professionals, public health workers, and community service providers, was largely unaware of the leading role the VA has played in promoting equality in health and health care among these traditionally underserved populations.