Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Doing Qualitative Research

Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.

Background Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. Methods We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. Results The physicians' mean (±SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1±19.3 percent, vs. 69.2±18.2 percent for men; P<0.001), younger patients (63.8±19.5 percent for patients who were 55 years old, vs. 69.5±17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3±19.0 percent, vs. 64.4±18.3 percent for patients with possible angina and 77.1±14.0 percent for those with definite angina; P<0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race–sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). Conclusions Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization

Purpose Underuse of adjuvant therapy is a potentially important and remediable explanation for the inferior survival of minority women with breast cancer. We sought to measure a racial disparity in the underuse of adjuvant treatments for early-stage breast cancer and to identify associated factors. Methods Cross-sectional study with review of all inpatient and outpatient medical records of 677 women treated surgically for a primary American Joint Committee on Cancer stage I or II breast cancer in 1999 to 2000. Underuse was defined as omissions of radiation therapy after breast-conserving surgery, adjuvant chemotherapy after resection of hormone-receptor-negative tumors ≥ 1 cm, or hormonal therapy for receptor-positive tumors ≥ 1 cm. Results One hundred forty-five (21%) of 677 women experienced underuse of appropriate adjuvant therapy: 16% in whites, 34% in blacks, and 23% in Hispanics (P < .001). Women referred to medical oncologists were less likely to experience underuse of necessary adjuvant treatments...

https://ascopubs.org/doi/pdf/10.1200/JCO.2005.04.5799

Missed Opportunities: Racial Disparities in Adjuvant Breast Cancer Treatment

What the scalpel is to the surgeon, words are to the clinician... the conversation between doctor and patient is the heart of the practice of medicine. 1 The physician-patient relationship is built through communication and the effective use of language. Along with clinical reasoning, observations, and nonverbal cues, skillful use of language endows the history with its clinical power and establishes the medical interview as the clinician's most powerful tool. 2-5 Language is the means by which a physician accesses a patient's beliefs about health and illness, 6 creating an opportunity to address and reconcile different belief systems. Furthermore, it is through language that physicians and patients achieve an empathic connection that may be therapeutic in itself. 7 Because of language barriers, millions of US residents cannot have this connection with their physician. According to the 1990 US Census, 8 almost 14 million people living in the United States do

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=387283&pdfFileName=jama_273_9_037.pdf

Language barriers in medicine in the United States.

Background Increasing time between symptom onset and treatment may be a risk factor for a ruptured appendix, but little is known about how the risk changes with passing time This study aimed to determine the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical intervention Study design We conducted a retrospective chart review of physician office, clinic, emergency room, and inpatient records of a random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals Conditional risks of rupture were calculated using life table methods Logistic regression was used to assess factors associated with rupture, and linear regression was used to assess factors affecting time from first examination to treatment Results Rupture risk was≤2% in patients with less than 36hours of untreated symptoms For patients with untreated symptoms beyond 36hours, the risk of rupture rose to and remained steady at 5% for each ensuing 12-hour period Rupture was greater in patients with36hours or more of untreated symptoms (estimated relative risk [RR]=66; 95% CI: 19 to 83), age 65 years and older (RR=42; 95% CI: 19 to 61), fever>389°C (RR=36; 95% CI: 12 to 57), and tachycardia (heart rate≥100 beats/minute; RR=34; 95% CI: 18 to 54) Time between first physician examination and treatment was shorter among patients presenting to the emergency department (median, 71hours versus 109hours; p Conclusions Risk of rupture in ensuing 12-hour periods rises to 5% after 36hours of untreated symptoms Physicians should be cautious about delaying surgery beyond 36hours from symptom onset in patients with appendicitis

How Time Affects the Risk of Rupture in Appendicitis

OBJECTIVES: The purpose of this study was to determine the effect of hospital volume on long-term survival for women with breast cancer. METHODS: Survival analysis and proportional-hazard modeling were used to assess 5-year survival and risk of death, adjusting for clinical and sociodemographic variables. RESULTS: At 5 years, patients from very low-volume hospitals had a 60% greater risk of all-cause mortality than patients from high-volume hospitals. CONCLUSIONS: Hospital volume of breast cancer surgical cases has a strong positive effect on 5-year survival. Research is needed to identify whether processes of care, especially postsurgical adjuvant treatments, contribute to survival differences.

https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.88.3.454

Hospital volume differences and five-year survival from breast cancer

▪Objective:To determine whether a gender bias exists in referral for coronary bypass graft surgery among patients with catheterization-documented coronary artery disease. ▪Design:Historica...

Nina A. Bickell

Papers

Missed Opportunities: Racial Disparities in Adjuvant Breast Cancer Treatment

Language barriers in medicine in the United States.

How Time Affects the Risk of Rupture in Appendicitis

Hospital volume differences and five-year survival from breast cancer

Referral patterns for coronary artery disease treatment: gender bias or good clinical judgment?