Showing papers in "Journal of General Internal Medicine in 2005"
TL;DR: This systematic review exhibits that limited health literacy, as depicted in the medical literature, is prevalent and is consistently associated with education, ethnicity, and age.
Abstract: OBJECTIVE: To systematically review U.S. studies examining the prevalence of limited health literacy and to synthesize these findings by evaluating demographic associations in pooled analyses.
1,200 citations
TL;DR: It is demonstrated that people vary substantially in their preferences for participation in decision making and Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.
Abstract: BACKGROUND: The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation. OBJECTIVES: 1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people’s preferences for participation in decision making. DESIGN AND PARTICIPANTS: A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N=2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences. MAIN RESULTS: Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined. CONCLUSION: This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.
1,059 citations
TL;DR: Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patients-centered care surveys, and publicly available information.
Abstract: Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.
599 citations
TL;DR: Limited English proficiency is a barrier to medical comprehension and increases the risk of adverse medication reactions and access to language-concordant physicians substantially mitigates but does not eliminate language barriers.
Abstract: OBJECTIVE: To determine the effect of limited English proficiency on medical comprehension in the presence and absence of language-concordant physicians.
537 citations
TL;DR: Following discharge, ADEs were common and many were preventable or ameliorable, and interventions should include better monitoring and target patients receiving specific drug classes or multiple medications.
Abstract: OBJECTIVE: To describe the incidence of adverse drug events (ADEs), preventable ADEs, and ameliorable ADEs occurring after hospital discharge and their associated risk factors.
460 citations
TL;DR: The overall incidence of HZ reported in the present study was found to be similar to rates observed in U.S. analyses conducted 10 to 20 years earlier, after age- and sex-standardizing estimates from all studies to the 2000 U.s. population.
Abstract: BACKGROUND: Few recent studies have reported data on the incidence of herpes zoster (HZ) in U.S. general clinical practice.
452 citations
TL;DR: This study aims to establish a baseline level of understanding of resident distress and its potential to negatively effect patient care and to investigate the mechanisms behind resident well-being problems.
Abstract: BACKGROUND
While resident distress and its potential to negatively effect patient care have been well documented, little is known bout resident well-being or its potential to enhance care.
382 citations
TL;DR: There is evidence to suggest that melatonin is not effective in treating most primary sleep disorders with short-term use (4 weeks or less); however, additional large-scale RCTs are needed before firm conclusions can be drawn.
Abstract: BACKGROUND: Exogenous melatonin has been increasingly used in the management of sleep disorders.
359 citations
TL;DR: Telephone administration of the PHQ-9 seems to be a reliable procedure for assessing depression in PC, and its internal consistency was high and close to the self-administered one.
Abstract: BACKGROUND: Telephone assessment of depression for research purposes is increasingly being used. The Patient Health Questionnaire 9-item depression module (PHQ-9) is a well-validated, brief, self-reported, diagnostic, and severity measure of depression designed for use in primary care (PC). To our knowledge, there are no available data regarding its validity when administered over the telephone. OBJECTIVE: The aims of the present study were to evaluate agreement between self-administered and telephone-administered PHQ-9, to investigate possible systematic bias, and to evaluate the internal consistency of the telephone-administered PHQ-9. METHODS: Three hundred and forty-six participants from two PC centers were assessed twice with the PHQ-9. Participants were divided into 4 groups according to administration procedure order and administration procedure of the PHQ-9: Self-administered/Telephone-administered; Telephone-administered/Self-administered; Telephone-administered/Telephone-administered; and Self-administered/Self-administered. The first 2 groups served for analyzing the procedural validity of telephone-administered PHQ-9. The last 2 allowed a test-retest reliability analysis of both self- and telephone-administered PHQ-9. Intraclass correlation coefficient (ICC) and weighted κ (for each item) were calculated as measures of concordance. Additionally, Pearson’s correlation coefficient, Student’s t-test, and Cronbach’s α were analyzed. RESULTS: Intraclass correlation coefficient and weighted κ between both administration procedures were excellent, revealing a strong concordance between telephone- and self-administered PHQ-9. A small and clinically nonsignificant tendency was observed toward lower scores for the telephone-administered PHQ-9. The internal consistency of the telephone-administered PHQ-9 was high and close to the self-administered one. CONCLUSIONS: Telephone and in-person assessments by means of the PHQ-9 yield similar results. Thus, telephone administration of the PHQ-9 seems to be a reliable procedure for assessing depression in PC.
338 citations
TL;DR: Several interventions have been developed to improve health for people with low literacy, but further research is required to understand better the types of interventions that are most effective and efficient for overcoming literacy-related barriers to good health.
Abstract: OBJECTIVE: To perform a systematic review of interventions designed to improve health outcomes for persons with low literacy skills.
315 citations
TL;DR: Engaging hospital inpatients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.
Abstract: PURPOSE: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.
TL;DR: Self-reported continuity of care is strongly associated with higher patient satisfaction, which suggests that improving continuity of Care may improve patient satisfaction with providers as well as with their health care organization.
Abstract: OBJECTIVE: The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction.
TL;DR: Adherence to screening colonoscopy referrals is suboptimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in Colonoscopy referral and scheduling mechanisms.
Abstract: BACKGROUND: Colonoscopy has become a preferred colorectal cancer (CRC) screening modality. Little is known about why patients who are referred for colonoscopy do not complete the recommended procedures. Prior adherence studies have evaluated colonoscopy only in combination with flexible sigmoidoscopy, failed to differentiate between screening and diagnostic procedures, and have examined cancellations/no-shows, but not nonscheduling, as mechanisms of nonadherence. METHODS: Sociodemographic predictors of screening completion were assessed in a retrospective cohort of 647 patients referred for colonoscopy at a major university hospital. Then, using a qualitative study design, a convenience sample of patients who never completed screening after referral (n=52) was interviewed by telephone, and comparisons in reported reasons for nonadherence were made by gender. RESULTS: Half of all patients referred for colonoscopy failed to complete the procedure, overwhelmingly because of nonscheduling. In multivariable analysis, female sex, younger age, and insurance type predicted poorer adherence. Patient-reported barriers to screening completion included cognitive-emotional factors (e.g., lack of perceived risk for CRC, fear of pain, and concerns about modesty and the bowel preparation), logistic obstacles (e.g., cost, other health problems, and competing demands), and health system barriers (e.g., scheduling challenges, long waiting times). Women reported more concerns about modesty and other aspects of the procedure than men. Only 40% of patients were aware of alternative screening options. CONCLUSIONS: Adherence to screening colonoscopy referrals is suboptimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in colonoscopy referral and scheduling mechanisms.
TL;DR: High mental well-being was associated with enhanced resident empathy in this cross-sectional survey, and the importance of a number of personal wellness promotion strategies differed for residents with higher mentalWell-being on the SF-8.
Abstract: BACKGROUND: While resident distress and its potential to negatively effect patient care have been well documented, little is known about resident well-being or its potential to enhance care.
TL;DR: Unmet health care needs due to cost increased with higher risk profiles for each racial and ethnic group, and whites were more likely than other racial/ethnic groups to report unmet needs.
Abstract: CONTEXT: Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks.
TL;DR: An evaluation of the feasibility and utility of a comprehensive screening and diagnosis program for dementia in primary care in England found it to be feasible and utility.
Abstract: BACKGROUND: Primary care physicians are positioned to provide early recognition and treatment of dementia. We evaluated the feasibility and utility of a comprehensive screening and diagnosis program for dementia in primary care. METHODS: We screened individuals aged 65 and older attending 7 urban and racially diverse primary care practices in Indianapolis. Dementia was diagnosed according to International Classification of Diseases (ICD)-10 criteria by an expert panel using the results of neuropsychologic testing and information collected from patients, caregivers, and medical records. RESULTS: Among 3,340 patients screened, 434 scored positive but only 227 would agree to a formal diagnostic assessment. Among those who completed the diagnostic assessment, 47% were diagnosed with dementia, 33% had cognitive impairment—no dementia (CIND), and 20% were considered to have no cognitive deficit. The overall estimated prevalence of dementia was 6.0% (95% confidence interval (CI) 5.5% to 6.6%) and the overall estimate of the program cost was $128 per patient screened for dementia and $3,983 per patient diagnosed with dementia. Only 19% of patients with confirmed dementia diagnosis had documentation of dementia in their medical record. CONCLUSIONS: Dementia is common and undiagnosed in primary care. Screening instruments alone have insufficient specificity to establish a valid diagnosis of dementia when used in a comprehensive screening program; these results may not be generalized to older adults presenting with cognitive complaints. Multiple health system and patient-level factors present barriers to this formal assessment and thus render the current standard of care for dementia diagnosis impractical in primary care settings.
TL;DR: Basic computerized prescribing systems may not be adequate to reduce errors and more advanced systems with dose and frequency checking are likely needed to prevent potentially harmful errors.
Abstract: BACKGROUND: Medication errors are common among inpatients and many are preventable with computerized prescribing. Relatively little is known about outpatient prescribing errors or the impact of computerized prescribing in this setting.
TL;DR: HIV-positive patients who currently smoke have increased mortality and decreased quality of life, as well as increased respiratory symptoms, COPD, and bacterial pneumonia, and these findings suggest that smoking cessation should be emphasized for HIV-infected patients.
Abstract: BACKGROUND: The impact of smoking on outcomes among those with HIV infection has not been determined in the era of highly active antiretroviral therapy (HAART). STUDY OBJECTIVE: Determine the impact of smoking on morbidity and mortality in HIV-positive patients post-HAART. DESIGN: Prospective observational study. PARTICIPANTS: Eight hundred and sixty-seven HIV-positive veterans enrolled in the Veterans Aging Cohort 3 Site Study. MEASUREMENTS: Clinical data were collected through patient questionnaire, International Classification of Diseases—9th edition codes, and standardized chart extraction, and laboratory and mortality data through the national VA database. Quality of life was assessed with the physical component summary (PCS) of the Short-Form 12. RESULTS: Current smokers had increased respiratory symptoms, chronic obstructive pulmonary disease (COPD), and bacterial pneumonia. In analyses adjusted for age, race/ethnicity, CD4 cell count, HIV RNA level, hemoglobin, illegal drug and alcohol use, quality of life was substantially decreased (β=−3.3, 95% confidence interval [CI] −5.3 to −1.4) and mortality was significantly increased (hazard ratio 1.99, 95% CI 1.03 to 3.86) in current smokers compared with never smokers. CONCLUSIONS: HIV-positive patients who currently smoke have increased mortality and decreased quality of life, as well as increased respiratory symptoms, COPD, and bacterial pneumonia. These findings suggest that smoking cessation should be emphasized for HIV-infected patients.
TL;DR: It is suggested that, although general knowledge and awareness of HTN is adequate, patients do not have a comprehensive understanding of this condition, and an opportunity exists to focus patient education programs and interventions on the cardiovascular risk associated with uncontrolled HTN, particularly elevated SBP levels.
Abstract: OBJECTIVE: Improved recognition of the importance of systolic blood pressure (SBP) has been identified as one of the major public health and medical challenges in the prevention and treatment of hypertension (HTN). SBP is a strong independent risk factor for cardiovascular disease but no information is available on whether patients understand the importance of their SBP level. The purpose of this study was to assess HTN knowledge, awareness, and attitudes, especially related to SBP in a hypertensive population.
TL;DR: It is asserted that a group peer, collaborative mentoring model founded on principles of adult education is one that is likely to be an effective and predictably reliable form of mentoring for both women and men in academic medicine.
Abstract: In this paper, we discuss an alternative structure and a broader vision for mentoring of medical faculty. While there is recognition of the need for mentoring for professional advancement in academic medicine, there is a dearth of research on the process and outcomes of mentoring medical faculty. Supported by the literature and our experience with both formal dyadic and group peer mentoring programs as part of our federally funded National Center of Leadership in Academic Medicine, we assert that a group peer, collaborative mentoring model founded on principles of adult education is one that is likely to be an effective and predictably reliable form of mentoring for both women and men in academic medicine.
TL;DR: Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution’s diversity climate and 4 strategies for improving the psychological climate and structural diversity of the institution.
Abstract: BACKGROUND: Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals.
TL;DR: Substantial changes in health status occurred over the course of pregnancy and insufficient money for food or housing and lack of exercise were associated with poor health status before, during, and after pregnancy.
Abstract: OBJECTIVE: To characterize the changes in health status experienced by a multi-ethnic cohort of women during and after pregnancy.
TL;DR: Patient health status, especially abnormal gait or lower extremity problems, medications, as well as care-related factors, increase the risk of falling, and fall prevention programs should target patients with these risk factors.
Abstract: OBJECTIVE: To comprehensively analyze potential risk factors for falling in the hospital and describe the circumstances surrounding falls.
TL;DR: Assessments of communication and health care quality for outpatient visits are similar for LEP Asian immigrants who use interpreters and those whose clinicians speak their language, however, interpreter use may compromise certain aspects of communication.
Abstract: BACKGROUND: Patients with limited English proficiency (LEP) have more difficulty communicating with health care providers and are less satisfied with their care than others. Both interpreter- and language-concordant clinicians may help overcome these problems but few studies have compared these approaches.
TL;DR: Doctors’ religious characteristics are diverse and they differ in many ways from those of the general population, and researchers, medical educators, and policy makers should further examine the ways in which physicians’religious commitments shape their clinical engagements.
Abstract: BACKGROUND: Patients’ religious commitments and religious communities are known to influence their experiences of illness and their medical decisions. Physicians are also dynamic partners in the doctorpatient relationship, yet little is known about the religious characteristics of physicians or how physicians’ religious commitments shape the clinical encounter. OBJECTIVE: To provide a baseline description of physicians’ religious characteristics, and to compare physicians’ characteristics with those of the general U.S. population. DESIGN/PARTICIPANTS: Mailed survey of a stratified random sample of 2,000 practicing U.S. physicians. Comparable U.S. population data are derived from the 1998 General Social Survey. MEASUREMENTS/RESULTS: The response rate was 63%. Fifty-five percent of physicians say their religious beliefs influence their practice of medicine. Compared with the general population, physicians are more likely to be affiliated with religions that are underrepresented in the United States, less likely to say they try to carry their religious beliefs over into all other dealings in life (58% vs 73%), twice as likely to consider themselves spiritual but not religious (20% vs 9%), and twice as likely to cope with major problems in life without relying on God (61% vs 29%). CONCLUSIONS: Physicians’ religious characteristics are diverse and they differ in many ways from those of the general population. Researchers, medical educators, and policy makers should further examine the ways in which physicians’ religious commitments shape their clinical engagements.
TL;DR: Effective use of computers in the outpatient exam room may be dependent upon clinicians’ baseline skills that are carried forward and are amplified, positively or negatively, in their effects on clinician-patient communication.
Abstract: OBJECTIVE: To evaluate the impact of exam-room computers on communication between clinicians and patients.
TL;DR: Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined, as many HIV-infected adults believe that their clinicians have discriminated against them.
Abstract: BACKGROUND: Perceived discrimination in clinical settings could discourage HIV-infected people from seeking health care, adhering to treatment regimens, or returning for follow-up. OBJECTIVES: This study aims to determine whether HIV-infected people perceive that physicians and other health care providers have discriminated against them. DESIGN, PARTICIPANTS: Cross-sectional data (1996 to 1997) from the HIV Cost and Services Utilization Study (HCSUS), which conducted in-person interviews with a nationally representative probability sample of 2,466 HIV-infected adults receiving health care within the contiguous U.S. MEASUREMENTS: Reports of whether health care providers have been uncomfortable with the respondent, treated the respondent as an inferior, preferred to avoid the respondent, or refused the respondent service. Questions also covered the types of providers who engaged in these behaviors. RESULTS: Twenty-six percent of HIV-infected adults receiving health care reported experiencing at least 1 of 4 types of perceived discrimination by a health care provider since becoming infected with HIV, including 8% who had been refused service. White respondents (32%) were more likely than others (27%) and Latinos (21%) and nearly twice as likely as African Americans (17%) to report perceived discrimination (P<.001). Respondents whose first positive HIV test was longer ago were also more likely to report discrimination (P<.001). Respondents who reported discrimination attributed it to physicians (54%), nurses and other clinical staff (39%), dentists (32%), hospital staff (31%), and case managers or social workers (8%). CONCLUSIONS: Many HIV-infected adults believe that their clinicians have discriminated against them. Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined.
TL;DR: Education was far more important than race/ethnicity as a determinant of LTPA and WRPA in multivariate analyses, and differences in educational attainment and health status accounted for virtually all of the racial and ethnic differences in LTPA.
Abstract: BACKGROUND: Racial and ethnic minority groups have lower levels of leisure-time physical activity (LTPA) than whites, but it is unclear how much of this is explained by differences in socioeconomic status and health. OBJECTIVE: To examine differences in LTPA, work-related physical activity (WRPA; heavy household chores and strenuous job activities), and total physical activity (TPA) by race, ethnicity, and education. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analyses of data from the 1992 Health and Retirement Study for a nationally representative cohort of 9,621 community-dwelling adults aged 51–61 years. MEASUREMENTS: Physical activity scores for LTPA, WRPA, and TPA based upon self-reported frequency of light or vigorous recreational activities, heavy household chores, and strenuous job-related physical activities. MAIN RESULTS: LTPA was lower for blacks and Hispanics compared to whites, and LTPA steadily declined with lower levels of education. WRPA showed the reverse pattern, being lowest for whites and persons with greater education. Education was far more important than race/ethnicity as a determinant of LTPA and WRPA in multivariate analyses. After adjusting for differences in overall health and physical functioning, mean TPA scores were similar across racial/ethnic and education categories; blacks (β=1.0; 95% confidence interval [CI], 0.5 to 1.5) and Spanish-speaking Hispanics (β=1.1; 95% CI, 0.3 to 1.9) had slightly higher levels of TPA than whites (P<.01 and P=.01, respectively). CONCLUSIONS: Differences in educational attainment and health status accounted for virtually all of the racial and ethnic differences in LTPA. After accounting for WRPA, TPA was similar across race, ethnicity, and education subgroups.
TL;DR: Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients admitted to an internal medicine service and can contribute to anemia, which may have significant consequences for patients with cardiorespiratory diseases.
Abstract: CONCLUSIONS: Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients admitted to an internal medicine service and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Knowing the expected changes in hemoglobin and hematocrit due to diagnostic phlebotomy will help guide when to investigate anemia in hospitalized patients.
TL;DR: In this diverse sample of older adults recruited from senior centers, low age-expectations are independently associated with very low levels of physical activity.
Abstract: BACKGROUND: New strategies to increase physical activity among sedentary older adults are urgently needed. OBJECTIVE: To examine whether low expectations regarding aging (age-expectations) are associated with low physical activity levels among older adults. DESIGN: Cross-sectional survey. PARTICIPANTS: Six hundred and thirty-six English- and Spanish-speaking adults aged 65 years and above attending 14 community-based senior centers in the Los Angeles region. Over 44% were non-Latino whites, 15% were African American, and 36% were Latino. The mean age was 77 years (range 65 to 100). MEASUREMENTS: Self-administered written surveys including previously tested measures of age-expectations and physical activity level in the previous week. RESULTS: Over 38% of participants reported <30 minutes of moderate-vigorous physical activity in the previous week. Older adults with lower age-expectations were more likely to report this very low level of physical activity than those with high age-expectations, even after controlling for the independent effect of age, sex, ethnicity, level of education, physical and mental health-related quality of life, comorbidity, activities of daily living impairment, depressive symptoms, self-efficacy, survey language, and clustering at the senior center. Compared with the quintile of participants having the highest age-expectations, participants with the lowest quintile of age-expectations had an adjusted odds ratio of 2.6 (95% confidence intervals: 1.5, 4.5) of reporting <30 minutes of moderate-vigorous physical activity in the previous week. CONCLUSIONS: In this diverse sample of older adults recruited from senior centers, low age-expectations are independently associated with very low levels of physical activity. Harboring low age-expectations may act as a barrier to physical activity among sedentary older adults.