Showing papers in "Journal of General Internal Medicine in 2007"
TL;DR: Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.
Abstract: Context
Studies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions.
1,149 citations
TL;DR: The PHQ9 is acceptable, and as good as longer clinician-administered instruments in a range of settings, countries, and populations, and more research is needed to validate the PHQ2 to see if its diagnostic properties approach those of thePHQ9.
Abstract: To summarize the psychometric properties of the PHQ2 and PHQ9 as screening instruments for depression. We identified 17 validation studies conducted in primary care; medical outpatients; and specialist medical services (cardiology, gynecology, stroke, dermatology, head injury, and otolaryngology). Electronic databases from 1994 to February 2007 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane registers) plus study reference lists have been used for this study. Translations included US English, Dutch, Italian, Spanish, German and Arabic). Summary sensitivity, specificity, likelihood and diagnostic odds ratios (OR) against a gold standard (DSM-IV) Major Depressive Disorder (MDD) were calculated for each study. We used random effects bivariate meta-analysis at recommended cut points to produce summary receiver–operator characteristic (sROC) curves. We explored heterogeneity with metaregression. Fourteen studies (5,026 participants) validated the PHQ9 against MDD: sensitivity = 0.80 (95% CI 0.71–0.87); specificity = 0.92 (95% CI 0.88–0.95); positive likelihood ratio = 10.12 (95% CI 6.52–15.67); negative likelihood ratio = 0.22 (0.15 to 0.32). There was substantial heterogeneity (Diagnostic Odds Ratio heterogeneity I2 = 82%), which was not explained by study setting (primary care versus general hospital); method of scoring (cutoff ≥ 10 versus “diagnostic algorithm”); or study quality (blinded versus unblinded). The diagnostic validity of the PHQ2 was only validated in 3 studies and showed wide variability in sensitivity. The PHQ9 is acceptable, and as good as longer clinician-administered instruments in a range of settings, countries, and populations. More research is needed to validate the PHQ2 to see if its diagnostic properties approach those of the PHQ9.
1,048 citations
TL;DR: This Medline review of publications examining somatic chronic conditions co-occurring with 1 or more additional specific chronic illness between January 2000 and March 2007 summarizes the state of the understanding of the prevalence and health challenges of multiple chronic conditions and the implications for quality, care management, and costs.
Abstract: Persons with multiple chronic conditions are a large and growing segment of the US population. However, little is known about how chronic conditions cluster, and the ramifications of having specific combinations of chronic conditions. Clinical guidelines and disease management programs focus on single conditions, and clinical research often excludes persons with multiple chronic conditions. Understanding how conditions in combination impact the burden of disease and the costs and quality of care received is critical to improving care for the 1 in 5 Americans with multiple chronic conditions. This Medline review of publications examining somatic chronic conditions co-occurring with 1 or more additional specific chronic illness between January 2000 and March 2007 summarizes the state of our understanding of the prevalence and health challenges of multiple chronic conditions and the implications for quality, care management, and costs.
987 citations
TL;DR: Among adults with food insecurity, increased consumption of inexpensive food alternatives, which are often calorically dense and nutritionally poor, may play a role in this relationship.
Abstract: BACKGROUND
Food insecurity refers to limited or uncertain access to food resulting from inadequate financial resources. There is a clear association between food insecurity and obesity among women, but little is known about the relationship between food insecurity and type 2 diabetes.
703 citations
TL;DR: Both distress and well-being are related to medical student empathy, and efforts to reduce student distress should be part of broader efforts to promote student well- Being, which may enhance aspects of professionalism.
Abstract: To determine whether lower levels of empathy among a sample of medical students in the United States are associated with personal and professional distress and to explore whether a high degree of personal well-being is associated with higher levels of empathy. Multi-institutional, cross-sectional survey. All medical schools in Minnesota (a private medical school, a traditional public university, and a public university with a focus in primary care). A total of 1,098 medical students. Validated instruments were used to measure empathy, distress (i.e., burnout and symptoms of depression), and well-being (high quality of life). Medical student empathy scores were higher than normative samples of similarly aged individuals and were similar to other medical student samples. Domains of burnout inversely correlated with empathy (depersonalization with empathy independent of gender, all P < .02, and emotional exhaustion with emotive empathy for men, P = .009). Symptoms of depression inversely correlated with empathy for women (all P ≤ .01). In contrast, students’ sense of personal accomplishment demonstrated a positive correlation with empathy independent of gender (all P < .001). Similarly, achieving a high quality of life in specific domains correlated with higher empathy scores (P < .05). On multivariate analysis evaluating measures of distress and well-being simultaneously, both burnout (negative correlation) and well-being (positive correlation) independently correlated with student empathy scores. Both distress and well-being are related to medical student empathy. Efforts to reduce student distress should be part of broader efforts to promote student well-being, which may enhance aspects of professionalism. Additional studies of student well-being and its potential influence on professionalism are needed.
516 citations
TL;DR: Empathy scores of students in the preclinical years were higher than in the clinical years, and efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education.
Abstract: Empathy is important in the physician–patient relationship. Prior studies have suggested that physician empathy may decline with clinical training. To measure and examine student empathy across medical school years. A cross-sectional study of students at Boston University School of Medicine in 2006. Incoming students plus each class near the end of the academic year were surveyed. The Jefferson Scale of Physician Empathy–Student Version (JSPE-S), a validated 20-item self-administered questionnaire with a total score ranging from 20 to 140. JSPE-S scores were controlled for potential confounders such as gender, age, anticipated financial debt upon graduation, and future career interest. 658 students participated in the study (81.4% of the school population). The first-year medical student class had the highest empathy scores (118.5), whereas the fourth-year class had the lowest empathy scores (106.6). Measured empathy differed between second- and third-year classes (118.2 vs 112.7, P < .001), corresponding to the first year of clinical training. Empathy appears to increase from the incoming to the first-year class (115.5 vs 118.5, P = .02). Students preferring people-oriented specialties had higher empathy scores than students preferring technology-oriented specialties (114.6 vs 111.4, P = .002). Female students were more likely than male students to choose people-oriented specialties (51.5 vs 26.9%, P < .001). Females had higher JSPE-S scores than males (116.5 vs 112.1, P < .001). Age and debt did not affect empathy scores. Empathy scores of students in the preclinical years were higher than in the clinical years. Efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education. Future research is needed to confirm whether clinical training impacts empathy negatively, and, if so, whether interventions can be designed to mitigate this impact.
467 citations
TL;DR: Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment, and Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.
Abstract: Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen ≥ 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.
421 citations
TL;DR: The paper provides a framework that outlines strategies and skills, which can be taught to medical trainees and practicing physicians, to prevent unconscious racial attitudes and stereotypes from negatively influencing the course and outcomes of clinical encounters.
Abstract: The paper sets forth a set of evidence-based recommendations for interventions to combat unintentional bias among health care providers, drawing upon theory and research in social cognitive psychology. Our primary aim is to provide a framework that outlines strategies and skills, which can be taught to medical trainees and practicing physicians, to prevent unconscious racial attitudes and stereotypes from negatively influencing the course and outcomes of clinical encounters. These strategies and skills are designed to: l) enhance internal motivation to reduce bias, while avoiding external pressure; 2) increase understanding about the psychological basis of bias; 3) enhance providers’ confidence in their ability to successfully interact with socially dissimilar patients; 4) enhance emotional regulation skills; and 5) improve the ability to build partnerships with patients. We emphasize the need for programs to provide a nonthreatening environment in which to practice new skills and the need to avoid making providers ashamed of having racial, ethnic, or cultural stereotypes. These recommendations are also intended to provide a springboard for research on interventions to reduce unintentional racial bias in health care.
400 citations
TL;DR: Benzodiazepines and non-benzodiazepine treatments for chronic insomnia are effective treatments in the management of chronic insomnia, although they pose a risk of harm.
Abstract: Background
Hypnotics have a role in the management of acute insomnia; however, the efficacy and safety of pharmacological interventions in the management of chronic insomnia is unclear.
383 citations
TL;DR: Patients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form, and both the learning and implementation of the intervention require very little time.
Abstract: Context
In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.
373 citations
TL;DR: Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare’s new drug benefit, and efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage.
Abstract: Objective
Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.
TL;DR: The most commonly used measure for pain screening may have only modest accuracy for identifying patients with clinically important pain in primary care.
Abstract: BACKGROUND
Universal pain screening with a 0–10 pain intensity numeric rating scale (NRS) has been widely implemented in primary care.
TL;DR: Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction, and using a clinic interpreter did not mitigate these effects and exacerbated disparities in patients’ perceptions of their providers.
Abstract: Background
Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients.
TL;DR: Further work with greater methodologic rigor is needed to identify evidence-based strategies for increasing minority enrollment in research studies; community outreach, as an isolated strategy, may be less successful than other strategies.
Abstract: Members of vulnerable populations are underrepresented in research studies. To evaluate and synthesize the evidence regarding interventions to enhance enrollment of vulnerable populations into health research studies. Studies were identified by searching MEDLINE, the Web of Science database, personal sources, hand searching of related journals, and article references. Studies that contained data on recruitment interventions for vulnerable populations (minority, underserved, poor, rural, urban, or inner city) and for which the parent study (study for which recruitment was taking place) was an intervention study were included. A total of 2,648 study titles were screened and 48 articles met inclusion criteria, representing 56 parent studies. Two investigators extracted data from each study. African Americans were the most frequently targeted population (82% of the studies), while 46% targeted Hispanics/Latinos. Many studies assessed 2 or more interventions, including social marketing (82% of studies), community outreach (80%), health system recruitment (52%), and referrals (28%). The methodologic rigor varied substantially. Only 40 studies (71%) incorporated a control group and 21% used statistical analysis to compare interventions. Social marketing, health system, and referral recruitment were each found to be the most successful intervention about 35–45% of the studies in which they were attempted, while community outreach was the most successful intervention in only 2 of 16 studies (13%) in which it was employed. People contacted as a result of social marketing were no less likely to enroll than people contacted through other mechanisms. Further work with greater methodologic rigor is needed to identify evidence-based strategies for increasing minority enrollment in research studies; community outreach, as an isolated strategy, may be less successful than other strategies.
TL;DR: Non-English speaking individuals had lower odds of receiving needed services than those who only spoke English, when other factors were controlled, and LEP is associated with lower use of mental health care.
Abstract: Background
Limited English proficiency (LEP) may contribute to mental health care disparities, yet empirical data are limited.
TL;DR: Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.
Abstract: BACKGROUND
The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.
TL;DR: Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.
Abstract: Background
Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists.
TL;DR: Literacy level appears to be an important determinant of patients’ participation in the medical encounter, and low-literacy patients ask fewer questions about their medical care, and this may affect their ability to learn about theirmedical conditions and treatments.
Abstract: Background
Although patient participation in the medical encounter confers significant benefits, many patients are reluctant to ask questions of their physicians. Patients’ literacy level may affect their level of participation and question-asking behaviors.
TL;DR: Mmong immigrants from diverse ethnic backgrounds, longer length of residence in the United States is associated with increased odds of obesity, hyperlipidemia, and cigarette smoking even after adjusting for relevant confounding factors.
Abstract: BACKGROUND
Although differences in cardiovascular disease (CVD) risk factors between immigrants and nonimmigrants have been examined previously, the effect of acculturation on CVD risk factors in immigrants has been less well studied.
TL;DR: The prevalence and operation of medical student-run health clinics nationwide are described for the first time, and they offer myriad services to disadvantaged patients and are also a notable phenomenon in medical education.
Abstract: Despite the popularity of medical student-run health clinics among U.S. medical schools, there is no information about how many clinics exist, how many students volunteer there, or how many patients they see and what services they offer. We describe, for the first time, the prevalence and operation of medical student-run health clinics nationwide. A web-based survey was sent to all 124 Association of American Medical Colleges allopathic schools in the 50 states. Ninety-four schools responded (76%); 49 schools had at least 1 student-run clinic (52%). Fifty-nine student-run clinics provided detailed data on their operation. The average clinic had 16 student volunteers a week, and most incorporated preclinical students (56/59, 93%). Nationally, clinics reported more than 36,000 annual patient–physician visits, in addition to more nonvisit encounters. Patients were predominantly minority: 31% Hispanic; 31% Black/African American; 25% White; 11% Asian; and 3% Native American or other. Most student-run health clinics had resources both to treat acute illness and also to manage chronic conditions. Clinics were most often funded by private grants (42/59, 71%); among 27 clinics disclosing finances, a median annual operating budget of $12,000 was reported. Medical student-run health clinics offer myriad services to disadvantaged patients and are also a notable phenomenon in medical education. Wider considerations of community health and medical education should not neglect the local role of a student-run health clinic.
TL;DR: This study proposes a conceptual approach to complex patients and demonstrates how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans, and examines availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.
Abstract: BACKGROUND
The conceptualization of patient complexity is just beginning in clinical medicine.
TL;DR: Homeless people’s perceptions of welcomeness and unwelcomeness are an important aspect of their encounters with health care providers, and Buber’'s “I–It” and ”I–You” concepts are potentially useful aids to health care provider who wish to understand how welcoming and unw Welcoming interactions are fostered.
Abstract: Background
Homeless people face many barriers to obtaining health care, and their attitudes toward seeking health care services may be shaped in part by previous encounters with health care providers.
TL;DR: Evidence-based practices that reduce barriers to communication must be integrated into, rather than just added to, health care work processes.
Abstract: Effective communication with patients is critical to the safety and quality of care. Barriers to this communication include differences in language, cultural differences, and low health literacy. Evidence-based practices that reduce these barriers must be integrated into, rather than just added to, health care work processes.
TL;DR: Experiences with discrimination were associated with delays in seeking medical care and poor adherence to medical care recommendations in independent of need, enabling, and predisposing factors, including medical MISTRUST; however, a prospective study is needed.
Abstract: Background
Past research indicates that access to health care and utilization of services varies by sociodemographic characteristics, but little is known about racial differences in health care utilization within racially integrated communities.
Objective
To determine whether perceived discrimination was associated with delays in seeking medical care and adherence to medical care recommendations among African Americans and whites living in a socioeconomically homogenous and racially integrated community.
Design
A cross-sectional analysis from the Exploring Health Disparities in Integrated Communities Study.
Participants
Study participants include 1,408 African-American (59.3%) and white (40.7%) adults (≥18 years) in Baltimore, Md.
Measurements
An interviewer-administered questionnaire was used to assess the associations of perceived discrimination with help-seeking behavior for and adherence to medical care.
Results
For both African Americans and whites, a report of 1–2 and >2 discrimination experiences in one’s lifetime were associated with more medical care delays and nonadherence compared to those with no experiences after adjustment for need, enabling, and predisposing factors (odds ratio [OR]=1.8, 2.6; OR=2.2, 3.3, respectively; all P<.05). Results were similar for perceived discrimination occurring in the past year.
Conclusions
Experiences with discrimination were associated with delays in seeking medical care and poor adherence to medical care recommendations INDEPENDENT OF NEED, ENABLING, AND PREDISPOSING FACTORS, INCLUDING MEDICAL MISTRUST; however, a prospective study is needed. Further research in this area should include exploration of other potential mechanisms for the association between perceived discrimination and health service utilization.
TL;DR: There is a communication gap between seniors and their physicians around prescription medications, and this communication problem takes on added salience as physicians and patients confront new challenges associated with coverage under new Medicare prescription drug plans.
Abstract: Understanding and improving the quality of medication management is particularly important in the context of the Medicare prescription drug benefit that took effect last January 2006. To determine the prevalence of physician–patient dialogue about medication cost and medication adherence among elderly adults nationwide. Cross-sectional survey. National stratified random sample of community-dwelling Medicare beneficiaries aged 65 and older. Rates of physician–patient dialogue about nonadherence and cost-related medication switching. Forty-one percent of seniors reported taking five or more prescription medications, and more than half has 2 or more prescribing physicians. Thirty-two percent overall and 24% of those with 3 or more chronic conditions reported not having talked with their doctor about all their different medicines in the last 12 months. Of seniors reporting skipping doses or stopping a medication because of side effects or perceived nonefficacy, 27% had not talked with a physician about it. Of those reporting cost-related nonadherence, 39% had not talked with a physician about it. Thirty-eight percent of those with cost-related nonadherence reported switching to a lower priced drug, and in a multivariable model, having had a discussion about drug cost was significantly associated with this switch (odds ratio [OR] 5.04, 95% confidence interval [CI] 4.28–5.93, P < .001). We show that there is a communication gap between seniors and their physicians around prescription medications. This communication problem is an important quality and safety issue, and takes on added salience as physicians and patients confront new challenges associated with coverage under new Medicare prescription drug plans. Meeting these challenges will require that more attention be devoted to medication management during all clinical encounters.
TL;DR: The federal mandates for language rights in health care are described, a broad overview of existing state laws are provided and recent legal developments in addressing language barriers are described.
Abstract: Over the past few decades, the number and diversity of limited English speakers in the USA has burgeoned. With this increased diversity has come increased pressure—including new legal requirements—on healthcare systems and clinicians to ensure equal treatment of limited English speakers. Healthcare providers are often unclear about their legal obligations to provide language services. In this article, we describe the federal mandates for language rights in health care, provide a broad overview of existing state laws and describe recent legal developments in addressing language barriers. We conclude with an analysis of key policy initiatives that would substantively improve health care for LEP patients.
TL;DR: The SAQ-A is a reliable tool for eliciting provider attitudes about the ambulatory work setting and compares attitudes among different types of providers in the outpatient setting.
Abstract: Provider attitudes about issues pertinent to patient safety may be related to errors and adverse events. We know of no instruments that measure safety-related attitudes in the outpatient setting. To adapt the safety attitudes questionnaire (SAQ) to the outpatient setting and compare attitudes among different types of providers in the outpatient setting. We modified the SAQ to create a 62-item SAQ—ambulatory version (SAQ-A). Patient care staff in a multispecialty, academic practice rated their agreement with the items using a 5-point Likert scale. Cronbach’s alpha was calculated to determine reliability of scale scores. Differences in SAQ-A scores between providers were assessed using ANOVA. Of the 409 staff, 282 (69%) returned surveys. One hundred ninety (46%) surveys were included in the analyses. Cronbach’s alpha ranged from 0.68 to 0.86 for the scales: teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition. Physicians had the least favorable attitudes about perceptions of management while managers had the most favorable attitudes (mean scores: 50.4 ± 22.5 vs 72.5 ± 19.6, P < 0.05; percent with positive attitudes 18% vs 70%, respectively). Nurses had the most positive stress recognition scores (mean score 66.0 ± 24.0). All providers had similar attitudes toward teamwork climate, safety climate, job satisfaction, and working conditions. The SAQ-A is a reliable tool for eliciting provider attitudes about the ambulatory work setting. Attitudes relevant to medical error may differ among provider types and reflect behavior and clinic operations that could be improved.
TL;DR: In insights into the challenges that surrogates encounter when making decisions for loved ones are provided and areas where clinicians could intervene are indicated to facilitate the process of surrogate decision-making.
Abstract: BACKGROUND
A majority of end-of-life medical decisions are made by surrogate decision-makers who have varying degrees of preparation and comfort with their role. Having a seriously ill family member is stressful for surrogates. Moreover, most clinicians have had little training in working effectively with surrogates.
TL;DR: The prevalence of PTSD in the urban primary care setting, and particularly among certain high-risk conditions, compels a critical examination of optimal approaches for screening, intervention, and referral to PTSD treatment.
Abstract: BACKGROUND
Posttraumatic stress disorder (PTSD) is associated with medical and psychological morbidity. The prevalence of PTSD in urban primary care has not been well described.
TL;DR: Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers, which may lead to delayed detection of behavior problems.
Abstract: Objectives
To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care.