Showing papers on "Health care published in 1999"

The Department of Health and Human Services.

Abstract: This letter is in response to your two Citizen Petitions dated November 17, 1994 and May 13, 2008, requesting that the Food and Drug Administration (FDA or the Agency) require a cancer warning on cosmetic talc products. Your 1994 Petition requests that all cosmetic talc bear labels with a warning such as \"Talcum powder causes cancer in laboratory animals. Frequent talc application in the female genital area increases the risk of ovarian cancer.\" Additionally, your 2008 Petition requests that cosmetic talcum powder products bear labels with a prominent warning such as: \"Frequent talc application in the female genital area is responsible for major risks of ovarian cancer.\" Further, both of your Petitions specifically request, pursuant to 21 CFR 1 0.30(h)(2), a hearing for you to present scientific evidence in support of this petition.

Validation and utility of a self-report version of PRIME-MD : The PHQ Primary Care Study

Abstract: ContextThe Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness.ObjectiveTo determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD.DesignCriterion standard study undertaken between May 1997 and November 1998.SettingEight primary care clinics in the United States.ParticipantsOf a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ.Main Outcome MeasuresPatient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions.ResultsA total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized.ConclusionOur study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use.

Qualitative Research in Health Care

Abstract: This fully revised and updated edition of Qualitative Research in Health Care offers a clear and accessible introduction to conducting and interpreting qualitative research, incorporating new examples, references and chapters relevant for a comprehensive introduction to the subject. New chapters and references include: • Synthesising qualitative research • Secondary analysis of primary data • Ethical issues • Mixed research methods and integrating qualitative with quantitative techniques • Consensus and other methods for eliciting public and professional views and preferences • Conversation analysis

Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?

Abstract: ContextAlthough physicians report spending a considerable amount of time in continuing medical education (CME) activities, studies have shown a sizable difference between real and ideal performance, suggesting a lack of effect of formal CME.ObjectiveTo review, collate, and interpret the effect of formal CME interventions on physician performance and health care outcomes.Data SourcesSources included searches of the complete Research and Development Resource Base in Continuing Medical Education and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group, supplemented by searches of MEDLINE from 1993 to January 1999.Study SelectionStudies were included in the analyses if they were randomized controlled trials of formal didactic and/or interactive CME interventions (conferences, courses, rounds, meetings, symposia, lectures, and other formats) in which at least 50% of the participants were practicing physicians. Fourteen of 64 studies identified met these criteria and were included in the analyses. Articles were reviewed independently by 3 of the authors.Data ExtractionDeterminations were made about the nature of the CME intervention (didactic, interactive, or mixed), its occurrence as a 1-time or sequenced event, and other information about its educational content and format. Two of 3 reviewers independently applied all inclusion/exclusion criteria. Data were then subjected to meta-analytic techniques.Data SynthesisThe 14 studies generated 17 interventions fitting our criteria. Nine generated positive changes in professional practice, and 3 of 4 interventions altered health care outcomes in 1 or more measures. In 7 studies, sufficient data were available for effect sizes to be calculated; overall, no significant effect of these educational methods was detected (standardized effect size, 0.34; 95% confidence interval [CI], −0.22 to 0.97). However, interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).ConclusionsOur data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.

Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.

Abstract: This is the first in a series of four articles on issues in the development and use of clinical guidelines Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned …

Quality End-of-Life Care: Patients' Perspectives

Abstract: ContextQuality end-of-life care is increasingly recognized as an ethical obligation of health care providers, both clinicians and organizations. However, this concept has not been examined from the perspective of patients.ObjectiveTo identify and describe elements of quality end-of-life care from the patient's perspective.DesignQualitative study using in-depth, open-ended, face-to-face interviews and content analysis.SettingToronto, Ontario.ParticipantsA total of 126 participants from 3 patient groups: dialysis patients (n = 48), people with human immunodeficiency virus infection (n = 40), and residents of a long-term care facility (n = 38).Outcome MeasuresParticipants' views on end-of-life issues.ResultsParticipants identified 5 domains of quality end-of-life care: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones.ConclusionThese domains, which characterize patients' perspectives on end-of-life care, can serve as focal points for improving the quality of end-of-life care.

Patient-physician racial concordance and the perceived quality and use of health care.

Abstract: Background Patients from racial and ethnic minority groups use fewer health care services and are less satisfied with their care than patients from the majority white population. These disparities may be attributable in part to racial or cultural differences between patients and their physicians. Objective To determine whether racial concordance between patients and physicians affects patients' satisfaction with and use of health care. Methods We analyzed data from the 1994 Commonwealth Fund's Minority Health Survey, a nationwide, telephone survey of noninstitutionalized adults. For the 2201 white, black, and Hispanic respondents who reported having a regular physician, we examined the association between patient-physician racial concordance and patients' ratings of their physicians, satisfaction with health care, reported receipt of preventive care, and reported receipt of needed medical care. Results Black respondents with black physicians were more likely than those with nonblack physicians to rate their physicians as excellent (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.55-3.72) and to report receiving preventive care (adjusted OR, 1.74; 95% CI, 1.01-2.98) and all needed medical care (adjusted OR, 2.94; 95% CI, 1.10-7.87) during the previous year. Hispanics with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their health care overall (adjusted OR, 1.74; 95% CI, 1.01-2.99). Conclusions Our findings confirm the importance of racial and cultural factors in the patient-physician relationship and reaffirm the role of black and Hispanic physicians in caring for black and Hispanic patients. Improving cultural competence among physicians may enhance the quality of health care for minority populations. In the meantime, by reducing the number of underrepresented minorities entering the US physician workforce, the reversal of affirmative action policies may adversely affect the delivery of health care to black and Hispanic Americans.

Application of discrete-event simulation in health care clinics: A survey

Abstract: In recent decades, health care costs have dramatically increased, while health care organisations have been under severe pressure to provide improved quality health care for their patients. Several health care administrators have used discrete-event simulation as an effective tool for allocating scarce resources to improve patient flow, while minimising health care delivery costs and increasing patient satisfaction. The rapid growth in simulation software technology has created numerous new application opportunities, including more sophisticated implementations, as well as combining optimisation and simulation for complex integrated facilities. This paper surveys the application of discrete-event simulation modeling to health care clinics and systems of clinics (for example, hospitals, outpatient clinics, emergency departments, and pharmacies). Future directions of research and applications are also discussed.

Health Literacy Among Medicare Enrollees in a Managed Care Organization

Abstract: ContextElderly patients may have limited ability to read and comprehend medical information pertinent to their health.ObjectiveTo determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization.DesignCross-sectional survey.SettingFour Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla).ParticipantsA total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language.Main Outcome MeasureFunctional health literacy as measured by the Short Test of Functional Health Literacy in Adults.ResultsOverall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years.ConclusionsElderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.

The development of a questionnaire to assess the readiness of health care students for interprofessional learning (ripls)

Abstract: Objectives: Although shared learning activities are gradually being introduced to health care undergraduates, it has not been possible to measure the effects of educational interventions on students' attitudes. The main objective of this study was to develop a rating scale using items based on the desired outcomes of shared learning, to assess the `readiness' of health care students for shared learning activities. Design and participants: A questionnaire study of 120 undergraduate students in 8 health care professions. Results: Principal components analysis resulted a 3-factor scale with 19 items and having an internal consistency of 0.9. The factors have been initially named `team-working and collaboration', professional identity' and `professional roles'. Conclusions: The new scale may be used to explore differences in students' perception and attitudes towards multi-professional learning. Further work is necessary to validate the scale amongst a larger population.

Five laws for integrating medical and social services: lessons from the United States and the United Kingdom.

Abstract: Because persons with disabilities (PWDs) use health and social services extensively, both the United States and the United Kingdom have begun to integrate care across systems. Initiatives in these two countries are examined within the context of the reality that personal needs and use of systems differ by age and by type and severity of disability. The lessons derived from this scrutiny are presented in the form of five “laws” of integration. These laws identify three levels of integration, point to alternative roles for physicians, outline resource requirements, highlight friction from differing medical and social paradigms, and urge policy makers and administrators to consider carefully who would be most appropriately selected to design, oversee, and administer integration initiatives. Both users and caregivers must be involved in planning to ensure that all three levels of integration are attended to and that the borders between medical and other systems are clarified.

The economic value of informal caregiving

Abstract: This study explores the current market value of the care provided by unpaid family members and friends to ill and disabled adults. Using large, national data sets we estimate that the national economic value of informal caregiving was $196 billion in 1997. This figure dwarfs national spending for formal home health care ($32 billion) and nursing home care ($83 billion). Estimates for five states also are presented. This study broadens the issue of informal caregiving from the micro level, where individual caregivers attempt to cope with the stresses and responsibilities of caregiving, to the macro level of the health care system, which must find more effective ways to support family caregivers.

Are health care professionals advising obese patients to lose weight

Abstract: ContextImplementation of the National Institutes of Health's 1998 guidelines, which recommended that health care professionals advise obese patients to lose weight, required baseline data for evaluation.ObjectivesTo describe the proportion and characteristics of obese persons advised to lose weight by their health care professional during the previous 12 months and to determine whether the advice was associated with reported attempts to lose weight.DesignThe Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted in 1996 by state health departments.SettingPopulation-based sample from 50 states and the District of Columbia.ParticipantsA total of 12,835 adults, 18 years and older, classified as obese (body mass index ≥30 kg/m2), who had visited their physician for a routine checkup during the previous 12 months.Main Outcome MeasuresReported advice from a health care professional to lose weight, and reported attempts to lose weight.ResultsForty-two percent of participants reported that their health care professional advised them to lose weight. Using multivariate logistic regression analysis, we found that the persons who were more likely to receive advice were female, middle aged, had higher levels of education, lived in the northeast, reported poorer perceived health, were more obese, and had diabetes mellitus. Persons who reported receiving advice to lose weight were significantly more likely to report trying to lose weight than those who did not (OR, 2.79; 95% CI, 2.53-3.08).ConclusionsLess than half of obese adults report being advised to lose weight by health care professionals. Barriers to counseling need to be identified and addressed.

Methods for analyzing health care utilization and costs

Abstract: Important questions about health care are often addressed by studying health care utilization. Utilization data have several characteristics that make them a challenge to analyze. In this paper we discuss sources of information, the statistical properties of utilization data, common analytic methods including the two-part model, and some newly available statistical methods including the generalized linear model. We also address issues of study design and new methods for dealing with censored data. Examples are presented.

Paternalism or partnership?: Patients have grown up—and there's no going back

Abstract: Paternalism is endemic in the NHS. Benign and well intentioned it may be, but it has the effect of creating and maintaining an unhealthy dependency which is out of step with other currents in society. Assumptions that doctor (or nurse) knows best, making decisions on behalf of patients without involving them and feeling threatened when patients have access to alternative sources of medical information—these signs of paternalism should have no place in modern health care. The articles assembled in this issue of the BMJ consider the scope for creating meaningful partnerships between doctors and patients and between health policymakers and local communities. Partners work together to achieve common goals. Their relationship is based on mutual respect for each other's skills and competencies and recognition of the advantages of combining these resources to achieve beneficial outcomes. Successful partnerships are non-hierarchical and the partners share decision making and responsibility. The key to successful doctor-patient partnerships is therefore to recognise that patients are experts too.1–3 The doctor is, or should be, well informed about diagnostic techniques, the causes of disease, prognosis, …

UK population norms for EQ-5D

Abstract: This discussion paper presents data from the Department of Health funded Measurement and Valuation of Health survey conducted at the Centre for Health Economics in 1993. This was a nationally representative interview survey of 3395 men and women aged 18 or over living in the UK. Amongst other things, the survey collected information on health status using the EuroQol (EQ-5D) descriptive system. The data is presented as a series of tables of age/sex population norms for the EQ-5D, for both self rated health status and weighted health state index. The tables are likely to be useful for researchers, clinicians, health care providers and policy makers, who are using EQ-5D to evaluate health care and who require baseline values for comparative purposes for monitoring population variations in health.

What do we mean by partnership in making decisions about treatment

Abstract: For many decades, the dominant approach to making decisions about treatment in the medical encounter has been one of paternalism.1–7 In recent years this model has been challenged by doctors, patients, medical ethicists, and researchers who advocate more of a partnership relation between doctors and patients.2 8–13 The reasons for this challenge have been described in detail elsewhere and include the rise of consumerism and the notion of consumer sovereignty in healthcare decision making; the women's movement with its emphasis on challenging medical authority; the passage of legislation focusing on patients' rights in health care; and small area variations in doctors' practice patterns that seem unrelated to differences in health status.7 Though the first three factors are seen as either contributors to or facilitators of patients' participation in making decisions about health care, the fourth highlights the imprecision or the “art” of medical care14: patients with similar clinical problems may receive different treatments from different doctors, due in part to systematic variations in practice patterns across geographical areas.14 15 The call for doctor-patient partnerships opens up options beyond paternalism for approaching the task of making decisions about treatment. But it also raises new complexities. Because a partnership between patient and doctor can take different forms, it is not intuitively apparent what this model would look like. The Oxford English Dictionary (1995) defines a partner as “a person who shares or takes part with another or others.” This definition leaves several important questions unanswered. For example, does the concept of a partnership imply that both doctor and patient need to share all parts of the decision making process? What is it that both parties are sharing, and to what degree? Who is responsible for determining if a partnership is possible and …

Why Patients Use Alternative Medicine: Results of a National Study

Abstract: Context.—Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood.Objective.—To investigate possible predictors of alternative health care use.Methods.—Three primary hypotheses were tested. People seek out these alternatives because (1) they are dissatisfied in some way with conventional treatment; (2) they see alternative treatments as offering more personal autonomy and control over health care decisions; and (3) the alternatives are seen as more compatible with the patients' values, worldview, or beliefs regarding the nature and meaning of health and illness. Additional predictor variables explored included demographics and health status.Design.—A written survey examining use of alternative health care, health status, values, and attitudes toward conventional medicine. Multiple logistic regression analyses were used in an effort to identify predictors of alternative health care use.Setting and Participants.—A total of 1035 individuals randomly selected from a panel who had agreed to participate in mail surveys and who live throughout the United States.Main Outcome Measure.—Use of alternative medicine within the previous year.Results.—The response rate was 69%.The following variables emerged as predictors of alternative health care use: more education (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.3); poorer health status (OR, 1.3; 95% CI, 1.1-1.5); a holistic orientation to health (OR, 1.4; 95% CI, 1.1-1.9); having had a transformational experience that changed the person's worldview (OR, 1.8; 95% CI, 1.3-2.5); any of the following health problems: anxiety (OR, 3.1; 95% CI, 1.6-6.0); back problems (OR, 2.3; 95% CI, 1.7-3.2); chronic pain (OR, 2.0; 95% CI, 1.1-3.5); urinary tract problems (OR, 2.2; 95% CI, 1.3-3.5); and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology (OR, 2.0; 95% CI, 1.4-2.7). Dissatisfaction with conventional medicine did not predict use of alternative medicine. Only 4.4% of those surveyed reported relying primarily on alternative therapies.Conclusion.—Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.

Validation of Patient Reports, Automated Pharmacy Records, and Pill Counts With Electronic Monitoring of Adherence to Antihypertensive Therapy

Abstract: Objectives.To evaluate the validity of patient report, pharmacy dispensing records, and pill counts as measures of antihypertensive adherence using electronic monitoring as the validation standard.Methods.The study was conducted among 286 members of Harvard Pilgrim Health Care, a managed care organi

Critical Delays in HIV Testing and Care The Potential Role of Stigma

Abstract: When learning of a positive HIV test, individuals face a host of psychological and social stresses. HIV-related stigma is associated with psychological distress and can interfere with coping, adjustment, and management of HIV disease. Effective management of HIV disease requires timely testing for HIV infection so that persons who are infected can learn of their serostatus and gain access to care, therefore benefiting from available treatment options. This article discusses the impact that HIV-related stigma has on HIV testing and care. Specifically, problems associated with delays in testing, disclosure of seropositive status, and implications for health care are presented.

Women's Health Australia: recruitment for a national longitudinal cohort study.

Abstract: The Women's Health Australia (WHA) project is a longitudinal study of several cohorts of Australian women, which aims to examine the relationships between biological, psychological, social and lifestyle factors and women's physical health, emotional well-being, and their use of and satisfaction with health care. Using the Medicare database as a sampling frame (with oversampling of women from rural and remote areas), 106,000 women in the three age groups 18-23, 45-50 and 70-75 were sent an invitation to participate and a 24-page self-complete questionnaire. Reminder letters, a nation-wide publicity campaign, information brochures, a freecall number for inquiries, and the option of completing the questionnaire by telephone in English or in the respondent's own language, were used to encourage participation. Statutory regulations precluded telephone follow-up of non-respondents. Response rates were 41% (N = 14,792), 54% (N = 14,200) and 36% (N = 12,614) for the three age groups. Comparison with Australian census data indicated that the samples are reasonably representative of Australian women in these age groups, except for a somewhat higher representation of women who are married or in a defacto relationship, and of women with post-school education. The most common reason for non-participation was lack of interest or time. Personal circumstances, objections to the questionnaire or specific items in it, and concerns about confidentiality were the other main reasons. Recruitment of three representative age-group cohorts of women, and the maintenance of these cohorts over a number of years, will provide a valuable opportunity to examine associations over time between aspects of women's lives and their physical and emotional health and well-being.

Time and the patient-physician relationship.

Abstract: Being a physician always has been a busy job. This is especially true for primary care physicians who set as their goal the delivery and coordination of comprehensive care for patients. Achieving such a goal requires availability, a broad spectrum of medical knowledge, effective use of the local health care system, and attention to both the “big picture” and the details of a patient's life and health. The technical resources that go into the delivery of health care have been studied extensively. Major advances are frequent in the arenas of diagnostic testing, therapeutics, and pharmaceuticals. Modern information transfer technology has made physicians' ability to access information about these advances easier and contributed to patients being more aware of changes in many aspects of health care. At the same time, physicians may be called on to limit utilization of health care resources to services that are judged to be “medically necessary.” There has been relatively little study of physician time as a resource.1 Yet both as a contribution to health care costs and as a key element in patient-doctor relationships, there is reason to believe that it deserves more attention. Furthermore, with an increasing emphasis on value and efficiency in health care delivery, quality time between physician and patient is an increasingly valuable resource. Physicians spend time in face-to-face contact with patients gathering information, and developing a relationship, doing administrative work related to visits, and maintaining their knowledge base. Importantly, time is always finite: no matter what demands a physician faces, there are only 24 hours in a day. In the current practice environment, physicians face mounting demands on their time. Increasing administrative requirements for health care delivery (e.g., service and authorization requests, utilization review processes) encroach on time spent with patients. The 1995 Commonwealth Fund survey found that 41% of physicians noted a decline in the amount of time spent with patients and 43% noted a decline in the amount of time spent with colleagues between 1992 and 1995.2 Because of social and demographic changes in the physician workforce, many physicians have family responsibilities that reduce their time available for work. These factors have moved time management for physicians, in their practices and in their lives, to the forefront as a critical issue. In this article we examine the effects of limiting time on the patient-doctor relationship. We review the effects that are attributable to managed care. Finally, we offer recommendations for teaching medical students and residents skills that will help establish and maintain their patient-doctor relationships in the face of time pressure.

Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care.

Abstract: Study Design. A double-blind, randomized controlled trial of a novel educational booklet compared with a traditional booklet for patients seeking treatment in primary care for acute or recurrent low back pain. Objective. To test the impact of a novel educational booklet on patients' beliefs about back pain and functional outcome. Summary of Background Data. The information and advice that health professionals give to patients may be important in health care intervention, but there is little scientific evidence of their effectiveness. A novel patient educational booklet, The Back Book, has been developed to provide evidence-based information and advice consistent with current clinical guidelines. Methods. One hundred sixty-two patients were given either the experimental booklet or a traditional booklet. The main outcomes studied were fear-avoidance beliefs about physical activity, beliefs about the inevitable consequences of back trouble, the Roland Disability Questionnaire, and visual analogue pain scales. Postal follow-up response at 1 year after initial treatment was 78%. Results. Patients receiving the experimental booklet showed a statistically significant greater early improvement in beliefs which was maintained at 1 year. A greater proportion of patients with an initially high fear-avoidance beliefs score who received the experimental booklet had clinically important improvement in fear-avoidance beliefs about physical activity at 2 weeks, followed by a clinically important improvement in the Roland Disability Questionnaire score at 3 months. There was no effect on pain. Conclusion. This trial shows that carefully selected and presented information and advice about back pain can have a positive effect on patients' beliefs and clinical outcomes, and suggests that a study of clinically important effects in individual patients may provide further insights into the management of low back pain. Nonspecific low back pain is a common and recurring symptom that most people usually deal with themselves and for which there is no effective cure. Hence, the information and advice that health professionals give to patients may be a potent element of the health care intervention. Von Korff and Saunders 36 and Bush et al 12 found that one of the main reasons patients consult physicians is to seek information and reassurance. Bush et al 12 suggested that these patients have practical and realistic desires to learn about their low back pain, what to expect, and what they can do about it. There is some evidence that greater congruence among the patient's and clinician's perception of the problem, the prognosis for the disorder, and its long-term management is associated with higher patient satisfaction and better short-term outcomes. 14 Qualitative studies 8,33 have demonstrated the complexity and heterogeneity of patients' perceptions of back pain, which may raise questions about how easily these can be modified by simple information and advice. Deyo and Diehl 18 and Bush et al 12 found that, for patients in the United States, the most frequent reason for dissatisfaction with medical care was failure to receive an adequate explanation of their back pain. Patients who believed that the physician's explanation was inadequate wanted more diagnostic tests, did not cooperate as well with treatment, and had poorer clinical outcomes at 3 weeks. Skelton et al 33 found that patients in the United Kingdom were skeptical of medical explanations for their back pain either because they doubted its validity or because it did not fit their own understanding of the problem. Borkan et al 8 found that Israeli patients also were quite critical of the medical system and more interested in what works. The first U.S. and U.K. clinical guidelines for acute low back pain 3,16 recommended that patients should be given accurate and up-to-date information and advice about back pain and its management; however, that recommendation was based on theoretical considerations and general clinical consensus rather than on any firm scientific evidence that such information improves outcomes. These guidelines gave few practical details on precisely what the content of that information and advice should be, apart from general reassurance about the absence of serious disease and that most back pain improves quickly with simple symptomatic measures and activity modification. There has been a progressive shift in subsequent international guidelines. 10 Based on additional evidence that is now available, 40 the more recent U.K. 31 and New Zealand 2 guidelines suggest that the physician provide more positive advice to stay active and continue ordinary activities as normally as possible. The New Zealand guidelines also provide a detailed assessment of psychosocial yellow flags (risk factors for chronic pain and disability) and suggest general behavioral principles for how patients with these features should be managed. 23 Discussion at the Second International Forum for Primary Care Research on Low Back Pain 9 identified the continuing need for a simple and convincing explanation of back pain that is acceptable to patients and that would form a logical basis for active management. Most guidelines recommend that printed educational material should be made available, though this recommendation is based on limited evidence. 10 There are hundreds of leaflets and booklets about back pain, but remarkably few have been submitted to any sort of scientific evaluation. 11 Roland and Dixon 28 reported on the only randomized controlled trial (RCT) of a traditional clinical booklet that showed any significant impact on patients: those receiving the booklet consulted less frequently and had fewer specialist referrals for back pain over the next year. Cherkin et al 15 reported on an RCT that compared a 15-minute session with an educational nurse with a booklet that was similar to the material accompanying the Agency for Health Care Policy and Research (AHCPR) guidelines. 3 The nurse intervention yielded higher patient satisfaction, perceived knowledge, and exercise participation in the short term. The booklet showed similar trends, but they did not reach statistical significance compared with the outcomes of usual care. Neither of these trials showed any effect of a booklet on pain or functional status. The aim of the current study was to determine the impact of a novel educational booklet on the beliefs and functional outcome of patients seeking treatment in primary care for an acute or recurrent episode of low back pain.

Gambling and the Health of the Public: Adopting a Public Health Perspective.

Abstract: During the last decade there has been an unprecedented expansion of legalized gambling throughout North America. Three primary forces appear to be motivating this growth: (1) the desire of governments to identify new sources of revenue without invoking new or higher taxes; (2) tourism entrepreneurs developing new destinations for entertainment and leisure; and (3) the rise of new technologies and forms of gambling (e.g., video lottery terminals, powerball mega-lotteries, and computer offshore gambling). Associated with this phenomenon, there has been an increase in the prevalence of problem and pathological gambling among the general adult population, as well as a sustained high level of gambling-related problems among youth. To date there has been little dialogue within the public health sector in particular, or among health care practitioners in general, about the potential health impact of gambling or gambling-related problems. This article encourages the adoption of a public health perspective towards gambling. More specifically, this discussion has four primary objectives:

Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care

Abstract: Already the recipient of extraordinary critical acclaim, this magisterial book provides a landmark account of American medical education in the twentieth century, concluding with a call for the reformation of a system currently handicapped by managed care and by narrow, self-centered professional interests. Kenneth M. Ludmerer describes the evolution of American medical education from 1910, when a muck-raking report on medical diploma mills spurred the reform and expansion of medical schools, to the current era of managed care, when commercial interests once more have come to the fore, compromising the training of the nation's future doctors. Ludmerer portrays the experience of learning medicine from the perspective of students, house officers, faculty, administrators, and patients, and he traces the immense impact on academic medical centers of outside factors such as World War II, the National Institutes of Health, private medical insurance, and Medicare and Medicaid. Most notably, the book explores the very real threats to medical education in the current environment of managed care, viewing these developments not as a catastrophe but as a challenge to make many long overdue changes in medical education and medical practice. Panoramic in scope, meticulously researched, brilliantly argued, and engagingly written, Time to Heal is both a stunning work of scholarship and a courageous critique of modern medical education. The definitive book on the subject, it provides an indispensable framework for making informed choices about the future of medical education and health care in America.

Bacterial Contamination of the Hands of Hospital Staff During Routine Patient Care

Abstract: Background Cross-transmission of microorganisms by the hands of health care workers is considered the main route of spread of nosocomial infections. Objective To study the process of bacterial contamination of health care workers' hands during routine patient care in a large teaching hospital. Methods Structured observations of 417 episodes of care were conducted by trained external observers (S.T. and V.S.). Each observation period started after a hand-cleansing procedure and ended when the health care worker proceeded to clean his or her hands or at the end of a coherent episode of care. At the end of each period of observation, an imprint of the 5 fingertips of the dominant hand was taken and bacterial colony counts were quantified. Regression methods were used to model the intensity of bacterial contamination as a function of method of hand cleansing, use of gloves during patient care, duration and type of care, and hospital ward. Results Bacterial contamination increased linearly with time on ungloved hands during patient care (average, 16 colony-forming units [CFUs] per minute; 95% confidence interval, 11-21 CFUs per minute). Patient care activities independently (P Conclusions The duration and type of patient care affect hand contamination. Furthermore, because hand antisepsis was superior to hand washing, intervention trials should explore the role of systematic hand antisepsis as a cornerstone of infection control to reduce cross-transmission in hospitals.