Simulated application of US cardiology guidelines for statin use to hospital patients in Turkey.

OBJECTIVES: Simulate the application of the new cardiology prevention guideline on statin use in an angiography clinic sample taken from a hospital in Turkey. METHODS: Taking statins was used as a quality indicator. All cases (323) included in the sample met criteria for taking statins upon arrival in the angiography clinic. The study population was divided into 3 groups: critical coronary artery disease (CAD) (>50%), noncritical (<50%), or individuals with normal coronary arteries. Patient risk factors were tested for association with taking statins using multiple logistic regression analysis. RESULTS: Only 20.2% of patients were taking statins when they were accepted for coronary angiography. Patients with critical CAD and noncritical CAD had higher odds of receiving statins than persons with no CAD [odds ratio (OR)=12.9, P<.001 and OR=3.5, P=.025, respectively]. Patients receiving angiographic interventions for stent control were more likely to be on statins than patients with angina (OR=5.298, P=0.004). Compared to those not taking the treadmill test, both those with positive and those with negative results had reduced odds of receiving statins (OR=0.260, P=.002, and OR=0.130, P=.002, respectively). Both former and current smokers had lower odds of receiving statins than persons who had never smoked (OR=0.148, P<.001, and OR=0.161, P=.001). Patients taking aspirin were at risk of not being on statins (OR=0.238, P = .001). CONCLUSIONS: Most of the patients in this study were not taking statins comparing according to US guidelines. Patients who exhibited risk factors for a cardiovascular event but who had not been diagnosed with CAD were at risk for not being on statins.

Association of HbA1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 diabetes mellitus.

BACKGROUND: The extant literature lacks breadth on psychological variables associated with health outcome for type 2 diabetes mellitus (T2DM). This investigation extends the scope of psychological information by reporting on previously unpublished factors. OBJECTIVE: To investigate if intolerance of uncertainty, emotion regulation, or purpose in life differentiate T2DM adults with sustained high HbA(1c) (HH) vs. sustained acceptable HbA(1c) (AH). SUBJECTS AND METHODS: Cross-sectional observational study. Adult patients with diagnosed T2DM meeting inclusionary criteria for AH, HH, or a nondiabetic reference group (NDR) were randomly selected and invited to participate. Patients who consented and participated resulted in a final sample of 312 subgrouped as follows: HH (n = 108); AH (n = 98); and NDR (n = 106). Data sources included a survey, self-report questionnaires, and electronic medical record (EMR). RESULTS: HH individuals with T2DM reported lower purpose in life satisfaction (p = 0.005) compared to the NDR group. The effect size for this finding is in the small-to-medium range using Cohen's guidelines for estimating clinical relevance. The HH-AH comparison on purpose in life was nonsignificant. The emotion regulation and intolerance of uncertainty comparisons across the three groups were not significant. CONCLUSIONS: The present study determined that lower purpose in life satisfaction is associated with higher HbA(1c). In a T2DM patient with sustained high HbA(1c), the primary care clinician is encouraged to consider screening for purpose in life satisfaction by asking a single question such as "Do the things you do in your life seem important and worthwhile?" The patient's response will assist the clinician in determining if meaning or purpose in life distress may be interferring with diabetes self-care. If this is the case, the clinician can shift the conversation to the value of behavioral and emotional health counseling.

Health reform: a community experience using design research as a guide.

Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improving individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient's personal physician coordinating care throughout a patient's lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery. Mixed methodology provides greater insight into the unexpressed health needs of individuals and into the creation of delivery systems more likely to achieve the triple aim. In a small, midwestern town, a mixed methods approach was used to assess community health needs to facilitate design and implementation of care delivery systems. The research findings suggest that health system design concepts should focus on the creation of health, not health care; foster simplicity; create nurturing relationships; eliminate user fear; and contain costs. These observations can be helpful to health care professionals who are developing new methods of care delivery and policymakers and payers contemplating new payment systems to achieve the goals of the triple aim.

Coping style in primary care adult patients with abridged somatoform disorders.

Background and objective Empirical data are scarce regarding the adaptive response to stress for patients with somatoform disorders. Our objective was to identify the preferred coping strategies of patients with abridged somatisation, a common condition in primary care. Because of the functional impairment associated with somatisation, we predicted a preference for less effective, emotion-focused coping strategies over more effective, problem-focused adaptations.Design We conducted a cross-sectional, observational study of physician referred primary care patients who presented with persistent, medically unexplained, physical symptoms. Patients were classified into two abridged somatisation groups by symptom frequency and duration, as determined by the Diagnostic Interview Schedule. The groups were compared with each other and with a non-clinical reference group; outcome variables were eight emotion- and problem-focused strategies, as measured by the Ways of Coping Questionnaire.Results Of the 72 eligible individuals, 48 participated in the study. Median age was 48 years and 75% of patients were women; 26 had somatic syndrome and 22 had a subthreshold somatising level. Patients with abridged somatisation disorders preferred emotion-focused coping strategies - typically detachment and impact minimisation, wishful thinking and problem avoidance.Conclusions Patients with abridged somatising disorder responded to stress with predominantly emotion-focused strategies, which may be associated with a lower level of positive adaptive outcome. Our findings suggest that patients with abridged somatising disorders might benefit from emphasis on problem-focused coping strategies, delivered through primary care, to improve quality of life and decrease healthcare utilisation costs.

The MMPI-2: a contemporary normative study of midwestern family medicine outpatients.

For more than 60 years it has been known that profiles from the Minnesota Multiphasic Personality Inventory (MMPI), obtained from medical patients, are elevated when scores are plotted using general population norms. These elevations have been most apparent on the neurotic triad (NTd), the first 3 clinical scales on the MMPI profile. More than 45 years have passed since a nonreferred, normative sample of MMPIs was established from 50,000 consecutive medical outpatients. We present comparable but contemporary normative data for the revised MMPI (MMPI-2) based on a nonreferred sample of 1,243 family medicine outpatients (590 women; 653 men). As true for the original MMPI, contemporary medical outpatients have profiles that are significantly different, clinically and statistically, from the general population norms for the MMPI-2. This is particularly evident in elevations on the NTd. New normative tables of uniform medical T (UMT) scores were developed following the procedures used to create the uniform T scores for the MMPI-2. Measures of internal consistency are reported; test-retest reliability was established over a mean of 3.7 weeks, and results characterizing the stability of the validity and clinical scales are presented.

Septic sternoclavicular joint: a case report.

A 23-year-old man presented to our sports medicine clinic with a history of nontraumatic left anterior chest pain. Prior to presentation, a magnetic resonance image (MRI) had been performed that showed increased signal in the soft tissues around the sternoclavicular joint, primarily in the pectoralis major, and a small amount of fluid in the joint, thought possibly consistent with sympathetic effusion from a muscle tear. On examination, the patient was toxic appearing and had severe pain with virtually any left upper-extremity movement and with walking. There was swelling, redness, warmth, and tenderness over the left sternoclavicular joint. Vital signs were normal, but due to concerns of possible septic arthritis, he was admitted to the hospital. After discontinuation of prednisone and hydrocodone-acetaminophen that he had been receiving, the patient became febrile. Blood and sternoclavicular joint aspirate cultures grew methicillin-sensitive Staphylococcus aureus. On re-review of the MRI, subtle abnormal signal compatible with the patient's joint infection was seen. The patient was treated with intravenous antibiotics and, eventually, surgical resection of the left sternoclavicular joint, proximal clavicle, and lateral manubrium with subsequent muscle flap. No predisposing factor for this infection was found. Septic sternoclavicular joint is rare, accounting for 1% of all septic joints. Infection or other unusual pathology should be suspected when clinical findings are not consistent with simple musculoskeletal injury.

Somatisation and alexithymia in patients with high use of medical care and medically unexplained symptoms.

Background and objective Few reports in the medical literature examine physician agreement on a standard assessment for somatisation in primary care patients. We describe somatising patients who were subjectively identified by family physicians and subsequently classified on the somatisation spectrum by a standard evaluation. We also examine the relation between somatisation and alexithymia.Method Responding to a brief verbal prompt, family physicians referred high-utilising patients 18 years old and older who had 'persistent medically unexplained symptoms for at least 6 months' (n = 72). Patients who agreed to participate in the study (n = 48) were assessed individually using a structured diagnostic interview and two measures of alexithymia.Results All participating patients met inclusion criteria for one of two abridged subtypes on the somatisation spectrum. Somatisation was not related to alexithymia.Conclusions Family physicians subjectively identified patients who had somatisation, with a high level of accuracy and without formal screening or diagnostic tests. Embedded in a disease-management system, especially an electronic version, a brief verbal prompt to physicians to identify patients on the somatisation spectrum could potentially realise considerable savings in physician time and medical system financial expenditures.

Collaborative psychiatric care in a rural family medicine setting reduces health care utilization in depressed patients.

Collaborative care by primary care physicians and psychiatrists has been shown to improve adherence to treatment and symptoms in patients with major depression. The authors examined whether such a care model would alter health care utilization by depressed patients. Ambulatory visits and inpatient hospital days were compared for 49 patients with depression and 49 matched patients (age/gender/ severity of co-morbid conditions) who were not depressed. Use of health care services was measured 1 year before intervention and 1 year after intervention and compared with that of the control patients. The authors concluded that depressed patients make fewer visits to health care providers when a psychiatrist is involved in their care.

Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms.

This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.

Assessment and diagnosis of attention-deficit/hyperactivity disorder by family physicians.

In this study, our aim was to determine the extent to which family physicians in Minnesota follow the American Academy of Pediatrics (AAP) guideline in the assessment and diagnosis of attention-deficit/hyperactivity disorder (ADHD) in school-aged children and to identify barriers to using the guideline. We surveyed 1,000 randomly chosen members of the Minnesota Academy of Family Physicians. Of 303 respondents, 36% always referred children for a diagnosis and 99.7% referred children for a diagnosis of ADHD some of the time. Fifty-four percent were unaware of the AAP guideline. However, among those who said they evaluate children for ADHD, most followed the criteria in the AAP guideline. For example, most family physicians (97%) used a child's response to stimulant medication in their assessment. Respondents also said that barriers to ADHD assessment included lack of reimbursement and training.

Preparticipation sports examinations.

Preview In most states, an examination is required before school-aged youngsters are allowed to play recreational and competitive sports. Examining physicians are responsible for conducting a thorough yet cost-effective evaluation to detect disqualifying or restricting conditions. The authors summarize the aspects to consider during history taking and physical examination and provide guidelines approved by the American Academy of Pediatrics.