Views on personalized medicine: do the attitudes of African American and white prescription drug consumers differ?

AIMS: Although recent advances in pharmacogenomics are making possible the use of genetic testing to determine the best medication for patients, little is known about how patients view such procedures. The aims for this study that were developed collaboratively as part of a community-academic partnership are: (1) What are the attitudes and perceptions of prescription drug consumers concerning personalized medicine and genetic testing for drug compatibility and how do they differ between African American and white patients? (2) What are the attitudes and perceptions of patients concerning race-based prescribing and how do they differ between African American and white patients? METHODS: We conducted 6 focus groups, 2 with white participants and 4 with African American participants. Focus groups were audio-recorded, transcribed, and analyzed to ascertain common themes. RESULTS: Our results suggest that personalized medicine and genetic testing, though not well understood by lay persons, were considered positive advances in medicine. However, participants also voiced concerns about these advances that differed by race. CONCLUSION: This study points to the need to include perspectives of at-risk communities as we move toward wider use of this technology.

Patient preferences regarding possible outcomes of lung resection: what outcomes should preoperative evaluations target?

CONTEXT: Lung resection can lead to significant postoperative complications: Although many reports describe the likelihood of postoperative problems, such as atelectasis, pneumonia, and prolonged ventilator dependence, it is unclear whether patients perceive these outcomes as sufficiently severe to influence their decisions about surgery. OBJECTIVE: To assess patients' preferences regarding possible outcomes of lung resection, including traditional complications reported in the lung surgery literature and outcomes that describe functional limitation. DESIGN: Utility analysis. SETTING: A community hospital internal medicine clinic, a private internal medicine practice, and a private pulmonary practice. PARTICIPANTS: Sixty-four patients, aged 50 to 75 years, who were awaiting appointments at the designated clinic sites. MAIN OUTCOME MEASURE: Patients' strength of preference regarding potential outcomes of lung resection as derived from health utility scores. RESULTS: Common postoperative complications were assigned high utility scores by patients. On a scale for which 1.0 represents perfect health and 0 represents death, postoperative atelectasis, pneumonia, and 3 days of mechanical ventilation were all rated >0.75. Scores describing limited physical function were strikingly low. Specifically, activity limited to bed to chair movement and the need for complete assistance with activities of daily living were all assigned utility scores <0.2. Twenty-four-hour oxygen dependence was scored at 0.33. Presence or absence of pulmonary illness did not predict scores for any outcome. CONCLUSIONS: Whether patients suffer from chronic lung disease or not, they do not regard the postoperative outcomes reported in the lung surgery literature as sufficiently morbid to forego important surgery. However, physical debility is perceived as extremely undesirable, and anticipation of its occurrence could deter surgery. Therefore, identification of preoperative predictors of postoperative physical debility would be invaluable for counseling patients who face difficult decisions about lung resection.

Telephone medicine for internists.

The role of the telephone in medical practice is important, but often problematic. Mistakes in telephone diagnosis and triage can have severe consequences. An effective office system can reduce liability risks, and in some cases telephone contact can substitute for office visits. Internists feel unprepared to provide telephone care. Therefore, residency education needs to focus on documentation, consultant availability, and performance feedback. Research should focus on improving outcomes, reimbursement issues, and technologic advances. This article describes internists' telephone interactions with ambulatory patients, preparation for telephone medicine, and aspects of office telephone systems and makes comparisons with other primary care fields.

Racial differences in patients' perceptions of debilitated health states.

OBJECTIVE: To determine health utility scores for specific debilitated health states and to identify whether race or other demographic differences predict significant variation in these utility scores. DESIGN: Utility analysis. SETTING: A community hospital general internal medicine clinic, a private internal medicine practice, and a private pulmonary medicine practice. PARTICIPANTS: Sixty-four consecutive patients aged 50 to 75 years awaiting appointments. In order to participate, patients at the pulmonary clinic had to meet prespecified criteria of breathing impairment. MEASUREMENTS: Individuals' strength of preference concerning specific states of limited physical function as measured by the standard gamble technique. MAIN RESULTS: Mean utility scores used to quantitate limitations in physical function were extremely low. Using a scale for which 0 represented death and 1.0 represented normal health, limitation in activities of daily living was rated 0. 19 (95% confidence interval [CI] 0.13, 0.25), tolerance of only bed-to-chair ambulation 0.17 (95% CI 0.11, 0.23), and permanent nursing home placement 0.16 (95% CI 0.10, 0.22). Bivariate analysis identified female gender and African-American race as predictors of higher utility scores ( p

Telephone medical care administered by internal medicine residents: concerns of program directors and implications for residency training.

The objective of this study was to determine the need for telephone medicine curricula and to help define important content for internal medicine residencies using scales that measure program director attitudes toward telephone medicine. Data were collected by surveying all 416 program directors of accredited internal medicine residencies in the United States. We applied factor analysis to develop reliable attitudinal scales and employed regression models to identify predictors of these attitudes. Response rate was 60%. Formal training for telephone medicine was available in only 6% of programs. The factor analysis showed three attitudinal concepts; all described marked program director discomfort with aspects of resident telephone prescription. Predictors of improved program director comfort included more frequent documentation of resident telephone calls, chart availability, and clear definition of resident roles pertaining to telephone interactions with patients (P < 0.02 for all predictor variables). These results identify a need for telephone curricula and suggest components that might alleviate program director discomfort with resident telephone practices.

Primary care physicians and capitated reimbursement. Experience, attitudes, and predictors.

Given the explosive expansion of capitated reimbursement for the services of primary care physicians, we conducted a national survey of a random sample of these practitioners to measure attitudes toward capitated payment and identify predictors of important attitudes. Descriptive, factor analytic, and regression techniques were used. The response rate was 54%. As measured by scales derived from factor analysis, perceptions were strong that capitation was costly to professional and patient relationships. Patients' access to care was perceived as slightly reduced. Actual participation in capitation attenuated feelings of lack of access but not those of capitation's costly effects. Physicians' attitudes toward capitation remain negative, but participants perceive their patients' access to appropriate care as reasonable.

Telephone management training in internal medicine residencies: a national survey of program directors.

BACKGROUND: Little is known about how internal medicine residents train for and practice telephone management. To address this deficiency, a national survey of program directors at accredited internal medicine training sites was conducted to evaluate residents' training for and practice of telephone medicine. METHOD: A 43-item questionnaire was mailed in December 1993 to all program directors at the 416 accredited internal medicine training sites in the United States. A limited questionnaire, regarding the most essential training questions, was mailed to all non-responders. RESULTS: The response rate was 60% (250) for the full questionnaire. Only 15 (6%) of the programs offered formal training in telephone management to their residents. This training usually consisted of single lectures (nine programs) or reading materials (seven programs). The respondents felt that formal training in telephone management was very important (155, 62%) and that such training should be a part of every internal medicine curriculum (150, 60%). CONCLUSION: Few internal medicine programs offered training in telephone management. When training occurred, it was usually limited and informal. Most program directors felt that training was important and that current training efforts were unsatisfactory, emphasizing the need for curriculum development and implementation in telephone management.

Health insurance does not guarantee access to primary care: a national study of physicians' acceptance of publicly insured patients.

The roles of reimbursement and other predictors that affect physicians' willingness to accept publicly insured continuing care patients were examined in a national survey. The response rate was 47%. Eighty-eight percent of the respondents were accepting new patients. Forty-two percent of these physicians were willing to accept new continuing care patients insured by Medicaid, 70% reported accepting those paying by Medicare assignment, and 85% said they accept patients covered by Medicare plus balance-billing payments. Low reimbursement was the strongest predictor for lack of acceptance. The results suggest that systems of multitiered reimbursement are associated with diminished access for patients insured in the lower tiers.

Will universal health insurance assure universal access to ongoing primary care for adults?

OBJECTIVE: To assess the impact of current public insurance status (Medicare and Medicaid) and hypothetical payment levels of a new insurance program on physician acceptance of adult primary care patients desiring continuing care. METHOD: Survey of 175 primary care physicians in a medium-sized city and six surrounding counties in North Carolina. MAIN OUTCOME MEASURE: Likelihood of accepting new continuing care patients covered by Medicare, Medicaid, or a hypothetical health insurance system mandated to cover the uninsured. RESULTS: The response rate was 80%; 86% of the respondents were accepting new patients with private insurance. Of the remaining physicians, 72% were not accepting new continuing care patients covered by Medicaid and 55% were not accepting patients who paid via Medicare assignment alone. Seventy-nine percent of respondents were unlikely to accept new continuing care patients insured by a hypothetical public plan that reimbursed physicians at 60% of reimbursement levels provided by privately insured patients, compared with only 25% who were unlikely to accept patients if the reimbursement was 80% of the private level. CONCLUSIONS: Medicaid and Medicare do not assure access to continuing primary care. Also, physician reimbursement is an important determinant in any new health care system designed to provide universal and consistent access to regular primary care services.