Advance directives: ambulatory patients' knowledge and perspectives.

BACKGROUND: There is a growing awareness of the need for discussion of advance directives (ADs) in the ambulatory setting, but rates of completion remain low. Clarification of patients' perceptions and knowledge would help in designing future strategies. METHODS: This is a prospective study of adult ambulatory patients at four academic internal medicine clinical sites at the University at Buffalo during a 6-week period in 2004. We obtained data using a standard instrument administered by a research assistant. The data included demographic variables, patients' awareness of and familiarity with specific ADs, and whether the patient had any ADs. Patients also were asked about attitudes concerning the appropriateness of ADs. We performed multivariate logistic regression on the variables. RESULTS: Of 508 patients, 86.2% were unfamiliar with the term "advance directives," but 93.5% were familiar with one or more specific kinds of ADs. Some 43.1% of patients claimed to have completed an AD, but of those who said they had, only 25% thought their provider had a copy. Multivariate logistic regression demonstrated significant correlation between having completed an AD and age, reading ability, and educational level (all P < .001). CONCLUSIONS: A large number of patients in an ambulatory internal medicine practice knew about ADs and believed they had completed such documents, but these documents were often not in the chart. Many patients believe discussions of ADs are not appropriate for them. A better understanding of this phenomenon will help in promoting effective advance care planning.

Asthma patients' knowledge, perception, and adherence to the asthma guidelines.

Asthma patients' knowledge and perceptions about asthma management regimens have been shown to correlate with the quality of their asthma management and outcomes. This study addresses adult ambulatory asthma patients' knowledge and perception of the asthma management guidelines issued by the National Asthma Education and Prevention Program. We interviewed 76 patients at three adult medicine outpatient clinics. Of 37 patients who knew about peak flow monitoring, 21 found it to be useful, only 10 were using it regularly, and 7 had a notation about it in their chart. Eight patients knew about patient self-assessment forms, 6 found them useful, 3 had used one recently, and only 1 patient had one in the chart. Six patients knew about asthma action plans, 4 of them thought that these plans were useful, but only 1 patient was actively using it. This study demonstrates major gaps in the asthma patients knowledge, perceptions, and their adherence to recommendations and also with the documentation in the medical record.

Encouraging a systems approach for adherence to national asthma guidelines.

PURPOSE: There is a lack of information in the literature reflecting systems effects on adherence to national asthma guidelines. The purpose of this pilot study is to provide a descriptive account of the preparedness of academic primary care sites to follow national asthma guidelines related to spirometry, peak flow meters, standard history forms, severity assessment, follow-up assessment sheets, patient self-assessment sheets, and asthma action plan templates. METHODS: This was a cross-sectional descriptive study. A short survey was mailed to medical directors on behalf of primary care academic clinical sites to assess the availability of guideline tools in their practices. Medical directors were also asked to rate their perception of how essential the guidelines were in the management of asthma. RESULTS: Medical directors agreed that the guideline tools were essential in managing asthma. However, with the exceptions of peak flow meters and standard history forms, most sites were not equipped with these tools for providers to use. CONCLUSIONS: The findings highlight the importance of the practice environment on the implementation of national asthma guidelines and encourage larger studies to include an assessment of the systems in place to enable guideline adherence. By taking systems into account, interventions may be potentially much more effective in improving the quality of care.

Patient Internet use for health information at three urban primary care clinics.

OBJECTIVE: To survey a cross section of patients presenting to three urban primary care clinics to understand online health information search behaviors. DESIGN AND ANALYSIS: At three urban primary care clinics affiliated with University at Buffalo, School of Medicine, 315 patients were interviewed. Interview questions included items on education, demographic information, employment, number of current prescriptions, insurance, online access, and specifics of health-searching behaviors. Chart review determined patient body mass index and number of chronic illnesses. Logistic regression and chi2 statistics were used to investigate the relationship between patient characteristics and the proportion of patients who use the Web for seeking health information. RESULTS: Approximately 53% of respondents reported using Web or e-mail in the past year and 68% (33% of total sample) of those who accessed the Web used it to search for health information. The two most commonly cited search areas included information about a physical illness and nutrition/fitness. Education and race significantly predicted online health-seeking behavior when considering all factors in the study. Many patients (22%) relied on friends and family to navigate the Web, and 45% of patients reported that the information that they sought was unrelated to their clinical visit. CONCLUSION: Current use of the Internet for health information was limited among more disadvantaged patient groups. More research is needed to examine the relationship between health-seeking behavior and patients' management of their health and well-being.

Use of complementary and alternative medicines by ambulatory patients.

BACKGROUND: Complementary and alternative medicines (CAM) include a number of different modalities to improve health. The popularity of such healing methods has increased, although reports of problems and adverse effects have also increased. Difficulties have also been identified in communication between patients and their providers. Previous reports concerning CAM may have undersampled lower socioeconomic groups as a result of the telephone survey techniques used. METHODS: All patients with valid appointments for internal medicine resident teaching clinics at 2 publicly supported centers were considered for eligibility. Patients were surveyed about current medications and a variety of CAM modalities. Medical records were reviewed for demographic information and to confirm diagnoses, allergies, medications, and any documented adverse effects. RESULTS: Use of CAM was common by 85.4% of patients, including those using some form of diet, exercise, and prayer. A smaller number (32.3%) were currently using alternate health care providers and products. About 5% of the population used 6 products or more. Use by this primarily poor urban population appeared similar to that in previous reports, with some exceptions. Expensive modalities were less frequently used, whereas use of prayer appears more prevalent. CONCLUSIONS: Complementary and alternate medical modalities are as commonly used by poor urban populations as by the general population. Quantification of use depends on the types of CAM used and the time frame asked. Although much of the use does not appear to be maladaptive, a small percentage of individuals have enthusiastically adapted CAM in ways that would not be endorsed by most allopathic physicians.

Screening for mental illness in primary care clinics.

OBJECTIVES: To assess the prevalence of mental disorders in inner city outpatient clinics and to improve the diagnosis of mental illness in primary care. METHODS: The Problem Oriented Patient Report (POPR), a patient self-report checklist, was administered to 362 outpatients at two inner-city Buffalo primary care clinics. Patients' completed POPR checklists were evaluated to identify those with potential mental illness diagnoses and were available for the physicians' review during the patients' visits. After the visit, clinical charts were reviewed to determine the frequency of new mental illness diagnoses among continuing and new patients. RESULTS: The screening checklist (POPR) revealed potential mental illnesses in 148/362 outpatients, of which 98% had not been identified by the physicians who had reviewed the patients' completed POPR forms. Only five new diagnoses of mental illnesses were independently made by clinics' physicians-all in follow-up (continuing) patients. CONCLUSIONS: The physicians in the two clinics did not diagnose mental illnesses in their patients, even when written checklists of self-reports were available to them. Differences in staff attitudes may influence the data collection process, and patients' as well as physicians' responses. A weakness of this study is that the POPR might generate false positive results. Even if this were the case, the rate of previous diagnoses was still extremely low.

Controlled trial of a patient-completed history questionnaire: effects on quality of documentation and patient and physician satisfaction.

The purpose of this work was to study the impact of a patient-self-completed history questionnaire upon the quality of the information in the medical record, resource utilization, patient satisfaction, and physician satisfaction. A controlled trial was performed in a primary care clinic of a public supported, urban, university hospital. The patients were mainly poor, minority, urban individuals visiting the clinic for their first primary care visit. The providers were attending physicians, nurse practitioners, and medical residents associated with the Department of Medicine teaching program. A self-administered history questionnaire was given to approximately half the new patients in a randomized, prospective manner. The physicians completed an assessment form on all new patients estimating the time spent, complexity of the case, and listing studies requested. If a history questionnaire was completed by the patient, the physician completed an assessment irrespective of whether it helped or hindered the evaluation of the patient. After the visit, nurses called the patient by telephone and asked questions concerning the patient's satisfaction. The patients' records were reviewed for the initial history papers. There were 127 patients receiving the history questionnaire and 114 controls. The presence of the history questionnaire in the medical record added to both the quantity and the quality of the information present. Of the provider responses, 87% (95% confidence interval: 78-93%) wanted all new patients to complete the questionnaire. Of the patients who received the questionnaire, all who were asked felt that all their issues were addressed, compared with only 83% in the control group (P = .015). No increases in physician time or in utilization of medical resources were found. The implementation of a self-administered history questionnaire in an urban primary care clinic resulted in improved chart quality and improved satisfaction of physicians and patients.