Prevalence and overlap of childhood and adult physical, sexual, and emotional abuse: a descriptive analysis of results from the Boston Area Community Health (BACH) survey.

Abuse is associated with a wide variety of health problems, yet comprehensive population-based data are scant. Existing literature focuses on a single type of abuse, population, or lifestage. Using a racially/ethnically diverse community-based sample, we document the prevalence of physical, emotional, and sexual abuse by lifestage and gender, assess variation in abuse by sociodemographics; establish overlap of abuses; and examine childhood abuse relationships with abuse in adulthood. Prevalence of abuse ranges from 15% to 27%; women report more adulthood emotional abuse and lifetime sexual abuse than men; reports of abuse can vary by race/ethnicity and poverty status, particularly in women; there is overlap between types of abuse; and a history of childhood abuse is associated with a greater risk of abuse as an adult.

Area-based variations in obesity are more than a function of the food and physical activity environment : area-based variations in obesity.

This study examines the area-based variations in obesity from a community-based epidemiologic survey of Boston, MA, USA, using a geographic information system and multilevel modeling techniques. A combination of quantitative and qualitative methods was used to assess whether a function of the food and the physical activity (PA) environment can explain the body weight of residents. First, a series of multilevel analyses was conducted after accounting for the well-established individual determinants and capturing a wide range of environmental attributes to represent a more realistic portrayal of urban typology. Second, the results of multilevel analysis were framed into the theoretical model of area-based variations in obesity to qualitatively summarize the association of contextual factors with the body weight of residents. Based on the overall correlation, the area-based variations defined by a function of the food and PA environment seem to be insufficient in explaining the body weight of residents. By testing the cross-level interactions of gender and race/ethnicity with contextual factors, the results suggest that the concept of area-based variations in obesity will have to consider how residents behave differently within a given environment. More research is needed to better understand the contextual determinants of obesity so as to put forth population-wide interventions.

Association of lower urinary tract symptoms and the metabolic syndrome: results from the Boston area community health survey.

PURPOSE: In this study we investigated the relationship between lower urinary tract symptoms as defined by the American Urological Association symptom index and the metabolic syndrome, and determined the relationship between individual symptoms comprising the American Urological Association symptom index and the metabolic syndrome. MATERIALS AND METHODS: The Boston Area Community Health Survey used a 2-stage cluster design to recruit a random sample of 2,301 men 30 to 79 years old. Analyses were conducted on 1,899 men who provided blood samples. Urological symptoms comprising the American Urological Association symptom index were included in the analysis. The metabolic syndrome was defined using a modification of the Adult Treatment Panel III guidelines. The association between lower urinary tract symptoms and the metabolic syndrome was assessed using odds ratios and 95% confidence intervals estimated using logistic regression models. RESULTS: Increased odds of the metabolic syndrome were observed in men with mild to severe symptoms (American Urological Association symptom index 2 to 35) compared to those with an American Urological Association symptom index score of 0 or 1 (multivariate OR 1.68, 95% CI 1.21-2.35). A statistically significant association was observed between the metabolic syndrome and a voiding symptom score of 5 or greater (multivariate adjusted OR 1.73, 95% CI 1.06-2.80) but not for a storage symptom score of 4 or greater (multivariate adjusted OR 0.94, 95% CI 0.66-1.33). Increased odds of the metabolic syndrome were observed even with mild symptoms, primarily for incomplete emptying, intermittency and nocturia. These associations were observed primarily in younger men (younger than 60 years) and were null in older men (60 years old or older). CONCLUSIONS: The observed association between urological symptoms and the metabolic syndrome provides further evidence of common underlying factors between lower urinary tract symptoms and chronic conditions outside the urinary tract.

Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) survey.

AIMS: To compare the descriptive epidemiology of overactive bladder (OAB) of presumed neurologic origin (NOAB) to OAB of non-neurologic origin (N-NOAB). METHODS: Five thousand five hundred three community-dwelling persons aged 30-79 were interviewed regarding urologic symptoms (2002-2005). NOAB was defined as symptoms of urgency and/or urgency incontinence among those with a self-reported history of healthcare provider diagnosed stroke (N = 98), multiple sclerosis (N = 21), or Parkinson's disease (N = 7). N-NOAB was defined identically but occurring among those not reporting neurologic disease (ND). Prevalence estimates were weighted to reflect sampling design; chi-square, Fisher's exact, or t-tests were used to test differences. Urologic symptom interference was assessed using the Epstein scale, while the impact of urinary incontinence (UI) on health-related quality-of-life (HRQOL) was measured using a modification of the Incontinence Impact Questionnaire-7. RESULTS: Forty-five (31.0%) of 125 persons with ND and 994 (16.7%) of 5378 persons without ND reported OAB symptoms. The overall prevalence of NOAB and N-NOAB was 0.6% and 16.4%, respectively. Persons with NOAB had higher (worse) mean American Urologic Association Symptom Index scores (13.0 vs. 10.0, P = 0.09) compared to those with N-NOAB, and were significantly more likely to have diabetes, high blood pressure, cardiac disease, and fair/poor self-reported health (all P < 0.05). Mean symptom interference and UI HRQOL scores were significantly higher (worse) in the NOAB group compared to persons with N-NOAB (all P < 0.05). CONCLUSIONS: Persons with NOAB appeared to have a greater burden of urologic illness with respect to symptom interference and HRQOL compared to persons with N-NOAB.

Talking about smoking in primary care medical practice--results of experimental studies from the US, UK and Germany.

OBJECTIVE: To analyse effects of patient and physician characteristics on questions and advice about smoking in primary care practice and to examine country differences. METHODS: We conducted a factorial experiment, employing filmed scenarios in which actors played the role of patients with symptoms of coronary heart disease (CHD) or type 2 diabetes. Versions were filmed with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to primary care physicians in the US, UK and Germany. Physicians were asked whether they would ask questions about smoking or give cessation advice. RESULTS: Female and older CHD patients are less likely to be asked or get advice about smoking in all three countries. Effects of physician attributes are weak and inconsistent. Compared to physicians in the US and the UK, German doctors are least likely to ask questions or give advice. CONCLUSIONS: Although all physicians viewed the same cases their questioning and advice giving differed according to patient attributes and country. Due to the experimental design external validity of the study may be limited. PRACTICE IMPLICATIONS: Findings have implications for medical education and professional training of physicians as well as for the organization and financing of health care.

Sexual desire problems in women seeking healthcare: a novel study design for ascertaining prevalence of hypoactive sexual desire disorder in clinic-based samples of U.S. women.

BACKGROUND: Hypoactive sexual desire disorder (HSDD) has been estimated to occur in 10%-15% of adult women in large population-representative and community-based studies. However, none of these studies have used in-person diagnostic interview assessment to rule out alternative diagnoses, nor has the impact of other health conditions or help-seeking experiences been investigated. The current study aimed to determine the prevalence of generalized acquired HSDD in women aged ≥18 who attended primary care or obstetrics and gynecology clinics for nonurgent clinic visits in the United States. METHODS: A total of 701 women were enrolled at 20 clinical sites across the United States between June 11, 2010, and October 15, 2010. Participants completed a two-part self-administered questionnaire, and a validated, structured, in-person diagnostic interview, conducted by a trained health professional was used for diagnosing HSDD according to DSM-IV-TR criteria. RESULTS: Fifty-two women (7.4%) were assigned a diagnosis of generalized acquired HSDD. Prevalence was lower in minority and postmenopausal women. Level of education and other sociodemographic factors did not appear to differentiate between women with and without HSDD. A marked increase in HSDD prevalence was noted in the perimenopausal (i.e., 40-49 years) and immediate postmenopausal (i.e., 50-59) age groups. Of the women diagnosed with HSDD, 53% had sought care from a health professional for HSDD. CONCLUSIONS: In this sample of women recruited in the clinical care setting, we observed an overall prevalence rate of 7.4% of acquired, generalized HSDD, with markedly increased prevalence in midlife women.

Commonly used antihypertensives and lower urinary tract symptoms: results from the Boston Area Community Health (BACH) Survey.

UNLABELLED: Study Type - Prevalence (inception cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Certain antihypertensives, particularly diuretics and calcium channel blockers, are known to be associated with increased risk of LUTS including nocturia, but little is known about gender-specific effects. This is the first epidemiological study, to our knowledge, to compare the prevalence of several urological symptoms (storage, voiding and nocturia) among male and female users of a wide variety of common antihypertensives using a community-based sample. OBJECTIVE: To examine differences in the prevalence of lower urinary tract symptom (LUTS) among users of five common AHT classes compared with non-users, adjusted for LUTS risk factors in a large, representative sample. SUBJECTS AND METHODS: Data were from the Boston Area Community Health Survey, a population-based study of community-dwelling male and female (30-79 years) residents of Boston, MA, USA for whom prescription drug information was collected between 2002 and 2005. The urological symptoms of storage, voiding, and nocturia were assessed using interviewer-administered questionnaires and the American Urological Association Symptom Index. This analysis was conducted among 1865 participants with an AHT indication. Associations of angiotensin-converting enzyme inhibitors, beta blockers, calcium channel blockers (CCBs) and loop and thiazide diuretics with the three groups of LUTS were estimated using odds ratios (ORs) and 95% confidence intervals (CIs) from multivariate logistic regression (referent group: untreated hypertension). Overlap in use was accounted for using monotherapy and combination therapy exposure categories. RESULTS: Among women, monotherapy with CCBs was associated with increased prevalence of nocturia (OR = 2.65, 95% CI: 1.04-6.74) and voiding symptoms (OR = 3.84, 95% CI: 1.24-11.87); these results were confined to women aged <55 years. Among men of all ages, positive associations were observed for thiazides and voiding symptoms (monotherapy OR = 2.90, 95% CI: 1.17-7.19), and loop diuretics and nocturia (combination therapy OR = 2.55, 95% CI: 1.26-5.14). CONCLUSION: Results are consistent with the hypothesis that certain AHTs may aggravate LUTS. The presence of new or worsening LUTS among AHT users suggests medications should be reviewed and a change in AHT class considered.

Are commonly used psychoactive medications associated with lower urinary tract symptoms?

PURPOSE: Lower urinary tract symptoms (LUTS) such as urinary frequency and urgency are bothersome and associated with reduced quality of life. Atypical antipsychotics (AAPs) have been implicated in increasing the risk of urinary incontinence. In a large community-based sample of men and women, we examined the associations of AAP and selective serotonin reuptake inhibitor (SSRIs) use with LUTS. METHODS: Data were collected (2002-2005) from a generalizable sample of Boston, MA, USA, residents aged 30-79 (N = 5503). LUTS were assessed using the American Urologic Association Symptom Index (AUA-SI). The prevalence of clinically-significant LUTS was estimated using a cutoff AUA-SI score of 8+ to indicate moderate-to-severe symptoms. Confounder-adjusted odds ratios (ORs) and 95% confidence intervals (CI) were calculated from multivariate logistic regression to estimate the associations for psychoactive drugs used in the previous month (SSRIs, AAPs, both) and LUTS. RESULTS: Among women, AAP users had a higher prevalence of LUTS (46.2%) compared with SSRI users (23.5%) and those with depressive symptoms not using SSRIs or AAPs (26.3%). Corresponding prevalence estimates among men were 32.7%, 29.8%, and 33.3%. In multivariate models, AAP use was significantly associated with LUTS among women when used either with (OR = 2.72, 95% CI:1.45-5.10) or without (OR = 3.05, 95% CI:1.30-7.16) SSRIs, but SSRI use without AAP use was not associated with LUTS compared with nonusers without depressive symptoms. No associations were observed among men. CONCLUSIONS: In our study, AAPs but not SSRIs were associated with increased prevalence of LUTS among women only. Further prospective research is needed to determine time sequence and cause and effect.

Disparities in the prevalence of obesity in Boston: results from the Boston Area Community Health (BACH) survey.

OBJECTIVE: This study examined disparities in the prevalence of obesity to determine how future prevention and/or intervention efforts should be developed to remedy obesity. METHODS: We obtained individual information of sociodemographic characteristics, comorbid conditions, and lifestyle behaviors from the Boston Area Community Health (BACH) survey for 2002-2005. To account for the complex BACH sampling design, observations were weighted inversely to their probability of selection, and sampling weights were poststratified to the Boston population from the U.S. Census 2000. We tested all possible two- and three-way interaction terms from a multivariate logistic regression model. RESULTS: After controlling for individual determinants in detail and focusing on the population within a single city, the associations of sociodemographic characteristics, comorbid conditions, and lifestyle behaviors with obesity were consistent with previous findings. Notably, three two-way interaction terms were significantly associated with obesity: (1) race/ethnicity and gender, (2) gender and other people in the household, and (3) race/ethnicity and alcohol consumption. CONCLUSIONS: Future obesity prevention and/or intervention programs in Boston need to be primarily gender- and racially/ethnically specific to minimize cost and maximize results. Additional considerations are needed to take into account the differences in age, the presence of other people in the household, and education level.

Differences between internists and family practitioners in the diagnosis and management of the same patient with coronary heart disease.

It has been suggested that internists and family practitioners have somewhat different "disease" perspectives, which may be generated by use of different explanatory models during medical training (pathophysiological vs. biopsychosocial, respectively). This article explores differences between internists and family practitioners in their suggested diagnoses, level of diagnostic certainty, test and prescription ordering, when encountering exactly the same "patient" with coronary heart disease (CHD). Internists were more certain of a CHD diagnosis than family practitioners and were more likely to act on this diagnosis. Family practitioners were more likely to diagnose (and were more certain of) a mental health condition. While many physicians simultaneously entertain several alternate diagnoses, diagnostic certainty has shown to have an important influence on subsequent clinical actions, such as stress testing and prescription of beta blockers. These results may inform future educational strategies designed to reduce diagnostic uncertainty in the face of life-threatening conditions, such as CHD.

Nonsteroidal antiinflammatory drug use and lower urinary tract symptoms: results from the Boston area community health survey.

There is evidence for a role of inflammation in the etiology of lower urinary tract symptoms (LUTS), raising the possibility that use of nonsteroidal antiinflammatory drugs (NSAIDs) may inhibit the development or progression of LUTS. The authors examined the association between use of prescription and over-the-counter NSAIDs and LUTS among 1,974 men and 2,661 women in the Boston Area Community Health Survey (2002-2005). Multivariable-adjusted logistic regression was used to estimate odds ratios and 95% confidence intervals for LUTS, voiding symptoms, storage symptoms, and nocturia. There was no clear association between use of prescription or over-the-counter NSAIDs (compared with no NSAID use) and overall LUTS, voiding symptoms, or nocturia in men or women. However, over-the-counter NSAID use was positively associated with storage symptoms in women (odds ratio = 1.37, 95% confidence interval: 1.03, 1.83), and there was a positive association between over-the-counter NSAID use and overall LUTS among women with a history of arthritis (odds ratio = 2.09, 95% confidence interval: 1.20, 3.64). These results do not provide strong support for an association between NSAIDs and LUTS. However, the associations between over-the-counter NSAID use and certain urologic symptoms, particularly among women with arthritis, and the potential mechanisms involved should be evaluated in future studies.

Are statin medications associated with lower urinary tract symptoms in men and women? Results from the Boston Area Community Health (BACH) Survey.

PURPOSE: Statins may ameliorate lower urinary tract symptoms (LUTS) through anti-inflammatory or other pathways. We investigated the association between statin use and storage, voiding, and overall LUTS symptoms. METHODS: The Boston Area Community Health Survey is an epidemiologic study of Boston, MA residents (2301 men; 3202 women) 30-79 years of age. LUTS, voiding, and storage symptoms were ascertained through an interviewer-administered questionnaire and defined as scores of greater than or equal to 8, greater than or equal to 5, and greater than or equal to 4, respectively, on relevant components of the American Urologic Association Symptom Index. Participants were included if they had a history of provider-diagnosed high cholesterol or recently used statin medications (n = 1346). Associations were estimated using odds ratios (ORs) and 95% confidence intervals (CI) from multivariate logistic regression. RESULTS: In multivariate models, statin use had no association with LUTS (OR= 1.03, 95% CI: 0.70, 1.51) among women. No associations were observed for any LUTS among younger (<60) men, but among older (60+) men, we observed significant inverse associations for voiding (OR= 0.23, 95% CI: 0.08, 0.66), storage (OR = 0.24, 95% CI: 0.11, 0.56), and overall LUTS (OR = 0.15, 95% CI: 0.05, 0.44). CONCLUSIONS: Our results suggest that use of statins is associated with a lower prevalence of urologic symptoms among older men but not among women or younger men.

The association of adiposity and overactive bladder appears to differ by gender: results from the Boston Area Community Health survey.

PURPOSE: We investigate the association of different measures of adiposity (waist circumference, hip circumference, waist-to-hip ratio and body mass index) with overactive bladder (urinary frequency and urgency), whether the association varies by gender or age and whether it persists when models are adjusted for other confounders. MATERIALS AND METHODS: Data were from the Boston Area Community Health epidemiological survey, a random sample of 5,503 Boston, Massachusetts, residents 30 to 79 years old with equal representation from 3 racial/ethnic groups (black, Hispanic and white). Statistical analysis involved nonparametric loess models and multivariate logistic regression. RESULTS: We noted distinct patterns by gender for the association of various adiposity measures with overactive bladder. Waist-to-hip ratio was not significantly associated with overactive bladder in either gender. In women the prevalence of overactive bladder increased as waist (OR adjusted for other confounders 1.10/10 cm increase) or hip circumference (OR 1.12/10 cm increase) or body mass index (OR 1.03/kg/m2 increase) increased. In men the prevalence of overactive bladder decreased as adiposity increased (OR 0.65/10 cm increase in waist circumference, OR 0.71/10 cm increase in hip circumference and OR 0.87/kg/m2 in body mass index) but only to a certain point (waist circumference 100 cm, hip circumference 115 cm and body mass index 27.5 kg/m2, respectively). At that point the prevalence of overactive bladder increased with increasing adiposity (OR 1.19/10 cm increase in waist circumference, OR 1.16/10 cm increase in hip circumference and OR 1.08/kg/m2 in body mass index). CONCLUSIONS: The relationship between adiposity and overactive bladder varies by gender.

Prevalence of post-micturition symptoms in association with lower urinary tract symptoms and health-related quality of life in men and women.

OBJECTIVE: • To estimate the prevalence of post-micturition symptoms (a feeling of incomplete emptying following urination and post-micturition dribble) in a population-based sample of men and women, and to examine overlap with storage and voiding LUTS and associations with health-related quality of life (HRQL). PATIENTS AND METHODS: • Data were obtained by in-person interview in the Boston Area Community Health survey, a population-based random sample of 2301 men and 3202 women aged 30-79 years in the USA. • Lower urinary tract symptoms (LUTS) were defined using the International Prostate Symptom Score and standardized terminology. • Multivariate linear regression was used to evaluate associations between urological symptoms and validated HRQL measures (SF-12 and activities interference) cross-sectionally. RESULTS: • The overall prevalence of post-micturition symptoms was 11.8% in men and 8.5% in women. • The prevalence increased with age in men but not women. • In men, post-void dribbling contributed to much of the post-micturition symptoms, whereas, in women, incomplete emptying was more common. • For both genders, over 50% with voiding symptoms also had post-micturition symptoms, compared to less than 50% of respondents who reported storage symptoms. • The presence of post-micturition symptoms, particularly incomplete emptying, was indicative of mildly impaired physical HRQL and activities interference in men and women, and mental HRQL in men (P < 0.01). CONCLUSIONS: • Post-micturition symptoms were more prevalent than any individual voiding symptom and commonly overlapped with other LUTS. • Over half of men and women with a voiding symptom also had a post-micturition symptom. • The presence of post-micturition symptoms was indicative of impaired HRQL.

Diagnosis and management of depression in 3 countries: results from a clinical vignette factorial experiment.

OBJECTIVE: International differences in disease prevalence rates are often reported and thought to reflect different lifestyles, genetics, or cultural differences in care-seeking behavior. However, they may also be produced by differences among health care systems. We sought to investigate variation in the diagnosis and management of a "patient" with exactly the same symptoms indicative of depression in 3 different health care systems (Germany, the United Kingdom, and the United States). METHOD: A factorial experiment was conducted between 2001 and 2006 in which 384 randomly selected primary care physicians viewed a video vignette of a patient presenting with symptoms suggestive of depression. Under the supervision of experienced clinicians, professional actors were trained to realistically portray patients who presented with 7 symptoms of depression: sleep disturbance, decreased interest, guilt, diminished energy, impaired concentration, poor appetite, and psychomotor agitation or retardation. RESULTS: Most physicians listed depression as one of their diagnoses (89.6%), but German physicians were more likely to diagnose depression in women, while British and American physicians were more likely to diagnose depression in men (P = .0251). American physicians were almost twice as likely to prescribe an antidepressant as British physicians (P = .0241). German physicians were significantly more likely to refer the patient to a mental health professional than British or American physicians (P < .0001). German physicians wanted to see the patient in follow-up sooner than British or American physicians (P < .0001). CONCLUSIONS: Primary care physicians in different countries diagnose the exact same symptoms of depression differently depending on the patient's gender. There are also significant differences between countries in the management of a patient with symptoms suggestive of depression. International differences in prevalence rates for depression, and perhaps other diseases, may in part result from differences among health care systems in different countries.

The relative contribution of patient, provider and organizational influences to the appropriate diagnosis and management of diabetes mellitus.

OBJECTIVE: To estimate the relative contribution of patient attributes, provider characteristics and organizational features of the doctors' workplace to the diagnosis and management of diabetes. RESEARCH DESIGN AND METHODS: In a factorial experimental design doctors (n = 192) viewed clinically authentic vignettes of 'patients' presenting with identical signs and symptoms. Doctor subjects were primary care doctors stratified according to gender and level of experience. During an in-person interview scheduled between real patients, doctors were asked how they would diagnosis and manage the vignette 'patients' in clinical practice. RESULTS: This study considered the relative contribution of patient, doctor and organizational factors. Taken together patient attributes explained only 4.4% of the variability in diabetes diagnosis. Doctor factors explained only 2.0%. The vast majority of the explained variance in diabetes diagnosis was due to organizational factors (14.3%). Relative contributions combined (patient, provider, organizational factors) explained only 20% of the total variance. CONCLUSION: Attempts to reduce health care variations usually focus on the education/activation of patients, or increased training of doctors. Our findings suggest that shifting quality improvement efforts to the area which contributes most to the creation and amplification of variations (organizational influences) may produce better results in terms of reduced variations in health care associated with diabetes.

Only half the problem is being addressed: underinsurance is as big a problem as uninsurance.

This article examines the sociodemographic and health characteristics of the underinsured-people who have some health insurance but are having trouble paying for health care or medications. It uses data from the Boston Area Community Health (BACH) Survey, a large (N=5503) community-based random sample of Boston residents aged 30 to 79 years (1767 black, 1,877 Hispanic, and 1859 white; 2301 men and 3202 women). The authors found that minorities were less likely than whites to have health insurance (for men and women, respectively, 30% and 19% of Hispanics, 16% and 9% of blacks, and 9% and 7% of whites lacked health insurance). Blacks were the most likely to be underinsured (for men and women, respectively, 18% and 20% of blacks vs. 9% and 14% of Hispanics and 8% and 12% of whites were underinsured). Those of lower and middle socioeconomic status were also more likely to be uninsured or underinsured. The health status of the uninsured was similar to that of the adequately insured, whereas those who were underinsured reported more co-morbidities and depression. The underinsured are generally older and sicker, and make greater use of the health care system, and may present a larger public health and health policy challenge than the uninsured.

Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.

PURPOSE: Premature closure has been identified as the single most common cause of diagnostic error. This factorial experiment explored which variables exert an unconfounded influence on physicians' diagnostic flexibility (changing their minds about the most likely diagnosis during a clinical case presentation). METHOD: In 2007-2008, 256 practicing physicians viewed a clinically authentic vignette simulating a patient presenting with possible coronary heart disease (CHD) and provided their initial impression midway through the case. At the end, they answered questions about the case, indicated how they would continue their clinical investigation, and made a final diagnosis. The authors used general linear models to determine which patient factors (age, gender, socioeconomic status, race), physician factors (gender, age/experience), and process variables were related to the likelihood of physicians' changing their minds about the most likely diagnosis. RESULTS: Physicians who had less experience, those who named a non-CHD diagnosis as their initial impression, and those who did not ask for information about the patient's prior cardiac disease history were the most likely to change their minds. Participants' certainty in their initial diagnosis, the additional information desired, the diagnostic hypotheses generated, and the follow-up intended were not related to the likelihood of change in diagnostic hypotheses. CONCLUSIONS: Although efforts encouraging physicians to avoid cognitive biases and to reason in a more analytic manner may yield some benefit, this study suggests that experience is a more important determinant of diagnostic flexibility than is the consideration of additional diagnoses or the amount of additional information collected.

In-clinic use of electronic pain diaries: barriers of implementation among pain physicians.

OBJECTIVES: The aim of this study was to examine barriers to the use of electronic diaries within the clinic setting and determine outcome differences between patients who used electronic diaries to monitor their progress with summary data feedback and patients who monitored their progress with paper diaries without summary data feedback. METHODS: One hundred thirty-four (n=134) chronic pain patients were asked to monitor their pain, mood, activity interference, medication use, and pain location on either a paper or electronic diary immediately before each monthly clinic visit for 10 months. Patients and their treating physicians in the electronic diary group (n=67) were able to observe changes in their ratings whereas patients using the paper diaries (n=67) had no feedback about their data entry. RESULTS: Most participants believed that completing pain diaries was beneficial; yet, only 23% of patients in the experimental condition felt that the data from the electronic diaries improved their care and less than 15% believed that their doctor made a change in their treatment based on the summary diary information. CONCLUSION: In general, treating physicians were positive about the use of electronic diaries, although they admitted that they did not regularly incorporate the summary data in their treatment decision making because either they forgot or they were too busy. Future studies in understanding barriers to physicians' and patients' use of diary data to impact treatment outcome are needed to improve care for persons with chronic pain.

Work stress of primary care physicians in the US, UK and German health care systems.

Work-related stress among physicians has been an issue of growing concern in recent years. How and why this may vary between different health care systems remains poorly understood. Using an established theoretical model (effort-reward imbalance), this study analyses levels of work stress among primary care physicians (PCPs) in three different health care systems, the United States, the United Kingdom and Germany. Whether professional autonomy and specific features of the work environment are associated with work stress and account for possible country differences are examined. Data are derived from self-administered questionnaires obtained from 640 randomly sampled physicians recruited for an international comparative study of medical decision making conducted from 2005 to 2007. Results demonstrate country-specific differences in work stress with the highest level in Germany, intermediate level in the US and lowest level among UK physicians. A negative correlation between professional autonomy and work stress is observed in all three countries, but neither this association nor features of the work environment account for the observed country differences. Whether there will be adequate numbers of PCPs, or even a field of primary care in the future, is of increasing concern in several countries. To the extent that work-related stress contributes to this, identification of its organizational correlates in different health care systems may offer opportunities for remedial interventions.