The patient-centered medical home: an ethical analysis of principles and practice.

The patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient-physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

Internist diagnosis and management of chronic hepatitis B virus infection.

Chronic infection with the hepatitis B virus can lead to hepatocellular carcinoma and cirrhosis in up to 25% of infected individuals. As many as 2 million individuals in the US may have chronic hepatitis B infection, most of whom immigrated to the US from hepatitis B-endemic regions of the world. A 2010 report from the Institute of Medicine noted that two thirds of patients with hepatitis B are unaware of their infection, and most health care providers do not screen for hepatitis B or know how to manage hepatitis B-positive patients. In 2010, the Hepatitis B Foundation convened a group of primary care providers to consider the existing evidenced-based recommendations and strategies for implementation of hepatitis B screening into routine practice. The group designed an easy-to-use algorithm for screening, initial evaluation, ongoing management, and referral to a subspecialist when appropriate. Internal medicine specialists, including primary care providers and subspecialists, need to understand the steps they can take to address this often under-recognized disorder.

Chronic hepatitis B infection: a workshop consensus statement and algorithm.

Here, presented with an evidence-based algorithm, are workshop consensus recommendations on whom to screen for hepatitis B and when to pursue further evaluation and management.

Pay-for-performance principles that promote patient-centered care: an ethics manifesto.

Pay-for-performance programs are growing, but little evidence exists on their effectiveness or on their potential unintended consequences and effects on the patient-physician relationship. Pay-for-performance has the potential to help improve the quality of care, if it can be aligned with the goals of medical professionalism. Initiatives that provide incentives for a few specific elements of a single disease or condition, however, may neglect the complexity of care for the whole patient, especially the elderly patient with multiple chronic conditions. Such programs could also result in the deselection of patients, "playing to the measures" rather than focusing on the patient as a whole, and misalignment of perceptions between physicians and patients. The primary focus of the quality movement in health care should not be on "pay for" or "performance" based on limited measures, but rather on the patient. The American College of Physicians hopes to move the pay-for-performance debate forward with a patient-centered focus--one that puts the needs and interests of the patient first--as these programs evolve.

Improving neuropsychological function after chronic brain injury with hyperbaric oxygen.

PURPOSE: One suggested treatment for chronic brain injury (CBI) is the use of hyperbaric oxygen therapy (HBOT). The present study was an evaluation of neuropsychological improvement after HBOT in CBI patients. METHOD: Study 1 compared test - retest results of 21 CBI children treated with HBOT against test - retest results of 42 untreated brain injured and normal children. Study 2 compared 21 CBI adults treated with HBOT against 42 untreated normal and brain injured adults. In each study, subjects received pre and post assessments to evaluate neuropsychological function. RESULTS: The HBOT-treated children showed significant improvement when compared with the two control groups on measures of daily living, socialization, communication, and motor skills. The treated adults made significant gains in all neuropsychological areas tested as compared to controls. CONCLUSION: The studies were strongly supportive of HBOT as a treatment for lessening the neurological impact of CBI. These studies indicate that HBOT can be an effective aid in ameliorating the neuropsychological and physiological effects of CBI. The absence of a clear sham HBOT treatment group is an issue as it could be that there was a placebo effect, but it should be noted that the controls were receiving more traditional interventions during the study.

Improvement in cerebral metabolism in chronic brain injury after hyperbaric oxygen therapy.

While no research study has yet demonstrated convincing evidence for the efficacy of Hyperbaric Oxygen Therapy (HBOT) in patients with chronic neurological disorders (CND), anecdotal studies have been supportive of its use in improving healing of the damaged brain. The current study hypothesized that (1) individuals with CND show increases in cerebral blood flow and metabolism as measured by Single Positron Emission Computed Tomography (SPECT) in the cerebral hemispheres, but not on measures of cerebellar and pons blood flow; and (2) younger patients show more improvement than older patients. The study used archival data to compare 25 older and 25 younger subjects who were given SPECT scans pretherapy, midtherapy, and posttherapy. ANOVAs using the SPECT scans as a within subjects variable and age as a between subjects variable confirmed the hypothesis that the cerebral measures all changed but that the cerebellar and pons measures did not. Post-hoc t-tests confirmed that there was improvement in blood flow from the beginning to the end of the study. An age effect was found on only two of the five measures; however, there were no interactions. Analysis by post-hoc t-tests showed that the younger group had higher blood flows, but not more improvement than the older group. The results provided the first statistical research data to show the effectiveness of HBOT in improving blood flow in CND. These results indicate that HBOT can be an effective part of the treatment for such clients. The implications of these findings and future research directions were discussed.