Rural-urban differences in end-of-life care: the use of feeding tubes.

Efforts to improve end-of-life care have increased during the past decade. The goals of these efforts include increasing patient autonomy and reducing or more selectively using intensive medical interventions near the end of life. In this light, examination of community-to-community variations in end-of-life practices may serve to clarify the values and goals of different populations, as well as the roles of patients, families and professionals in bringing about specific patterns of medical care. This study examined the use of feeding tubes among Kansas nursing home residents between Jan. 1, 1994, and June 30, 1998 (n = 78,895), using the Minimum Data Set. Residents with very severe, persistent and irreversible cognitive impairment (n = 4,847) were included in the study population. The location of nursing homes in urban, midsize and rural counties was an independent variable. Feeding tubes were used in 19.3 percent of the urban nursing home residents, 8.0 percent of the residents in midsize counties and 6.4 percent of the rural residents. The rate of feeding tube use was significantly higher in urban counties for most subpopulations, including men, women, whites, nonwhites, and those eligible and ineligible for Medicaid. The observed rural-urban differences in feeding tube use near the end of life may be associated with differences in access to surgical or nursing services, differences in the relationships between providers and consumers of care in different communities or differences in rural and urban cultures. Qualitative research may be useful in clarifying the roles of each of these factors.

What do managed care plans do to affect care? Results from a survey of physicians.

Little is known about physicians' exposure to managed care techniques that affect clinical practice. In 1995, we conducted a survey of 2,003 U.S. physicians asking them about their share of patients subject to a variety of managed care techniques. Nationally, 24% of physicians received some form of capitation payment for their patients. The two most widely used techniques were utilization review (UR), applied to an average of 59% of patients, and discounted fees, applied to an average of 38% of patients. Although UR was common, ultimate denial rates of coverage were very low: at most 3% for the types of care studied. Use of managed care techniques varied more within states than between states. Conventional measures of HMO market penetration revealed little about how managed care affects physicians.

Impact of age on the severity, course, and complications of alcohol withdrawal.

BACKGROUND: Early identification of alcohol-dependent patients at increased risk for severe or complicated alcohol withdrawal would improve triage and treatment. However, the role of age in predicting alcohol withdrawal outcomes has not been well studied. OBJECTIVE: To assess the impact of age on the severity, course, and complications of alcohol withdrawal. METHODS: We performed a retrospective cohort study of 284 inpatients admitted for alcohol withdrawal between September 1992 and August 1994. Outcomes included alcohol withdrawal severity measured by the revised Clinical Institute Withdrawal Assessment for Alcohol scale, quantity and duration of benzodiazepine therapy, and complications during withdrawal. RESULTS: Initial and maximal withdrawal severity scores, amount of benzodiazepine administered, and duration of benzodiazepine treatment for elevated withdrawal severity scores did not change significantly with age. However, patients aged 60 years and older had increased risk for delirium (adjusted odds ratio [OR], 4.7; 95% confidence interval [CI], 1.5-15.0; P = .008), falls (OR, 3.1; 95% CI, 0.9-11.2; P = .08), and transient dependency in 2 or more activities of daily living (OR, 5.8; 95% CI, 2.9-11.7; P < .001). As age increased, there were significant increases in length of stay (P < .001) and frequency of discharge to an extended care facility (P < .001). CONCLUSIONS: Although alcohol withdrawal severity scores and benzodiazepine requirements were similar across age groups, patients aged 60 years and older were at increased risk for cognitive and functional impairment during withdrawal. These findings support recommendations that older patients with alcohol withdrawal are best treated in closely supervised settings.

The new medical marketplace: physicians' views.

The transformation of the medical marketplace has major implications for the physician workforce. Findings are reported here from national surveys of physicians, hospitals, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and medical group practices conducted in 1995 to measure the impact of those changes. Physicians in higher HMO penetration states were more likely to report serious problems with several aspects of medical practice and patient care and were more likely to perceived oversupply in their specialty areas and changes in their practice arrangements. Some divergence is noted in views of supply between physicians and those that employ them. The majority of physicians would still recommend medicine and their specialty as a career.

Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan.

BACKGROUND: The quality of discharge planning is an important determinant of patient outcomes following hospital discharge. Patients often report inadequate discussion prior to discharge regarding major elements of the postdischarge treatment plan, including medication and daily activities. OBJECTIVE: To determine whether this apparent lack of communication might be the result of differing perceptions on the part of patients and physicians regarding the patients' understanding of the treatment plan. METHODS: We surveyed 99 patients and their attending physicians. All patients had been discharged recently from an academic medical center with the diagnosis of acute myocardial infarction or pneumonia. We asked both patients and physicians about time spent prior to discharge discussing the postdischarge treatment plan and the patients' understanding of this plan. McNemar test was used to determine whether responses of patients and physicians differed. RESULTS: Physicians reported spending more time discussing postdischarge care than did patients (P = .10). Physicians believed that 89% of patients understood the potential side effects of their medications, but only 57% of patients reported that they understood (P < .001). Similarly, physicians believed that 95% of patients understood when to resume normal activities, while only 58% of patients reported that they understood (P < .001). CONCLUSIONS: Physicians overestimate patients' understanding of the postdischarge treatment plan. Steps should be taken to improve communication about postdischarge treatment.

Evaluating cholesterol screening. The importance of controlling for regression to the mean.

OBJECTIVES: To determine the overall impact of a voluntary cholesterol screening program and to assess the importance of controlling for regression to the mean when evaluating the impact on higher-risk subgroups. DESIGN: Longitudinal study comparing baseline survey and cholesterol results with those obtained 17 months later, with adjustment for regression to the mean. SETTING: Participants were seen at three sites: an academic teaching hospital, an intermediate-care hospital, and a suburban community center. PARTICIPANTS: One thousand fifty-three participants were enrolled in a voluntary cholesterol screening program. MEASUREMENTS/MAIN RESULTS: Of 1053 study enrollees, 785 (75%) completed a follow-up questionnaire and 656 (62%) returned for follow-up cholesterol tests. Among all participants at high risk, measured cholesterol levels were 0.66 mmol/L (25.5 mg/dL) lower at follow-up, but 58% of this apparent change (0.38 mmol/L [14.7 mg/dL]) was attributable to the statistical phenomenon of regression to the mean. Among all participants at increased (both high and moderate) risk, after controlling for regression to the mean, reductions in cholesterol levels were significant for those younger than 60 years (-0.28 mmol/L [-10.8 mg/dL]; 95% confidence interval, -0.43 to -0.13; n = 390) but not for those 60 years or older (+0.007 mmol/L [+0.3 mg/dL]; 95% confidence interval, -0.16 to +0.17; n = 266). CONCLUSIONS: For subjects found at high risk in a cholesterol screening program, more than half of the apparent beneficial change in cholesterol level is attributable to regression to the mean. For participants older than 60 years, no clear benefit of cholesterol screening was documented.

Clinical correlates of secondary meningitis in HIV-infected adults.

BACKGROUND: Neurologic complaints are common in adults infected with the human immunodeficiency virus, but little is known about which clinical features are associated with secondary causes of meningitis. METHODS: A retrospective cross-sectional study of adults infected with the human immunodeficiency virus who received a diagnostic lumbar puncture (LP) in the infectious disease clinic, emergency department, and inpatient wards of the Deaconess Hospital, Boston, Mass, from 1989 through 1992 to determine which clinical features available at the time of LP are correlated with definite or probable secondary meningitis. RESULTS: Of the 491 LPs, 90% were performed in whites, 93% in men, and 11% in injection drug users. Cerebrospinal fluid test results revealed secondary meningitis in 39 (7.9%) of 491 LPs performed on 322 individuals. Cryptococcal meningitis was the predominant type (27 cases); no bacterial or tuberculous meningitis was found. In multivariate analyses, a history of non-Hodgkin's lymphoma (adjusted odds ratio [OR], 4.3; 95% confidence interval [CI], 1.5 to 12.5), a history of herpes simplex virus infection (OR, 2.5; 95% CI, 1.2 to 5.0), nausea and/or vomiting (OR, 2.0; 95% CI, 1.03 to 4.0), headache in a person with the acquired immunodeficiency syndrome (OR, 2.1; 95% CI, 1.03 to 4.4), and cranial nerve abnormalities (OR, 5.1; 95% CI, 1.8 to 14.1) were positive correlates of opportunistic meningitis; current fluconazole use (OR, 0.3; 95% CI, 0.1 to 0.8) conferred a lower risk. CONCLUSION: In similar clinical settings, physicians and their human immunodeficiency virus-infected patients should consider these features when assessing the risk of secondary meningitis and the necessity for immediate LP.

Functional disability screening of ambulatory patients: a randomized controlled trial in a hospital-based group practice.

The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and social function. The experimental group physicians received reports summarizing their patients' responses; the control group physicians received no report. At the end of one year the authors found no significant difference between the patients of the experimental and control group physicians on any measure of functional status. Functional disability screening alone does not improve patient function.

Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial.

OBJECTIVE: To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal. DESIGN: A randomized double-blind, controlled trial. SETTING: An inpatient detoxification unit in a Veterans Affairs medical center. PATIENTS: One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal. INTERVENTION: Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptom-triggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal. MAIN OUTCOME MEASURES: Duration of medication treatment and total chlordiazepoxide administered. RESULTS: The median duration of treatment in the symptom-triggered group was 9 hours, compared with 68 hours in the fixed-schedule group (P < .001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P < .001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens. CONCLUSIONS: Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.

Effect of computer-based alerts on the treatment and outcomes of hospitalized patients.

BACKGROUND: Hospital computing systems play an important part in the communication of clinical information to physicians. We sought to determine whether computer-based alerts for hospitalized patients can affect physicians' behavior and improve patients' outcomes. METHODS: We performed a prospective time-series study to determine whether computerized alerts to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic or renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to determine whether such alerts protected renal function. RESULTS: Laboratory data were observed for 20,228 hospitalizations, with documentation of 1573 events (instances of rising creatinine levels during treatment with a nephrotoxic or renally excreted drug). During the intervention period, doses were adjusted or medications discontinued an average of 21.6 hours sooner after such an event (P < .0001). For patients receiving nephrotoxic medications during the intervention period, the relative risk of serious renal impairment was 0.45 (95% confidence interval, 0.22 to 0.94) as compared with the control period, and the mean serum creatinine level was 14.1 mumol/L (0.16 mg/dL) lower on day 3 (P < .01) and 25.6 mumol/L (0.29 mg/dL) lower on day 7 (P < .05) after an event. Forty-four percent of physicians who responded to a questionnaire said that the alerts had been helpful in the care of their patients, whereas 28% found them annoying. Sixty-five percent wished to continue receiving alerts. CONCLUSIONS: Computer-based alerts regarding patients with rising creatinine levels affect physician behavior, prevent serious renal impairment, preserve renal function, and are accepted by clinicians.

Unconventional medicine in the United States. Prevalence, costs, and patterns of use.

BACKGROUND: Many people use unconventional therapies for health problems, but the extent of this use and the costs are not known. We conducted a national survey to determine the prevalence, costs, and patterns of use of unconventional therapies, such as acupuncture and chiropractic. METHODS: We limited the therapies studied to 16 commonly used interventions neither taught widely in U.S. medical schools nor generally available in U.S. hospitals. We completed telephone interviews with 1539 adults (response rate, 67 percent) in a national sample of adults 18 years of age or older in 1990. We asked respondents to report any serious or bothersome medical conditions and details of their use of conventional medical services; we then inquired about their use of unconventional therapy. RESULTS: One in three respondents (34 percent) reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy. The latter group had made an average of 19 visits to such providers during the preceding year, with an average charge per visit of $27.60. The frequency of use of unconventional therapy varied somewhat among socio-demographic groups, with the highest use reported by nonblack persons from 25 to 49 years of age who had relatively more education and higher incomes. The majority used unconventional therapy for chronic, as opposed to life-threatening, medical conditions. Among those who used unconventional therapy for serious medical conditions, the vast majority (83 percent) also sought treatment for the same condition from a medical doctor; however, 72 percent of the respondents who used unconventional therapy did not inform their medical doctor that they had done so. Extrapolation to the U.S. population suggests that in 1990 Americans made an estimated 425 million visits to providers of unconventional therapy. This number exceeds the number of visits to all U.S. primary care physicians (388 million). Expenditures associated with use of unconventional therapy in 1990 amounted to approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. This figure is comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States. CONCLUSIONS: The frequency of use of unconventional therapy in the United States is far higher than previously reported. Medical doctors should ask about their patients' use of unconventional therapy whenever they obtain a medical history.

[Health promotion and wellness programs in private corporate organizations. Problems of trans-national and trans-cultural transferability]. / Gesundheitsförderung und "Wellness"-Programme in privaten korporativen Unternehmen. Probleme transnationaler und -kultureller Ubertragbarkeit.

Health promotion and wellness programmes in corporate organisations are subjects of considerable interest to both the providers (companies) and the consumers (employees). Economic considerations constitute a significant factor in businesses' interest in adopting health promotion programmes and in the wellness communities attempts to sell such programming to business. Substantial elements of both the business and wellness communities believe that health promotion programmes are financially profitable in addition to, and as a result of, improving employee's health. A fact which has not yet attracted significant research activities is a comparative analysis of corporate health promotion and wellness programmes in different societies with different cultural backgrounds, corporate cultures and external environments. Especially the emerging of a "New Europe" after the full realisation of the Common Market (EC) after 1992 and the tremendous economic possibilities after substantial political changes in the political structure of the eastern part of Europe (on its way to capitalism) might make it worth to look into corporate wellness programs of European organisations and to discuss pros and cons after comparing them with the ones of their American counterparts. Most important facts in which US organisations differ from most European corporations are not only the internal corporate culture but also the external environment, such as direct government interventions and political pressure from the consumer interest groups (strong unions). In many European countries the government imposes a very tight regulatory and legal framework and dictates the way corporate organisations have to share the burden of health related costs and have to provide occupational, wellness or preventive programmes for their employees.(ABSTRACT TRUNCATED AT 250 WORDS)

Small cell carcinoma of the esophagus in a patient with longstanding primary achalasia.

Achalasia is believed to be a predisposing factor for the development of esophageal cancer. Small cell carcinoma of the esophagus is a rare neoplasm, with fewer than 150 cases having been reported in the world literature, and it has been described only once previously in a patient with longstanding achalasia. We describe a case of an 85-yr-old woman with long-term primary achalasia who developed primary small cell carcinoma of the esophagus. We hypothesize that this patient's recurrent, worsening dysphagia is related to a paraneoplastic phenomenon. We discuss this association and review the literature.

Failure of physicians to recognize functional disability in ambulatory patients.

OBJECTIVE: To assess the ability of internists to identify functional disabilities reported by their patients. DESIGN: Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. SETTING: A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. SUBJECTS: Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. MEASUREMENTS AND MAIN RESULTS: Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. CONCLUSIONS: Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.

The effect of computer-based reminders on the management of hospitalized patients with worsening renal function.

We performed a prospective time-series study to determine whether computerized reminders to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic and renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to evaluate physician acceptance of computerized reminders. Laboratory data were followed on 10,076 patients over 13,703 admissions generating 1104 events of rising creatinine levels during treatment with nephrotoxic or renally excreted medications. During the intervention period, medications were adjusted or discontinued an average of 21.1 hours sooner (p less than 0.0001) after such an event occurred when compared with the control period. This effect of the reminders was strongest for patients receiving renally excreted and mildly nephrotoxic medications. Of physicians who responded to a computerized survey, 53% said that the reminders had been helpful in the care of their patients, while 31% felt that the reminders were annoying. Seventy-three percent wished to continue receiving computerized reminders. We conclude that computerized reminders are well-accepted in our hospital and have a strong effect on physician behavior.

Improving patient function: a randomized trial of functional disability screening.

STUDY OBJECTIVES: To test whether a 34-item functional status questionnaire measuring physical, psychological, and social function can be used by physicians in practice to help improve their patients' outcomes. DESIGN: Prospective randomized trial. SETTING: Community internal medicine practices. PATIENTS: Five hundred and ten continuing patients with functional disabilities who saw their physicians at least four times a year. PHYSICIANS: Seventy-six UCLA clinical volunteer faculty who are internists in community office practices. INTERVENTIONS: Physicians and their patients were randomly assigned to the experimental or the control group. Experimental group physicians attended a 2-hour multimedia educational session and received four functional status reports on each of their study patients over a 1-year period. Control group physicians received no education and no functional status feedback. Control group and experimental group patients were tested for functional status with the functional status questionnaire every 4 months for 1 year. Both groups also completed monthly diaries that measured use of health services. Experimental group physicians answered an anonymous evaluation questionnaire at 6 months after study entry. MEASUREMENTS AND MAIN RESULTS: Forty-three percent of experimental group physicians reported that they had used the functional status questionnaire to change therapy. Ninety-five percent reported that it was useful and accurate. Patient diaries did not show any difference between experimental group patients and control group patients in number of medications used, visits to physicians or other health professionals, equipment purchased, diet, or exercise programs. There were no significant differences between experimental and control group patients at exit from the study on any functional status or health outcome measure. CONCLUSION: A more powerful intervention than a 2-hour educational session and the regular provision of functional status information is needed to help office-based internists improve patient outcomes.

Participation of volunteer faculty members in education research projects.

Physicians in private practice who are also volunteer clinical faculty members are a recognized resource for teaching and patient care at teaching hospitals. Clinical faculty members have seldom been included in education research despite the frequent complaint from community practitioners that the results from studies at teaching hospitals are not applicable to community practice. The authors report on a study involving volunteer clinical faculty members in a randomized education trial to improve patients' everyday functioning. Seventy-six clinical faculty physicians in office practice of internal medicine participated. At the end of the study the physician participants were asked to complete an evaluation questionnaire concerning the appropriateness of clinical faculty members' participation in such research projects. Ninety-five percent said the experiment was appropriate, and 88 percent would participate again.