Where to refer patients who abuse alcohol or other drugs.

Maryland has a rich diversity of substance abuse treatment programs. This article introduces some of the resources available to help physicians prescribe a workable treatment plan for their substance-abusing patients.

A controlled study of a standardized behavioral stepped treatment for hypertension.

A standardized behavioral stepped care (SC) treatment for hypertension (blood pressure monitoring followed by self-administered systolic blood pressure biofeedback and relaxation, in sequence, as needed) was administered to 51 patients whose blood pressures were medically controlled to within normal limits. The effects of treatment upon blood pressure, medication requirements, and cost of care were compared with those of 51 referred care (RC) control patients who continued their usual care for hypertension. SC and RC patients were matched in groups on the basis of medication requirements (Group I, diuretics; Group II, beta-blockers alone or with a diuretic; and Group III, vasodilators alone or with a drug from Group I or II). The duration of the SC procedure was 1, 4, or 7 months--as necessary--and the follow-up period was 12 months. The RC protocol lasted 19 months. Medication requirements for SC patients declined to levels significantly (p less than 0.05) lower than those of RC patients from the biofeedback phase throughout follow-up for all drug groups combined. However, when the drug groups were analyzed separately, this was true for Groups I and II only. Similarly, the cost of care for all drug groups combined was lower for SC patients from the biofeedback phase through 9 months of follow-up, also reflecting changes seen in Drug Groups I and II only. Blood pressure levels remained controlled, in all groups, throughout the investigation. Clinical possibilities for combined behavioral and pharmacological treatment of hypertension are discussed relative to the pathophysiology of hypertension, and questions for future research are suggested.

The use of successive blood-pressure measurements to estimate blood-pressure variability.

Multiple daily, self-determined blood-pressure measurements were obtained from 254 hypertensive patients for 1 month. In an effort to establish a practical and reliable technique for estimating blood-pressure variability, standard deviations from three (at one time of day) or nine (throughout the day) successive self-determinations were compared with a reference value, taken to be the standard deviation for the entire month (252 determinations per subject). Neither the standard deviation of three measures taken on one occasion nor that of nine measures taken throughout the day correlated well with the reference value (average R3 = .21 for SBP, .20 for DBP; average R9 = .39 for SBP, .38 for DBP). However, when a sample consisting of 12 measures (taken three at a time, at the same time of day, weekly for 4 weeks) was used, the average correlation rose to .60 for SBP and .54 for DBP. Thus, it appears that 12 samples taken in this way provide a reliable estimate of the standard deviation for an entire month, and it is suggested that this sampling technique also would enhance the reliability of conclusions drawn from assessments of the prognostic value of blood-pressure variability.

Out-patient detoxification of patients addicted to sedative-hypnotics and anxiolytics.

Due to the risk of seizures and other potentially life threatening complications, it has been accepted practice to detoxify patients addicted to sedative-hypnotics or minor tranquilizers in an in-patient setting. Using the procedures for patient selection and management described below, we have been able to detoxify as out-patients approximately two-thirds of 69 patients who were found to be in need of detoxification. Out-patients experienced no serious complications during or immediately following detoxification and were not significantly less likely than in-patients to complete treatment. We present here some guidelines which will assist practitioners in identifying patients who are appropriate for out-patient detoxification and describe approaches to patient management that have proven effective.

The influence of patient-practitioner agreement on outcome of care.

A previous study suggested that patient-practitioner agreement and follow-up in ambulatory care facilitates problem resolution as judged by patients. In this study in another medical practice, practitioner-patient agreement on what problems required follow-up was associated with greater problem resolution as judged by the practitioners regardless of the severity of the problems. In this study, patients did not judge problems mentioned only by themselves to be less improved than problems mentioned by both them and their practitioners. However, in this study more of the problems mentioned only by patients were mentioned in the note of the visit contained in the medical record. Patients expected less and reported less improvements of problems that were neither mentioned by the practitioner nor written in the medical record than was the case for problems listed both by patients and practitioners. The findings of this study confirm those of the previous study in suggesting that practitioner-patient agreement about problems is associated with greater expectations for improvement and with better outcome as perceived by patients. In addition, they indicate that practitioners also report better outcome under the same circumstances.

A practice plan in a municipal teaching hospital: a model for the funding of clinical faculty.

Academic-practice plans have become increasingly important as a source of financial support for the faculty of academic centers. We describe the planning, implementation, and development of one such plan in a municipal hospital, a major affiliate of a medical school. The incorporated practice plan is nonprofit and is owned and governed by physicians. Its success during the eight years of its existence has resulted in growth of the faculty, the development of innovative ambulatory-care programs, and increased financial stability of the hospital. Although such problems as payment for teaching costs and academic advancement for primary-care physicians remain, it is clear that academic-practice plans can support the clinical, teaching, and research goals of academic physicians.