Association of educational attainment with HIV risk in African American active injection drug users.

This study explored the association between educational attainment and HIV/AIDS risk among African American active injection drug users (IDUs) in Chicago, US. Using snowball sampling techniques, 813 African American active IDUs were recruited for semi-structured interviewing and HIV counseling, testing and partner notification. Logistic regression examined the relationship between level of education attained (three categories: less than high school; equivalent to high school; and greater than high school) and HIV risk behaviors (12 unsafe sex and drug-related practices) and HIV serostatus (positive or negative). Compared with the reference category (less than high school education), those with education equal to high school were less likely to share water, p = 0.044, OR = 0.70 (95%CI: 0.50-0.99). Compared with the reference category, those with education greater than high school were less likely to receive money for sex, p = 0.048, OR = 0.62 (95%CI: 0.38-0.99); share needles with person having HIV or AIDS, p = 0.015, OR = 0.58 (95%CI: 0.37-0.90); and test positive for HIV, p = 0.027, OR = 0.58 (95%CI: 0.36-0.94). The significant associations found between educational attainment and certain HIV risk behaviors and HIV serostatus have implications for tailoring HIV prevention efforts for less educated African American IDUs.

Influence of religiosity on HIV risk behaviors in active injection drug users.

Previous studies have shown a positive relationship between religiosity and the practice or adoption of protective health behaviors, including reduction of illicit drug use among hard-core injecting drug users (IDUs). The purpose of this study was to examine the role of religiosity in predicting HIV high-risk drug and sexual practices among a sample of IDUs in Chicago, USA. We hypothesized that high religiosity would be associated with a lower likelihood of IDUs engaging in risky behaviors for HIV transmission. Snowball sampling techniques were used to recruit 1,095 active IDUs for HIV testing, counseling and partner notification. Data were analyzed from 880 subjects who self-identified with one of three religions, Christianity, Islam or Judaism. Logistic regression was used to examine the relationship between religiosity (based on self-reports of personal strength of religious belief: very strong; somewhat strong; not at all), independent of specific religion, and HIV risk behaviors (defined as 12 unsafe sex- and drug-related practices) as well as HIV serostatus. Contrary to our hypothesis, subjects with stronger religiosity were more likely to engage in four risk behaviors related to sharing injection paraphernalia. Compared to those who self-reported having no religiosity, subjects who stated that their lives were strongly influenced by religious beliefs were significantly more likely to share injection outfits, cookers, cotton and water. The association of certain HIV risk behaviors with higher religiosity has implications for HIV prevention and warrants further research to explore IDUs' interpretation of religious teachings and the role of religious education in HIV prevention programs.

Improving delivery of preventive health care with the comprehensive annotated reminder tool (CART).

OBJECTIVES: We assessed the effect of the Comprehensive Annotated Reminder Tool (CART) on physician adherence to preventive services recommendations. STUDY DESIGN: Using a randomized pretest/posttest control group design, we assigned physicians to the CART group or the control group, followed up prospectively, and evaluated for appropriate adherence to guidelines. The 3 age-specific versions of the CART annotated history and physical examination form contained up to 49 preventive services recommendations. POPULATION: All resident physicians in a large family practice residency program were studied over the course of 1 academic year. OUTCOMES MEASURED: We performed blinded chart reviews to assess the appropriateness of preventive services ordered by the physicians before the introduction of the CART, during its use, and after its removal. A multiple-choice test completed before and after the use of the CART forms assessed knowledge. RESULTS: When the CART was used, the appropriateness of physician preventive behavior increased by 21% overall. The appropriateness of history, physical examination, and laboratory interventions increased by 33%. When the CART was removed, physician behavior returned to baseline (P < or = .0025 for 16 of 20 interventions). No significant differences were observed in the control group over time. Knowledge increased over the study period for all physicians (P < or = .005) but did not differ significantly between the treatment and control groups (P = .608). CONCLUSIONS: Use of the CART significantly improved physician performance in the appropriate delivery of preventive care.

A method for measuring interrater agreement on checklists.

A method for measuring interrater agreement on checklists is presented. This technique does not assign individual scores to raters, but computes a single agreement score from the concordance of their check mark configurations. An overall coefficient of agreement, called phi, is derived. The agreement coefficient that is expected by chance and the statistical significance of phi are determined by statistical simulation. Despite the dichotomous nature of the checklist agreement (raters either agree or disagree on items), we show that the binomial distribution does not provide a means for testing the statistical significance of phi. A medical education study is used to illustrate the phi methodology.

HITS: a short domestic violence screening tool for use in a family practice setting.

BACKGROUND AND OBJECTIVES: Domestic violence is an important problem that is often not recognized by physicians. We designed a short instrument for domestic violence screening that could be easily remembered and administered by family physicians. METHODS: In phase one of the study, 160 adult female family practice office patients living with a partner for at least 12 months completed two questionnaires. One questionnaire was the verbal and physical aggression items of the Conflict Tactics Scale (CTS). The other was a new four-item questionnaire that asked respondents how often their partner physically Hurt, Insulted, Threatened with harm, and Screamed at them. These four items make the acronym HITS. In phase two, 99 women, who were self-identified victims of domestic violence, completed the HITS. RESULTS: For phase one, Cronbach's alpha was .80 for the HITS scale. The correlation of HITS and CTS scores was .85. For phase two, the mean HITS scores for office patients and abuse victims were 6.13 and 15.15, respectively. Optimal data analysis revealed that a cut score of 10.5 on the HITS reliably differentiated respondents in the two groups. Using this cut score, 91% of patients and 96% of abuse victims were accurately classified. CONCLUSIONS: The HITS scale showed good internal consistency and concurrent validity with the CTS verbal and physical aggression items. The HITS scale also showed good construct validity in its ability to differentiate family practice patients from abuse victims. The HITS scale is promising as a domestic violence screening mnemonic for family practice physicians and residents.

The association of urinary tract infection with a recent pelvic examination in women.

We tried to determine whether women with a urinary tract infection (UTI) were more likely to have had a recent pelvic examination than were women seen for other reasons. We compared 56 women who were diagnosed as having a UTI with 49 controls who had an unrelated complaint (sinusitis). Significantly more women with UTIs had received a pelvic examination within the preceding 2 months (43% vs 16%, P = .01). We conclude that having a pelvic examination is associated with an increased risk of a UTI developing within the following 2 months. This may be due to physical factors related to the examination or to risk factors related to the patients' reasons for obtaining a pelvic examination. Further study is needed to determine if the pelvic examination is an independent risk factor. If so, established preventive measures could reduce this risk.

A survey of exercise beliefs and exercise habits among people with arthritis.

OBJECTIVE: To explore a possible explanation for the problem of why few people exercise despite the positive health advantages, by examining the relationship between exercise beliefs and participation in exercise activities. METHODS: Eighty-one respondents aged 27-80 were recruited from 3 Chicago-area health care facilities to complete the study survey; 68 (84%) did so. Participants were asked about their participation in 6 types of exercise activities; they also reported their beliefs concerning their ability to exercise (self-efficacy for exercise), barriers to exercise, benefits of exercise, and the impact of exercise on their arthritis. RESULTS: Study results indicate that belief in the benefits of exercise and self-efficacy for exercise are associated with participation in exercise activities. Also, severity of disease differentiated exercisers from non-exercisers. CONCLUSIONS: Results suggest the importance of finding ways to strengthen belief in the benefits of exercise and self-efficacy for exercise in people with arthritis, particularly people with moderate to severe disease-related limitations.

Recombinant human interleukin-1 receptor type I in the treatment of patients with active rheumatoid arthritis.

OBJECTIVE: To determine the safety and efficacy of recombinant soluble human interleukin-1 receptor type I (rHuIL-1RI) administered subcutaneously in patients with active rheumatoid arthritis (RA). METHODS: Twenty-three patients with active RA (>5 swollen joints) were enrolled into a randomized, double-blind, 2-center study. Patients received subcutaneous doses of rHuIL-1RI or placebo for 28 consecutive days. Patients were treated with 125, 250, 500, or 1,000 micrograms/m2/day of rHuIL-1RI. Physical examinations and laboratory assessments were performed at baseline (day 1), and 8, 15, 22, 29, 43, and 57 days after the start of the study. Analysis of peripheral blood by flow cytometry was performed on days 1 and 29 to determine the effects of rHuIL-1RI on the distribution and phenotypic characteristics of circulating inflammatory cells. RESULTS: Four of 8 patients who received rHuIL-1RI at 1,000 micrograms/m2/day demonstrated improvement in at least 1 of 8 individual measures of disease activity; however, only 1 of these 4 patients experienced clinically relevant improvement as defined by predetermined criteria. None of the patients treated with smaller doses of rHuIL-1RI, and none of the placebo-treated control patients, experienced any improvement as defined by the predetermined criteria. Monocyte cell surface IL-1alpha was significantly reduced following treatment with rHuIL-1RI at each dosage. Administration of rHuIL-1RI was stopped prematurely because of dose-limiting rashes in 2 patients treated with 1,000 micrograms/m2/day. No other adverse events prevented completion of the study. CONCLUSION: Only 1 patient, who was treated with the highest concentration of rHuIL-1RI employed (1,000 micrograms/m2/day), demonstrated clinically relevant improvement in this phase I study on this small group of patients with active RA. Dose-limiting toxicity was also observed in 2 patients treated with this highest concentration of rHuIL-1RI. Treatment with rHuIL-1RI did result in a reduction of monocyte cell surface IL-1alpha, which indicates that the dosages of rHuIL-1RI employed were functional.

A comparative study of seven measures of patient satisfaction.

The acceptability of satisfaction as a quality indicator is qualified by several well known measurement problems. This study examines the variability in satisfaction evaluations related to different measurement methods and the effect of response biases on reported satisfaction. Satisfaction evaluations using seven different, commonly used measures of patient satisfaction were obtained from the same sample of respondents. The seven measures were: 1) a global measure of satisfaction using a visual analogue scale; 2) a multidimensional measure of satisfaction based on the Patient Satisfaction Questionnaire using an evaluation response format (poor, fair, good, very good, excellent); 3) a two-item overall evaluation of quality using the evaluation response format; 4) a six-item attitude measure of general satisfaction using a five-point Likert agree-disagree response format; 5) a four-item attitude measure of satisfaction with physician, using the agree-disagree response format; 6) a four-item measure of behavioral intention; and 7) willingness-to-pay in dollars. The percentage of favorable evaluations of care ranged from 63% to 82% across six of the seven measures. Willingness-to-pay does not appear to be a valid measure of satisfaction. Correlations were highest between measures with similar response formats. Although an oppositional response bias was not found, a very substantial acquiescent response bias was detected. Acquiescence reduced the internal consistency of three multiple-item measures, the general and physician attitude and behavioral intention measures, to levels unacceptable even for group comparisons. Between highly and nonacquiescent respondents, levels of satisfaction were somewhat lower for the multidimensional measure of satisfaction and significantly lower for the two attitude satisfaction measures. Highly acquiescent respondents were older, less well educated, and in poorer health than nonacquiescent subjects. Results of satisfaction evaluations dependent on the measurement method used, and unreliability of measurement may be a significant problem in satisfaction measurement, especially for the oldest and most ill patients.

Alteration in multijoint dynamics in patients with bilateral knee osteoarthritis.

OBJECTIVE: To document the alterations of joint motion and torque in patients with bilateral knee osteoarthritis (OA), using a well-defined functional maneuver, the sit-to-stand (STS) task. METHODS: Twelve patients with bilateral knee OA and 12 age-, sex-, and height-matched control subjects performed the STS maneuver from a stool of a standard height at their natural speeds. A motion analysis system and 2 force platforms were employed to determine the dynamic joint motion and the resultant joint torques at the ankle, knee, and hip joints. RESULTS: The results showed that OA patients exhibited substantially reduced knee extension torques, accompanied by other alterations in initial sitting posture (more extended knee and more plantar-flexed ankle), movement duration (increased), dynamic range of motion at the knee (reduced), and extension torques at the hip (increased). CONCLUSION: The alterations in joint dynamics among patients with knee OA may have revealed an adaptive motor behavior characterized by redistributing the load from impaired to less-impaired or nonimpaired joints through multijoint dynamics. Two major potential pitfalls of such a movement strategy have subsequently been postulated.

Predicting stroke inpatient rehabilitation outcome using a classification tree approach.

A classification tree, a nonparametric statistical analysis, was used to develop decision rules to predict a favorable inpatient stroke rehabilitation outcome. Descriptive and functional status data collected on admission from 225 patients were the predictor variables. Favorable outcome was defined as having met three criteria: discharged to community, survival greater than 3 months postdischarge, and no more than minimal physical assistance required in functional activities on discharge. The classification tree correctly classified 88% of the sample using only four of the predictor variables (level of independence in Toilet Management, Bladder Management, and Toilet Transfer, and adequacy of Financial Resources). The cross validation error rate was 18%. The advantages of the classification tree approach over parametric methods are that it is desirable for ordinal data, it readily identifies the interactions among predictor variables, the results are easily communicated, and it provides additional insights into the factors that predict outcome.

Stroke inpatient rehabilitation: a comparison across age groups.

OBJECTIVE: To examine and compare the inpatient stroke rehabilitation experience of older adults (> or = 75 years) with that of young adults (< 65 years) and young-old adults (65-74 years). DESIGN: Cross-sectional descriptive study. SETTING: A large university-affiliated free-standing rehabilitation hospital. PARTICIPANTS: 260 adults who were admitted to inpatient stroke rehabilitation with a primary diagnosis of recent (< 120 days) stroke (ICD9 430-436). VARIABLES: Demographic data, diagnosis, time between stroke onset and rehabilitation admission, discharge disposition, and functional status on admission and discharge were obtained from the patient's medical record. Treatment intensity and type, length of stay, and primary payment source data were obtained from the patient's billing record. Three-month mortality data were available from the hospital's routine follow-up survey. MAIN RESULTS: Compared with the younger adults (< 65 yrs and 65-75 years), the older adults (> or = 75 years) were admitted to rehabilitation earlier and with comparable cognitive but poorer motor function. Rehabilitation treatment intensity (per day) and type were similar across age groups, but the older adults (> or = 75 years) had significantly shorter rehabilitation stays. Three-month survival was comparable across age groups, but the older adults (> or = 75 years) had poorer motor function at discharge and were more often discharged to a nursing home or required a paid caregiver. CONCLUSIONS: Age-associated factors may influence inpatient stroke rehabilitation referral, treatment, and outcome, particularly for patients over age 75. The cumulative effects of frailty and co-morbid disease upon stroke disability and treatment are possible explanations for the findings. The study provides evidence of a need for further investigation of stroke rehabilitation strategies for adults over 75 years old.

The importance of patient preferences in the measurement of health care satisfaction.

The idea that patients will be more satisfied with health care services that are delivered to meet their preferences is central to the concept of health care marketing. Health care providers increasingly use market segmentation and target marketing to optimize the fit between their services and the consumers who receive them. This study evaluates one model for incorporation of patient preferences into the measurement of satisfaction. Using multiple regression analysis, evaluations of three dimensions of health care satisfaction, interpersonal care, technical quality, access to care accounted for 63% of the variance in overall satisfaction. Inclusion of preferences, defined as importance ranks of each dimension, did not improve ability to predict satisfaction. Four preference segments were identified: interpersonal care seekers, access/quality seekers, access seekers and quality seekers. These four subgroups differed significantly on a number of sociodemographic, health status and health service use characteristics but no significant differences were found in satisfaction between preference segments. Patient satisfaction can best be measured as quality evaluations of dimensions without regard to preferences. In considering the merits of market segmentation and target marketing, alternative satisfaction models that link preferences to health care satisfaction or the possibility that preference targeting does not lead to greater satisfaction should be evaluated.

Psychological factors affecting reported pain in juvenile rheumatoid arthritis.

Examined the extent to which psychological variables are correlated with pain reported by children with juvenile rheumatoid arthritis (JRA). In a hierarchical multiple regression analysis with pain as the dependent variable, four psychological measures of child and family functioning resulted in a significant increase in R2 = .31, p < .0001, after the effects of disease characteristics were considered. Greater emotional distress in the child, greater emotional distress of the mother, and greater family harmony were related to higher reported pain. Findings suggest that more attention should be given to nonpharmacological aspects of pain and pain management in children with JRA.

Assessment of clinical competence of medical students by using standardized patients with musculoskeletal problems.

OBJECTIVE: To assess medical students' clinical competence in addressing musculoskeletal problems. METHODS: Nineteen junior medical students completed 2 standardized patient-based tests structured to capture their clinical decisions from undiagnosed chief complaint to management. RESULTS: No student approached the highest possible score on either test, and the students as a group received less than half the possible points on 5 important aspects of diagnostic reasoning. CONCLUSION: Standardized patient-based tests can be structured to provide enlightening information about medical students' clinical competence with regard to musculoskeletal problems.