Search

Background: The Internet is valuable for those with limited access to health care services because of its low cost and wealth of information. Our objectives were to investigate how the Internet is used to obtain health-related information and how individuals with differing socioeconomic resources navigate it when presented with a health decision.Methods: Study participants were recruited from public settings and social service agencies. Participants listened to one of two clinical scenarios - consistent with influenza or bacterial meningitis - and then conducted an Internet search. Screen-capture video software captured the Internet search. Participant Internet search strategies were analyzed and coded for pre- and post-Internet search guess at diagnosis and information seeking patterns. Individuals who did not have a college degree and were recruited from locations offering social services were categorized as "lower socioeconomic status" (SES); the remainder was categorized as "higher SES." Participants were 78 Internet health information seekers, ranging from 21-35 years of age, who experienced barriers to accessing health care services.Results: Lower-SES individuals were more likely to use an intuitive, rather than deliberative, approach to Internet health information seeking. Lower- and higher-SES participants did not differ in the tendency to make diagnostic guesses based on Internet searches. Lower-SES participants were more likely than their higher-SES counterparts to narrow the scope of their search.Conclusions: Our findings suggest that individuals with different levels of socioeconomic status vary in the heuristics and search patterns they rely upon to direct their searches. The influence and use of credible information in the process of making a decision is associated with education and prior experiences with healthcare services. Those with limited resources may be disadvantaged when turning to the Internet to make a health decision. [ABSTRACT FROM AUTHOR]

PURPOSE Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample. METHODS We undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas). RESULTS Adjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI -4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language. CONCLUSIONS Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain. [ABSTRACT FROM AUTHOR]

Background: Over the past 30 years, patients' options for accessing information about prescription drugs have expanded dramatically. In this narrative review, we address four questions: (1) What information sources are patients exposed to, and are they paying attention? (2) Is the information they hear credible and accurate? (3) When patients ask for a prescription, what do they really want and need? Finally, (4) How can physicians reconcile what patients hear, want, and need? Analysis: A critical synthesis of the literature is reported. Observations indicate that the public is generally aware of and attends to a growing body of health information resources, including traditional news media, advertising, and social networking. However, lay audiences often have no reliable way to assess the accuracy of health information found in the media, on the Internet, or in direct-to-consumer advertising. This inability to assess the information can lead to decision paralysis, with patients questioning what is known, what is knowable, and what their physicians know. Many patients have specific expectations for the care they wish to receive and have little difficulty making those expectations known. However, there are hazards in assuming that patients' expressed desires are direct reflections of their underlying wants or needs. In trying to reconcile patients' wants and needs for information about prescription medicines, a combination of policy and clinical initiatives may offer greater promise than either approach alone. Conclusions: Patients are bombarded by information about medicines. The problem is not a lack of information; rather, it is knowing what information to trust. Making sure patients get the medications they need and are prepared to take them safely requires a combination of policy and clinical interventions. [ABSTRACT FROM AUTHOR]

People who the author would like to thank for their assistance in serving as peer reviewers for the "Journal of General Internal Medicine" are presented.

Importance: Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.Objective: To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.Design, Setting, and Participants: Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.Interventions: DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).Main Outcomes and Measures: Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.Results: Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control,  0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,  0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control,  0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority).Conclusions and Relevance: A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.Trial Registration: clinicaltrials.gov Identifier: NCT01144104. [ABSTRACT FROM AUTHOR]

IMPORTANCE Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment. OBJECTIVE TO determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing. DESIGN, SETTING. AND PARTICIPANTS Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California. INTERVENTIONS DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control). MAIN OUTCOMES AND MEASURES Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted. RESULTS Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control, 0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control, 0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control, 0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority). CONCLUSIONS AND RELEVANCE A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-weel< follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01144104 [ABSTRACT FROM AUTHOR]

IMPORTANCE Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment. OBJECTIVE To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California. INTERVENTIONS DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control). MAIN OUTCOMES AND MEASURES Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted. RESULTS Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5%for DEV, 26%for IMCP, and 16.3%for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95%CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95%CI, -1.2 to 0.8); IMCP vs control, 0.9 (95%CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90%CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control, 0.9 [90%CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control, 0.3 [90%CI, -5.1 to 5.7], P = .16 for noninferiority). CONCLUSIONS AND RELEVANCE A tailored IMCP increased clinician recommendations for antidepressant drugs, amental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01144104 [ABSTRACT FROM AUTHOR]

Objective: To raise awareness among clinicians and epidemiologists that single-patient (n-of-1) trials are potentially useful for informing personalized treatment decisions for patients with chronic conditions. Study Design and Setting: We reviewed the clinical and statistical literature on methods and applications of single-patient trials and then critically evaluated the needs for further methodological developments. Results: Existing literature reports application of 2,154 single-patient trials in 108 studies for diverse clinical conditions; various recent commentaries advocate for wider application of such trials in clinical decision making. Preliminary evidence from several recent pilot acceptability studies suggests that single-patient trials have the potential for widespread acceptance by patients and clinicians as an effective modality for increasing the therapeutic precision. Bayesian and adaptive statistical methods hold promise for increasing the informational yield of single-patient trials while reducing participant burden, but are not widely used. Personalized applications of single-patient trials can be enhanced through further development and application of methodologies on adaptive trial design, stopping rules, network meta-analysis, washout methods, and methods for communicating trial findings to patients and clinicians. Conclusions: Single-patient trials may be poised to emerge as an important part of the methodological armamentarium for comparative effectiveness research and patient-centered outcomes research. By permitting direct estimation of individual treatment effects, they can facilitate finely graded individualized care, enhance therapeutic precision, improve patient outcomes, and reduce costs. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Commercial advertising and patient education have separate theoretical underpinnings, approaches, and practitioners. This paper aims to describe a collaboration between academic researchers and a marketing firm working to produce demographically targeted public service anouncements (PSAs) designed to enhance depression care-seeking in primary care. Methods: An interdisciplinary group of academic researchers contracted with a marketing firm in Rochester, NY to produce PSAs that would help patients with depressive symptoms engage more effectively with their primary care physicians (PCPs). The researchers brought perspectives derived from clinical experience and the social sciences and conducted empirical research using focus groups, conjoint analysis, and a population-based survey. Results were shared with the marketing firm, which produced four PSA variants targeted to gender and socioeconomic position. Results: There was no simple, one-to-one relationship between research results and the form, content, or style of the PSAs. Instead, empirical findings served as a springboard for discussion and kept the creative process tethered to the experiences, attitudes, and opinions of actual patients. Reflecting research findings highlighting patients’ struggles to recognize, label, and disclose depressive symptoms, the marketing firm generated communication objectives that emphasized: (a) educating the patient to consider and investigate the possibility of depression; (b) creating the belief that the PCP is interested in discussing depression and capable of offering helpful treatment; and (c) modelling different ways of communicating with physicians about depression. Before production, PSA prototypes were vetted with additional focus groups. The winning prototype, “Faces,” involved a multi-ethnic montage of formerly depressed persons talking about how depression affected them and how they improved with treatment, punctuated by a physician who provided clinical information. A member of the academic team was present and consulted closely during production. Challenges included reconciling the marketing tradition of audience segmentation with the overall project goal of reaching as broad an audience as possible; integrating research findings across dimensions of words, images, music, and tone; and dealing with misunderstandings related to project scope and budget. Conclusion: Mixed methods research can usefully inform PSAs that incorporate patient perspectives and are produced to professional standards. However, tensions between the academic and commercial worlds exist and must be addressed. Practice implications: While rewarding, academic-marketing collaborations introduce tensions which must be addressed. [Copyright &y& Elsevier]

Abstract: Objective: Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences – a precursor of behavior change in some studies – is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English). Methods: Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N =1164) and the three ethnicity/language subgroups. Results: Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P <0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME)=9.5%, 95% CI 5.3–13.6; P <0.001]. AMEs were similar across ethnicity/language subgroups. Conclusion: Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups. Practice Implications: If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors. [Copyright &y& Elsevier]

Abstract: Context: For patients with cancer-related pain and their physicians, routine oncology visits are an opportunity to adjust the analgesic regimen and secure better pain control. However, treatment intensification occurs haphazardly in practice. Objectives: To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits, and in turn, the influence of treatment adjustment on subsequent cancer pain control, we studied patients enrolled in a randomized trial of TEC. Methods: Just before a scheduled oncology visit, 258 patients with at least moderate baseline pain received TEC or control; just after the same visit, they reported on whether the physician recommended a new pain medicine or a change in dose of an existing medicine. Pain severity and pain-related impairment were measured two, six, and 12 weeks later. Results: Patients assigned to TEC were more likely than controls to report a change in the analgesic treatment regimen (60% vs. 36%, P <0.01); significant effects persisted after adjustment for baseline pain, study site, and physician (adjusted odds ratio 2.61, 95% confidence interval 1.55, 4.40, P <0.01). In a mixed-effects repeated measures regression, analgesic change (but not TEC itself) was associated with a sustained decrease in pain severity (P <0.05). Conclusion: TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing, and treatment intensification is associated with better cancer pain outcomes. [Copyright &y& Elsevier]

Abstract: We aimed to determine the effectiveness of a lay-administered tailored education and coaching (TEC) intervention (aimed at reducing pain misconceptions and enhancing self-efficacy for communicating with physicians) on cancer pain severity, pain-related impairment, and quality of life. Cancer patients with baseline “worst pain” of ⩾4 on a 0–10 scale or at least moderate functional impairment due to pain were randomly assigned to TEC or enhanced usual care (EUC) during a telephone interview conducted in advance of a planned oncology office visit (265 patients randomized to TEC or EUC; 258 completed at least one follow-up). Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 6, and 12 weeks. Mixed effects regressions were used to evaluate the intervention adjusting for patient, practice, and site characteristics. Compared to EUC, TEC was associated with increased pain communication self-efficacy after the intervention (P <.001); both groups showed significant (P <.0001), similar, reductions in pain misconceptions. At 2 weeks, assignment to TEC was associated with improvement in pain-related impairment (−0.25 points on a 5-point scale, 95% confidence interval −0.43 to −0.06, P =.01) but not in pain severity (−0.21 points on an 11-point scale, −0.60 to 0.17, P =.27). The improvement in pain-related impairment was not sustained at 6 and 12 weeks. There were no significant intervention by subgroup interactions (P >.10). We conclude that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in pain severity. Compared with control, tailored education and coaching for patients with cancer-related pain improved communication self-efficacy and reduced pain-related impairment in the short term but had no sustained benefits. [Copyright &y& Elsevier]

An interview with physician David Judge is presented. When asked about problems with office practice of medicine, he states that every patient is put through 15-20 minutes of office visits even though their needs would be different. He mentions that the Ambulatory Practice of the Future (AFP) project will try to related to medical homes by building them. He highlights that Massachusetts General Hospital is working on software tools which will allow physicians to input care plan.

Objective: To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States. Methods: Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25–64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes. Results: Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient–physician trust. While many reflected positively on their primary care experiences, some doubted PCPs’ knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust. Conclusion: Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs’ mental health-related capabilities and interests. Practice implications: PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions. [Copyright &y& Elsevier]

The article offers information related to the "Journal of General Internal Medicine" (JGIM). It states that the JGIM featured new columns which include From the Editor's Desk, Exercises in Clinical Reasoning, and Healing Arts. It says that JGIM will renew the Innovations in Medical Education, provide article series on health policy, and collaborate with the "Annals of Internal Medicine." It also presents the lists of JGIM reviewers from 2009-2010 including Elmer Abbo, Lisa Hess, and Jenny Yi.

The article focuses on the screening and treating depression in the U.S. It states that risk factors for depression include older age associated neurologic conditions, female sex, alcohol dependence and stressful life events. It infers that depression may benefit equally from psychotherapy or medication because it may protect better against relapse.

An interview with Christine Sinsky of Medical Associates Clinic (MAC) is presented. She informs that MAC is a multi-specialty group of approximately 120 physicians and around 30 "midlevel" providers. She claims that the ability to work together and form a relationship with the nursing staff is really important. She mentions that the role of the nurse is particularly important when there is discontinuity.

Background: Editorial peer review is universally used but little studied. We examined the relationship between external reviewers’ recommendations and the editorial outcome of manuscripts undergoing external peer-review at the Journal of General Internal Medicine (JGIM). Methodology/Principal Findings: We examined reviewer recommendations and editors’ decisions at JGIM between 2004 and 2008. For manuscripts undergoing peer review, we calculated chance-corrected agreement among reviewers on recommendations to reject versus accept or revise. Using mixed effects logistic regression models, we estimated intra-class correlation coefficients (ICC) at the reviewer and manuscript level. Finally, we examined the probability of rejection in relation to reviewer agreement and disagreement. The 2264 manuscripts sent for external review during the study period received 5881 reviews provided by 2916 reviewers; 28% of reviews recommended rejection. Chance corrected agreement (kappa statistic) on rejection among reviewers was 0.11 (p<01). In mixed effects models adjusting for study year and manuscript type, the reviewer-level ICC was 0.23 (95% confidence interval [CI], 0.19–0.29) and the manuscript-level ICC was 0.17 (95% CI, 0.12–0.22). The editors’ overall rejection rate was 48%: 88% when all reviewers for a manuscript agreed on rejection (7% of manuscripts) and 20% when all reviewers agreed that the manuscript should not be rejected (48% of manuscripts) (p<0.01). Conclusions/Significance: Reviewers at JGIM agreed on recommendations to reject vs. accept/revise at levels barely beyond chance, yet editors placed considerable weight on reviewers’ recommendations. Efforts are needed to improve the reliability of the peer-review process while helping editors understand the limitations of reviewers’ recommendations. [ABSTRACT FROM AUTHOR]

Abstract: Background: N-of-1 trials may enhance therapeutic precision by predicting the long-term effectiveness of medical treatment on an individual basis. However, the n-of-1 approach has gained little traction with the clinical community. To learn why, we interviewed physicians and patients, focusing on the perceived benefits and drawbacks of n-of-1 trials and factors influencing these perceptions. Methods: We convened focus groups and individual interviews with 21 physicians and 32 patients, most with chronic conditions. The study employed qualitative interview methods to explore and analyze subjects'' views of n-of-1 trials. Analysis involved an iterative process of review and data abstraction after specific topics for coding, definitions of codes, and strategies for abstraction had been established. Previously defined domains and topics were then expanded and enriched, with key themes emerging during the analytic process. Results: Physicians and patients remarked on 4 salient aspects of n-of-1 trials: scientific, relational, clinical, and logistical. Neither physicians nor patients were highly familiar with the n-of-1 concept, but both groups readily grasped the fundamental logic and appreciated the potential scientific benefits. Physicians saw n-of-1 trials as promoting an exciting but possibly threatening paradigm shift in the doctor–patient relationship, while patients viewed the relational consequences as modest. The best n-of-1 candidates were felt to be proactive, cognitively intact, reliable, motivated, and engaged in a trusting physician–patient relationship. Conclusions: Researchers interested in expanding the appeal of n-of-1 trials will need to address these concerns by carefully explaining the approach, emphasizing the benefits, and minimizing the effort required of doctors and patients. [Copyright &y& Elsevier]

Background: Current interventions to enhance patient self-efficacy, a key mediator of health behavior, have limited primary care application.Objective: To explore the effectiveness of an office-based intervention for training resident physicians to use self-efficacy-enhancing interviewing techniques (SEE IT).Design: Randomized controlled trial.Participants: Family medicine and internal medicine resident physicians (N = 64) at an academic medical center.Measurements: Resident use of SEE IT (a count of ten possible behaviors) was coded from audio recordings of the physician-patient portion of two standardized patient (SP) instructor training visits and two unannounced post-training SP visits, all involving common physical and mental health conditions and behavior change issues. One post-training SP visit involved health conditions similar to those experienced in training, while the other involved new conditions.Results: Experimental group residents demonstrated significantly greater use of SEE IT than controls, starting after the first training visit and sustained through the final post-training visit. The mean effect of the intervention was significant [adjusted incidence rate ratio for increased use of SEE IT = 1.94 (95% confidence interval = 1.34, 2.79; p < 0.001)]. There were no significant effects of resident gender, race/ethnicity, specialty, training level, or SP health conditions.Conclusions: SP instructors can teach resident physicians to apply SEE IT during SP office visits, and the effects extend to health conditions beyond those used for training. Future studies should explore the effects of the intervention on practicing physicians, physician use of SEE IT during actual patient visits, and its influence on patient health behaviors and outcomes. [ABSTRACT FROM AUTHOR]

Context: When feasible, randomized, blinded single-patient (n-of-1) trials are uniquely capable of establishing the best treatment in an individual patient. Despite early enthusiasm, by the turn of the twenty-first century, few academic centers were conducting n-of-1 trials on a regular basis. Methods: The authors reviewed the literature and conducted in-depth telephone interviews with leaders in the n-of-1 trial movement. Findings: N-of-1 trials can improve care by increasing therapeutic precision. However, they have not been widely adopted, in part because physicians do not sufficiently value the reduction in uncertainty they yield weighed against the inconvenience they impose. Limited evidence suggests that patients may be receptive to n-of-1 trials once they understand the benefits. Conclusions: N-of-1 trials offer a unique opportunity to individualize clinical care and enrich clinical research. While ongoing changes in drug discovery, manufacture, and marketing may ultimately spur pharmaceutical makers and health care payers to support n-of-1 trials, at present the most promising resuscitation strategy is stripping n-of-1 trials to their essentials and marketing them directly to patients. In order to optimize statistical inference from these trials, empirical Bayes methods can be used to combine individual patient data with aggregate data from comparable patients. [ABSTRACT FROM AUTHOR]

Objective: To describe patient counseling by physicians on hypertension and lifestyle and assess its impact on participants’ satisfaction. Methods: An analysis was conducted of transcripts of audio-recorded outpatient visits, augmented with patient and physician surveys. Participants were 30 primary care physicians, 11 cardiologists, and 120 hypertensive patients. Each transcript was coded into categories descriptive of physicians’ counseling behaviors. Patients and physicians completed pre- and post-visit questionnaires; patients also completed a survey 2 weeks after their visit. Results: Most physicians assessed patient medication adherence, but counseling on hypertension and lifestyle was limited. Receipt of lifestyle counseling had a positive, short-lived impact on patient satisfaction. Physicians reported greater satisfaction with visits characterized by more lifestyle counseling. Amount of counseling provided was unrelated to the presence of cardiovascular comorbidities. Provision of counseling was not associated with physicians’ perceptions of visit burden. Lifestyle counseling was associated with longer visits. Conclusion: Hypertensive patients received relatively little information about hypertension and beneficial lifestyle changes. Practice Implications: Office visits provide an important opportunity for physicians to reinforce key hypertension-related educational messages. Physicians could do more to underscore the importance of medication adherence and healthy living to their patients with hypertension. [Copyright &y& Elsevier]

The article reports on N-of-1 trials of expensive biological therapies. According to the author, N-of-1 clinical trials are multiple crossover trials to a single patient wherein patients with rheumatoid arthritis are given the chance to choose a much cheaper treatment for their illness. The author informs that in this trial option, it was found out that the N-of-1 trial was more expensive than stepped care but 47% cheaper than open access to the etanercept which is offered to patients with rheumatoid arthritis.

Abstract: Objective: Screening reduces colorectal cancer (CRC) mortality and is cost-effective, yet uptake is suboptimal. We developed and evaluated a personally tailored interactive multimedia computer program (IMCP) to encourage CRC screening. Methods: Randomized controlled pilot trial evaluating the effects of the personally tailored CRC screening IMCP as compared with a non-tailored IMCP (“electronic leaflet”) control. The IMCP was tailored to patient preference, self-efficacy, barriers, and readiness and deployed in busy primary care offices before scheduled doctor visits. Main outcomes were: CRC screening knowledge, self-efficacy, benefits and barriers, and stage of readiness. Results: We enrolled 54 subjects; software glitches occurred in 5, leaving 49 subjects for analysis. In adjusted analyses, compared with control, the experimental group had a significant increase in CRC screening self-efficacy (p =0.049), a significantly greater likelihood of moving to a more advanced stage of readiness for screening (p =0.034), a trend toward fewer perceived barriers to screening (p =0.149), and no difference in perceived benefits or knowledge of screening. Conclusion: Our personally tailored IMCP was significantly more effective than control in bolstering CRC screening readiness and self-efficacy. Practice implications: If further streamlined, personally tailored IMCPs might be usefully deployed in busy primary care offices to improve uptake of CRC screening. [Copyright &y& Elsevier]

The author offers his views on a comment regarding the advertising of Merck & Co. Incorporated's Vioxx drug. He noted that a two-year moratorium on direct-to-consumer advertising of new drugs could prevent the Vioxx problem wherein drug marketing got well ahead of science. He also pointed out that knowing the benefit ratio of Vioxx prior to mass marketing would have resulted in more informed prescribing.

Background: Referral from primary care to the mental health specialty sector is important but poorly understood.Objective: Identify physician characteristics influencing mental health referral.Design: Randomized controlled trial using Standardized Patients (SPs).Setting: Offices of primary care physicians in 3 cities.Participants: One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.Intervention: Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.Measurements: Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire.Results: Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92).Limitation: The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients.Conclusions: Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care. [ABSTRACT FROM AUTHOR]

Context: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. Objective: To ascertain the effects of patients’ DTC-related requests on physicians’ initial treatment decisions in patients with depressive symptoms. Design: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). Setting: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. Participants: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. Interventions: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. Main Outcome Measures: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. Results: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). Conclusions: Patients’ requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse. [ABSTRACT FROM AUTHOR]

Evidence-based medicine is the application of scientific evidence to clinical practice. This article discusses the difficulties of applying global evidence (“average effects” measured as population means) to local problems (individual patients or groups who might depart from the population average). It argues that the benefit or harm of most treatments in clinical trials can be misleading and fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few. Heterogeneity of treatment effects reflects patient diversity in risk of disease, responsiveness to treatment, vulnerability to adverse effects, and utility for different outcomes. Recognizing these factors, researchers can design studies that better characterize who will benefit from medical treatments, and clinicians and policymakers can make better use of the results. [ABSTRACT FROM AUTHOR]

The objective was to determine whether obstetric opinion leaders can be identified and to characterize them in terms of their demographic and professional characteristics and their attitudes toward caesarean delivery. In late 1998, we surveyed 527 obstetricians, 138 family physicians, and 80 certified nurse midwives (overall response rate, 57.8%) practicing in a stratified random sample of California hospitals with at least 1000 annual deliveries (n=52). Participants reported on demographic and professional characteristics and attitudes towards caesarean delivery; they also checked off those hospital colleagues from whom they had sought or would seek advice on labour and delivery. A composite measure of nomination frequency was used to characterize each respondent''s degree of “opinion leadership”. All analyses were corrected for the complex survey design. Using a nomination cutoff of 0.4 (0–1 scale), opinion leaders were identified in 31% of California hospitals; they were identified in 81% of hospitals using a cutoff of 0.2. Compared with their peers in the lowest fifth of the nomination distribution, clinicians in the top fifth were younger and more likely to be male, to speak English as a first language, to practice obstetrics, to have a maternal–foetal medicine subspecialty, and to practice in higher volume hospitals (p<0.05). Regardless of discipline, opinion leaders held attitudes concordant with reducing the caesarean delivery rate more often than non-opinion leaders. However, only 48% of obstetrical opinion leaders would support reducing the caesarean delivery rate to levels targeted by Healthy People 2000. In conclusion, obstetric opinion leaders could be identified in many California hospitals. However, they did not consistently support policies designed to reduce the caesarean delivery rate. The results have implications for the generalizability of opinion leader strategies. [Copyright &y& Elsevier]

: ObjectiveTo assess recent trends in professional satisfaction, perceptions of ability to provide high-quality care, and perceptions of ability to obtain needed services for patients in a national sample of obstetricians and gynecologists; to compare obstetrician–gynecologists with physicians in other specialties; and to identify demographic, professional, and practice characteristics associated with high career satisfaction.: MethodsWe used data from the 1996–1997 (n = 12,385; response rate, 65%) and 1998–1999 (n = 12,280; response rate, 61%) waves of the nationally representative Community Tracking Study physicians'' survey. The principal outcome measures were one item related to overall career satisfaction, six items measuring physicians'' perceptions of their ability to provide high-quality care, and five items measuring physicians'' perceptions of their ability to obtain needed services for patients. All results were weighted and adjusted to reflect the complex survey design.: ResultsIn 1996–1997, 34% of obstetrician–gynecologists (n = 545) were very satisfied with their careers, and 24% were very or somewhat dissatisfied. Up to 45% perceived significant barriers to the delivery of high-quality care, and up to 58% were unable to “almost or almost always” obtain necessary services for patients. Results in 1998–1999 (n = 484 obstetricians and gynecologists) were similar, except for a deterioration in perceived amount of time with patients and ability to obtain high-quality ancillary services. In comparison with primary care physicians, obstetrician–gynecologists were less satisfied (P = .001); in comparison with both primary care physicians and general surgeons, they had more problems delivering high-quality care (P < .001) and greater difficulties obtaining needed services for patients (P < .001). Controlling for selected demographic and professional characteristics, higher career satisfaction was associated with age greater than 65 years, practicing in small metropolitan areas and in academic settings, and having better perceptions of quality and ability to obtain services (P < .05).: ConclusionAlthough most obstetricians and gynecologists are satisfied with their careers, many are experiencing significant professional distress. [Copyright &y& Elsevier]

Background: Requests can influence the conduct and content of the medical visit. However, little is known about the nature, frequency, and impact of such requests. We performed this study to ascertain the prevalence, antecedents, and consequences of patients' requests for clinical services in ambulatory practice. Methods: This observational study combined patient and physician surveys with audiotaping of 559 visits to 45 physicians in 2 health care systems between January and November 1999. All patients had a new problem or significant health concern. Main outcome measures included prevalence of 8 categories of requests for physician action; odds of patients' requesting tests, referrals, or new prescriptions; odds of physicians' ordering diagnostic tests, making specialty referrals, or writing new prescriptions; patient satisfaction; and physicians' perceptions of the visit. Results: The 559 patients made 545 audiocoded requests for physician action; 23% requested at least 1 diagnostic test, specialty referral, or new prescription medication. Requests for diagnostic tests were more common among new patients (P<.001). Requests for any clinical service were more common among patients experiencing greater health-related distress (P<.05) and less common among patients of cardiologists (P<.001). After adjusting for predisposing, need, and contextual factors, referral requests were associated with higher odds of receiving specialty referrals (adjusted odds ratio [AOR], 4.1; 95% confidence interval [CI], 1.6-10.7) and prescription requests were associated with higher odds of receiving new prescription medications (AOR, 2.8; 95% CI, 1.2-6.3). Physicians reported that visits during which patients requested diagnostic tests were more demanding than visits in which no such requests were made (P = .02). Conclusions: Though more common in primary care than in cardiology, patients' requests for clinical services are both pervasive and influential. The results support placing greater emphasis on understanding and addressing the patient's role in determining health care utilization. [ABSTRACT FROM AUTHOR]

Objective: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations.Design: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit.Setting: The offices of 45 family practice, internal medicine, and cardiology physicians.Patients: Nine hundred nine adults reporting a health problem or concern.Measurements and Main Results: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled.Conclusions: Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care. [ABSTRACT FROM AUTHOR]

Background: The career satisfaction and dissatisfaction physicians experience likely influence the quality of medical care. Objective: To compare career satisfaction across specialties among US physicians. Methods: We analyzed data from the Community Tracking Study of 12474 physicians (response rate, 65%) for the late 1990s. Data are cross-sectional. Two satisfaction variables were created: very satisfied and dissatisfied. Thirty-three specialty categories were analyzed. Results: After adjusting for control variables, the following specialties are significantly more likely than family medicine to be very satisfying: geriatric internal medicine (odds ratio [OR], 2.04); neonatal-perinatal medicine (OR, 1.89); dermatology (OR, 1.48); and pediatrics (OR, 1.36). The following are significantly more likely than family medicine to be dissatisfying: otolaryngology (OR, 1.78); obstetrics-gynecology (OR, 1.61); ophthalmology (OR, 1.51); orthopedics (OR, 1.36); and internal medicine (OR, 1.22). Among the control variables, we also found nonlinear relations between age and satisfaction; high satisfaction among physicians in the west north Central and New England states and high dissatisfaction in the south Atlantic, west south Central, Mountain, and Pacific states; positive associations between income and satisfaction; and no differences between women and men. Conclusions: Career satisfaction and dissatisfaction vary across specialty as well as age, income, and region. These variations are likely to be of interest to residency directors, managed care administrators, students selecting a specialty, and physicians in the groups with high satisfaction and dissatisfaction. [ABSTRACT FROM AUTHOR]

Objective. To assess the reliability, applicability, and validity of a refined system (taxonomy of requests by patients [TORP]) for characterizing patient requests and physician responses in office practice. Study Settings. Data were obtained from visits to six general internists practicing in North-Central California in 1994 and eight cardiologists practicing in the same region in 1998. Study Design. This was an observational study of patient requests and physician responses in two practice settings. Patients were surveyed before and after the visit. Physicians were surveyed immediately after the visit, and all visits were audio recorded for future study. Data Collection/Extraction Methods. TORP was refined using input from a multidisciplinary panel. Audiotape recordings of 131 visits (71 in internal medicine and 60 in cardiology) were rated independently by two coders. Estimates of classifying reliability (intercoder agreement on the sorting of requests into categories) and unitizing reliability (intercoder agreement on the labeling of elements of discourse as “requests” and subsequent classification into categories) were calculated. Validity was assessed by testing three specific hypotheses concerning the antecedents and consequences of patient requests and request fulfillment. Principal Findings. The overall unitizing kappa for identifying patients’ requests was 0.64, and the classification kappa was 0.73, indicating substantial agreement beyond chance. The average patient made 4.19 requests for information and 0.88 requests for physician action; there were few differences in the spectrum of requests between internal medicine and cardiology. Approximately 15 percent of visits included a direct request for completion of paperwork. Patients who were very or extremely worried about their health made more requests than those who were not (6.06 vs. 3.89, p < 0.05). Visits involving more patient requests took longer (p < 0.05) and were perceived as more demanding by the treating physician (p = 0.025). The vast majority of requests were fulfilled. Conclusions. The refined TORP shows evidence of both unitizing and classification reliability and should be a useful tool for understanding the clinical negotiation. In addition, the system appears applicable to both generalist and specialist practices. More experience with the system is necessary to appraise TORP’s ability to predict important clinical outcomes. [ABSTRACT FROM AUTHOR]

Examines the patient, physician and health care system characteristics associated with unvoiced desires for action. Effect of unexpressed desires on patients' and physicians' evaluations of the office visit; Association of patients' unvoiced desires with health outcomes and subsequent health care utilization; Patterns of verbal and nonverbal behaviors exhibited in clinical encounters.

Assesses the conceptual relationships linking patients' expectations, requests and satisfaction with medical care. Survey of contemporary approaches to the measurement of expectations and requests; Highlight of recent empirical findings; Worry by patients on the underlying causes of their symptoms; Wide ranging expectations that can be measured and have important clinical consequences.

BACKGROUND • We conducted a content analysis of consumer-targeted prescription drug advertisements to explore trends in prevalence, shifts in the medical conditions for which drugs are promoted, reliance on financial and nonmonetary inducements, and appeals used to attract public interest, METHODS • We collected the drug advertisements appealing in 18 consumer magazines from 1989 through 1998, Two judges independently coded each advertisement and placed it in a category pertaining to the target audience, use of inducements, and product benefits (mean κ=0.93). We employed descriptive statistics, cross-tabulations, anct curve estimation procedures. RESULTS • A total of 320 distinct advertisements were identified, representing 101 brands and 14 medical conditions. New advertisement and brand introductions increased dramatically during this decade. Advertisements for drugs used for dermatologic, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and obstetric/gynecologic conditions were most common. Almost all of the advertisements were aimed at the potential user of the drug, not third-party intermediaries such as parents and spouses. Although most advertisements were gender-neutral, women were more likely to be exclusively targeted. One eighth of the advertisements offered a monetary incentive (eg, a rebate or money-back guarantee), and one third made an offer of additional information in printed or audio/video form. The most common appeals used were eftectiveness, symptom control innovativeness, and convenience. CONCLUSIONS • Consumer-directed prescription drug advertising has increased dramatically during the past decade. The pharmaceutical industry is turning to this type of advertising to generate interest in its products. Our data may be useful to physicians who want to stay abreast of the treatments that are being directly marketed to their patients. [ABSTRACT FROM AUTHOR]

Tests the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests (EDT) in low back pain. Greater ordering of EDT for appropriate vignettes by physicians receiving specific guidelines; Importance of clarity and clinical applicability of a guideline.

Focuses on the perceptions of patients on omitted examinations and test in California. Concerns on the basis of the illness; Diagnostic value of the therapy; Failure of physician to care for the patient.

BACKGROUND. The goal of our investigation was to facilitate research on clinical negotiation between patients and physicians by developing a reliable and valid classification system for patients' requests in office practice. METHODS. We developed the Taxonomy of Requests by Patients (TORP) using input from researchers, clinicians, and patient focus groups. To assess the system's reliability and validity, we applied TORP to audiotaped encounters between 139 patients and 6 northern California internists. Reliability was assessed with the κ statistic as a measure of interrater agreement. Face validity was assessed through expert and patient judgment of the coding system. Content validity was examined by monitoring the incidence of unclassifiable requests. Construct validity was evaluated by examining the relationship between patient requests and patient health status; patient request fulfillment and patient satisfaction; and patient requests and physician perceptions of the visit. RESULTS. The 139 patients made 772 requests (619 requests for information and 153 requests for physician action). Average interrater agreement across a sample of 40 cases was 94% (κ = 0.93; P < .001). Patients with better health status made fewer requests (r = -0.17; P = .048). Having more chronic diseases was associated with more requests for physician action (r = 0.32; P = .0002). Patients with more unfulfilled requests had lower visit satisfaction (r = -0.32; P < .001). More patient requests was also associated with physician reports of longer visit times (P = .016) and increased visit demands (P = .006). CONCLUSIONS. Our study provides evidence that TORP is a reliable and valid system for capturing and categorizing patients' requests in adult primary care. Further research is needed to confirm the system's validity, expand its applicability, and explore its usefulness as a tool for studying clinical negotiation. [ABSTRACT FROM AUTHOR]

Objective: Drug manufacturers are intensely promoting their products directly to consumers, but the impact has not been widely studied. Consumers' awareness and understanding of, attitudes toward, and susceptibility to direct-to-consumer (DTC) drug advertising were examined.Design: Random-digit dialing telephone survey with a random household member selection procedure (completion and response rates, 58% and 69%, respectively).Setting: Respondents were interviewed while they were at their residences.Participants: Complete data were obtained from 329 adults in Sacramento County, California.Measurements and Main Results: Outcome measures included awareness of advertisements for 10 selected drugs, misconceptions about DTC advertising, attitudes toward DTC ads, and behavioral responses to such promotions. The influence of demographic characteristics, health status, attitudes, beliefs, and media exposure on awareness and behaviors was examined. On average, respondents were aware of advertisements for 3.7 of the 10 drugs; awareness varied from 8% for Buspar (buspirone) to 72% for Claritin (loratadine). Awareness was associated with prescription drug use, media exposure, positive attitudes toward DTC advertising, poorer health, and insurance status. Substantial misconceptions were revealed; e.g., 43% thought that only "completely safe" drugs could be advertised. Direct-to-consumer advertisements had led one third of respondents to ask their physicians for drug information and one fifth to request a prescription.Conclusions: Direct-to-consumer advertisements are reaching the public, but selectively so, and affecting their behaviors. Implications for public policy are examined. [ABSTRACT FROM AUTHOR]

Objective: To determine the relative importance of medical and nonmedical factors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals.Design: Prospective survey of all referrals from generalists to subspecialists over a 5-month period.Setting: University hospital outpatient clinics.Participants: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology.Measurements and Main Results: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals.Conclusions: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost. [ABSTRACT FROM AUTHOR]

Abstract: To identify factors associated with participation in the 1986 Ontario, Canada doctors' strike, we surveyed 1,028 physicians; 69 percent responded, of whom 42 percent participated in the strike. Risk factors for participation included income > $135,000, being a surgeon or gynecologist, having previously "opted out" of the Ontario Health Insurance Plan, being professionally dissatisfied, being politically conservative, favoring political activism by physicians, holding a positive view of the social consequences of extra-billing, and perceiving family, associates, patients and the public to favor the strike. Eighty percent of strikers, but 32 percent of non-strikers, met criteria we established for four strike-prone groups: the "economically rational," the "ideologically committed," the "professionally disaffected," and the "socially malleable." Respondents belonging to one or more of these groups were much more likely to have participated in the strike (64 percent vs 17 percent). Strategies to deal with physician militancy should address the multiplicity of motives that appeared to have influenced doctors in Ontario. (Am J Public Health 1989; 79:1227-1233.) INSET: ANA Opts for New Structure and Broader Membership Plan. [ABSTRACT FROM AUTHOR]

Examines the association between adherence to medical recommendations and health outcomes in a 4-year longitudinal, observational study of adult patients with chronic medical conditions. Association of patient adherence with improvement in health outcomes.

Assesses criteria used for detecting underuse of coronary artery revascularization procedures in terms of patient outcomes. Development of criteria for appropriateness and necessity; Application of necessary criteria; Determination of clinical outcomes; Statistical analysis; Patient population; Receipt of necessary revascularization and risk of death.

Studies the experience of recently published authors with the news media. Study of all first authors of scientific articles published in `JAMA' and `The New England Journal of Medicine' during a six-month period; Study methods, results and conclusions; Characteristics of authors; More.

Focuses on a study which explored nurses' perceptions of a public hospital nurses' strike. Account of related research on nurses' strikes; Methodology; Causes of the strike; Support for and participation in the strike; Factors associated with participation in the strike; Discussion of results.

Describes the malpractice environment as it relates to defensive medicine based on omission-related claims from the Physician Insurers Association of America. Identification of diagnostic and monitoring omissions; Occurrence rates for omission-related and total paid claims; Probability of payment including payment distribution.

Presents issues on patients' expectations of medical care. Framework of factors affecting patient satisfaction; Understanding of medical care improvements and patient satisfaction; Belief and attitudes affecting patients' understanding of medical care evaluations.