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Primary care is a crucial aspect of healthcare that contributes to better population health, equity, affordability, and quality. However, primary care is facing threats to its survival, including inadequate reimbursement and underfunding. These challenges have led to difficulties in attracting and retaining primary care clinicians, resulting in a shortage of primary care providers. To address these issues, the development of a practice registry is proposed to monitor the health and performance of primary care practices. This registry would collect data at the practice level and provide valuable information for policymakers, communities, and researchers to support and improve primary care. [Extracted from the article]

Background: Rectal bleeding is the most common presenting symptom of colorectal cancer, and guidelines recommend timely follow-up, usually with colonoscopy to ensure timely diagnoses of colorectal cancer. Objective: Identify loop closure rates and vulnerable process points for patients with rectal bleeding. Design: Retrospective cohort study, using medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices—an urban academic practice and affiliated community health center, between January 1, 2018, and December 31, 2020. Patients were classified as having completed recommended follow-up workup ("closed loop") vs. not ("open loop"). Open loop patient cases were categorized into six types of process failures. Participants: A total of 837 patients had coded diagnoses of rectal bleeding within study window. Sixty-seven were excluded based on prior colectomy, clinical presentation more consistent with upper GI bleed, no rectal bleeding documented on chart review, or expired during the follow-up period, leaving 770 patients included. Main Measures: Primary outcomes were percentages of patient cases classified as "open loops" and distribution of these cases into six categories of process failure that were identified. Key Results: 22.3% of patients (N = 172) failed to undergo timely recommended workup for rectal bleeding. Largest failure categories were patients for whom no procedure was ordered (N = 62, 36%), followed by patients with procedures ordered but never scheduled (N = 44, 26%) or scheduled but subsequently cancelled or not kept (N = 31, 18%). While open loops increased after the onset of the COVID-19 pandemic, this difference was not significant within our study period. Conclusions: Significant numbers of patients presenting to primary care with rectal bleeding fail to undergo recommended workup. The majority either have no procedure ordered, or procedure ordered but never scheduled or cancelled and not kept, suggesting these are important failure modes to target in future interventions. Ensuring reliable ordering and processes for timely scheduling and completion of procedures represent critical areas for improving the diagnostic process for patients with rectal bleeding in primary care. [ABSTRACT FROM AUTHOR]

Primary care is foundational to health systems and a common good. The workforce is threatened by outdated approaches to organizing work, payment, and technology. Primary care work should be restructured to support a team-based model, optimized to efficiently achieve the best population health outcomes. In a virtual-first, outcomes-based primary care model, a majority of professional time for primary care team members is protected for virtual, asynchronous patient interactions, collaboration across clinical disciplines, and real-time management of patients with acute and complex concerns. Payments must be re-structured to cover the cost of, and reward the value created by, this advanced model. Technology investments should shift from legacy electronic health records to patient relationship management systems, built to support continuous, outcome-based care. These changes enable primary care team members to focus on building engaged, trusting relationships with patients and their families and collaborating on complex management decisions, and reconnecting team members with joy in clinical practice. [ABSTRACT FROM AUTHOR]

Reliable systems that track the continuation, progression, or resolution of a patient's symptoms over time are essential for reliable diagnosis and ensuring that patients harboring more worrisome diagnoses are safely followed up. Given their first-contact role and increasing stresses on busy primary care clinicians and practices, new processes that make these tasks easier rather than creating more work for busy clinicians are especially needed.Some symptoms are sufficiently worrisome that they demand an urgent diagnosis and treatment while others result in a differential that can be more safely explored over time, or less differentiated and worrisome that they are best managed with the "test of time" to see if they resolve, worsen, or evolve into symptoms that are more worrisome. Regardless, it is essential that clinicians are able to reliably track symptoms over time, yet this capacity is rarely available or explicit. Working with systems engineers, we are developing prototypes for such systems and are working on their implementation and evaluation. In this commentary, we describe approaches to this essential, but underappreciated, problem in primary care. [ABSTRACT FROM AUTHOR]

Accompaniment strengthens the primary care team-patient relationship by building empathy and trust. Critical aspects of primary care that align with accompaniment such as continuity and comprehensiveness reduce health care costs by engaging the primary care team and patient across time and settings to reduce care fragmentation. [Extracted from the article]

DISCUSSION Medicare payment changes that will take effect in 2021 will likely be insufficient to reach state target levels of primary care spending alone, but if all other payers follow Medicare, primary care spending levels may approach target levels. Available from: https://www.milbank.org/programs/primary-care-spend/other-resources/ 2 Koller CF, Khullar D. Primary Care Spending Rate - A Lever for Encouraging Investment in Primary Care [Internet]. Primary care is - ideally - accessible, timely, first-contact care that is comprehensive, coordinated, and longitudinal. [Extracted from the article]

Background: New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities.Objective: To evaluate the financial impact for primary care practices of integrating behavioral health services.Design: Microsimulation model.Participants: We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey.Interventions: A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist.Main Measures: Net revenue change per full-time physician.Key Results: When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types.Conclusions: New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration. [ABSTRACT FROM AUTHOR]

The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training. [ABSTRACT FROM AUTHOR]

Background: As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending.Methods: We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design.Results: Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all).Discussion: Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization. [ABSTRACT FROM AUTHOR]

From the 2011 Medicare data, we identified 1,107,709 beneficiaries cared for by 2682 general internists and 3396 family physicians. Despite differences in training and practice, general internists share with family physicians associations between increasing comprehensiveness and lower Medicare beneficiary costs highlighting the importance of comprehensiveness in primary care regardless of the type of primary care physician providing the care. [Extracted from the article]

After five decades of growth that has included advances in medical education and health care delivery, value cohesion, and integration of diversity, we propose an overarching mission for academic general internal medicine to lead excellence, change, and innovation in clinical care, education, and research. General internal medicine aims to achieve health care delivery that is comprehensive, technologically advanced and individualized; instills trust within a culture of respect; is efficient in the use of time, people, and resources; is organized and financed to achieve optimal health outcomes; maximizes equity; and continually learns and adapts. This mission of health care transformation has implications for the clinical, educational, and research activities of divisions of general internal medicine over the next several decades. [ABSTRACT FROM AUTHOR]

Background: Despite the absence of conclusive evidence of effectiveness, complementary and alternative medicine (CAM) is used by 4 of 10 adults in the US; little is known about the association between CAM use and health status.Objective: To determine the relation between CAM use and self-reported health status and health improvement over time.Design and Participants: We performed a secondary database analysis using data from the 2007 National Health Interview Survey of non-institutionalized US residents conducted by the National Center of Health Statistics of the Center for Disease Control. We identified CAM users and compared them to non-users. We used multivariable logistic regression to model the health status of respondents. We controlled for confounders including socio-demographic, clinical, and behavioral factors. The models were evaluated for discrimination and calibration.Main Measures: The likelihood of respondents to report 'Excellent' current health and 'Better' health than in the prior year.Key Results: Based on 23,393 respondents, we found 37% of U.S. adults used complementary and alternative medicine and 63% did not use any CAM. Compared to those who did not use CAM, CAM users were more likely to rate their health as 'Excellent' (adjusted-odds ratio (AOR) = 1.14, 95% CI = [1.03,1.26]). Similarly, CAM users were more likely to report their health as 'Better' than in the prior year (AOR = 1.64, 95% CI = [1.49,1.83]). The c-statistics for the two models were 0.755 and 0.616, respectively.Conclusion: We found a significant association between CAM use and self-rated excellent health and health improvement over the prior year. Prospective trials are required to determine whether CAM use is causally related to excellent health status and better health than in the prior year. [ABSTRACT FROM AUTHOR]

Background: Some herbal supplements may contain lead.Objective: To examine whether use of specific herbal dietary supplements during the last 30 days is associated with blood lead levels in US men and women.Design: Cross-sectional analysis.Study Population: NHANES participants from 1999-2004, a representative sample of the civilian non-institutionalized US population.Measurements: Lead was measured in blood. Associations between lead and self-reported supplement use were estimated using multivariable regression weighted to account for NHANES sampling. Herbal supplements investigated were those previously reported to contain high heavy metal content: Ayurvedic or traditional Chinese medicine herbs, echinacea, ginkgo, ginseng, St. John's wort, and "other" herbs (specifically, kava, valerian, black cohosh, bee pollen, and nettle).Main Results: Among 6,712 women > or =20 years, those using herbal supplements had lead levels that were 10% higher than non-users (95% CI 3%-17%, p = 0.005). Women using Ayurvedic or traditional Chinese medicine herbs, St. John's wort, and "other" herbs had lead levels 24% (95% CI 5%-45%, p = 0.01), 23% (95% CI 4%-46%), p = 0.02), and 21% (95% CI 2%-44%, p = 0.03) higher, respectively, than non-users. No significant associations were observed between herb use and lead levels among men (n = 6,095). Among reproductive-aged women (16-45 years), herbal supplement users had lead levels 20% higher than non-users (95% CI 5%-34%, p = 0.008). In contrast, garlic and other dietary supplements were not associated with higher lead levels.Conclusion: Use of specific herbal supplements is associated with higher blood lead levels among women. Our data suggest testing guidelines for herbal supplements and regulations limiting lead in supplements are needed. [ABSTRACT FROM AUTHOR]

Background: There are limited data on the characteristics of yoga users in the U.S.Objective: To characterize yoga users, medical reasons for use, perceptions of helpfulness, and disclosure of use to medical professionals.Methods: Utilizing cross-sectional survey data from the 2002 National Health Interview Survey (NHIS) Alternative Medicine Supplement (n = 31044), we examined correlates of yoga use for health. The estimated prevalence from 2002 NHIS of yoga for health was 5.1% corresponding to over 10 million adults.Results: In 2002, yoga users were predominately Caucasian (85%) and female (76%) with a mean age of 39.5 years. Compared to non-yoga users, yoga users were more likely female (OR 3.76, 95% CI 3.11-4.33); less likely black than white (OR 0.65, 95% CI 0.53-0.80); tended to be younger; and more likely college educated (OR 2.70, 95% CI 2.37-3.08). Musculoskeletal conditions (OR 1.61, 95% CI 1.42-1.83), mental health conditions (OR 1.43, 95% CI 1.22-1.67), severe sprains in the last 12 months (OR 1.49, 95% CI 1.22-1.81), and asthma (OR 1.27, 95% CI 1.05-1.54) were independently associated with higher yoga use, while hypertension (OR 0.78, 95% CI 0.64-0.95) and chronic obstructive lung disease (OR 0.69, 95% CI 0.48-1.00) were associated with lower use. Yoga was most commonly used to treat musculoskeletal or mental health conditions, and most users reported yoga to be helpful for these conditions. A majority of yoga users (61%) felt yoga was important in maintaining health, though only 25% disclosed yoga practice to their medical professional.Conclusions: We found that yoga users are more likely to be white, female, young and college educated. Yoga users report benefit for musculoskeletal conditions and mental health, indicating that further research on the efficacy of yoga for the treatment and/or prevention of these conditions is warranted. [ABSTRACT FROM AUTHOR]

Background: Few studies have evaluated the association between patient expectations for recovery and clinical outcomes, and no study has evaluated whether asking patients to choose their therapy modifies such an association.Objective: To evaluate the association between patients' expectations and functional recovery in patients with acute low back pain (LBP), and to determine whether that association is affected by giving patients choice of therapy.Design and Participants: A secondary analysis of a randomized controlled trial comparing usual care alone to usual care plus choice of chiropractic, acupuncture, or massage in 444 adults with acute LBP, lasting less than 21 days.Measurements and Main Results: Primary outcome was functional disability (Roland score) at 5 and 12 weeks. Patients' general expectations for improvement were associated with improvement in functional status (beta = 0.96, 95% CI = 0.56, 1.36). A 1-point increase in general expectations was associated with a 0.96-point improvement in Roland score. The association of expectation with outcome was 2-3 times greater in the usual care group than the choice group. However, these differences did not reach statistical significance.Conclusions: In patients with acute LBP, higher expectations for recovery are associated with greater functional improvement. Eliciting patient expectations for improvement may be a simple way to identify patients with the highest (or lowest) likelihood of experiencing functional improvement. Incorporating questions about patient expectations in future trials may clarify the role of this important correlate of clinical outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Provider-patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients. OBJECTIVE: We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes. DESIGN: Cross-sectional survey, response rate 74%. PARTICIPANTS: A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities. MEASUREMENTS: Provider-patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding. RESULTS: Patients with language-discordant providers reported receiving less health education (β=0.17, p< 0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β= 0.28, p<0.05), and were more likely to give low ratings to their providers (odds ratio [OR]= 1.61; CI=0.97-2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients' perceptions of their providers. CONCLUSION: Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients' ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider. [ABSTRACT FROM AUTHOR]

Very little is known about complementary and alternative medicine (CAM) use in Asian Americans (AA), especially on a national level. To compare CAM use, reasons for use, and disclosure rates between Asian and non-Hispanic white Americans (NHW), and examine ethnic variations among AA. Data on CAM use in the past year (excluding prayer) were used from the 2002 National Health Interview Survey for 917 AA and 20,442 NHW. Compared with NHW, AA were as likely to use any CAM modality [42 vs. 38%; adjusted prevalence ratio = 1.09, 95% confidence interval (0.94, 1.27)]. Asian Americans were less likely than NHW to disclose the use of herbal medicines (16 vs. 34%, p < 0.001) and mind/body therapies (15 vs. 25%, p < 0.05). Mind/body therapies were used more often by Asian Indians (31%) than by Chinese (21%) and Filipinos (22%), whereas herbal medicines were used more often by Chinese (32%) than by Filipinos (26%) and Asian Indians (19%). Among AA, CAM use was associated with being female, having higher education, and having a chronic medical condition; foreign-birth was not associated with CAM use. Complementary and alternative medicine use is common among AA, and there are important ethnic variations in use. Asian Americans are less likely than NHW to disclose CAM use to conventional healthcare providers, suggesting that it is particularly important that physicians query AA patients about CAM use. [ABSTRACT FROM AUTHOR]

Purpose: Mentoring during the early stages of a career has been associated with high career satisfaction and may guide development of professional expertise. Little is known about mentoring experiences during residency training. Our purpose was to describe mentoring relationships among internal medicine residents, and to examine the relationship between mentoring and perceived career preparation.Subjects and Methods: We designed and administered a mailed survey to all interns and residents enrolled in the five independent Internal Medicine Residency Training Programs affiliated with Harvard Medical School. We examined the development of mentoring relationships during residency training, and measured satisfaction with mentoring and with perceived career preparation.Results: Of the 329 respondents (65% response rate), 93% reported that it is important to have a mentor during residency, but only half identified a current or past mentor. Interns [adjusted odds ratio (AOR) 0.3 (95% confidence interval (CI) 0.2, 0.5)] and underrepresented minority residents [0.3 (0.1, 0.7)] were significantly less likely to establish a mentoring relationship than their peers. Mentored residents were nearly twice as likely to describe excellent career preparation [1.8 (1.1, 3.1)].Conclusion: Our findings demonstrate the importance of mentoring to medical residents, and identify a relationship between mentoring and perceived career preparation. We also identify a relative lack of mentoring among interns and underrepresented minority residents. [ABSTRACT FROM AUTHOR]

Background and Objective: Many women with increased breast cancer risk have not been screened recently. Provider recommendation for mammography is an important reason many women undergo screening. We examined the association between breast cancer risk and reported provider recommendation for mammography in recently unscreened women.Design: Cross-sectional study using 2000 National Health Interview Survey.Participants: In all, 1673 women ages 40 to 75 years without cancer who saw a health care provider in the prior year and had no mammogram within 2 years.Measurements and Analysis: We assessed breast cancer risk by Gail score and risk factors. We used multivariable logistic regression models in SUDAAN adjusted for age, race and illness burden, to examine the association between risk and reported recommendation for mammography within 1 year for all women and women ages 50 to 75 years.Results: Of 1673 recently unscreened women, 29% reported a recommendation. Twelve percent of women had increased Gail risk and of these recently unscreened, high-risk women, 25% reported a recommendation. After adjustment, high-risk women were not more likely to report a recommendation than average-risk women. Results were similar for women 50 to 75 years old. No individual breast cancer factors other than age were associated with reporting a recommendation.Conclusions: Approximately 70% of recently unscreened women seen by a health care provider in the prior year reported no recommendation for mammography, regardless of breast cancer risk. This did not include women who received a recommendation and were screened. Increasing reported recommendation rates may represent an opportunity to increase screening participation among recently unscreened women, particularly for women with increased breast cancer risk. [ABSTRACT FROM AUTHOR]

Background: Patients with limited English proficiency (LEP) have more difficulty communicating with health care providers and are less satisfied with their care than others. Both interpreter- and language-concordant clinicians may help overcome these problems but few studies have compared these approaches.Objective: To compare self-reported communication and visit ratings for LEP Asian immigrants whose visits involve either a clinic interpreter or a clinician speaking their native language.Design: Cross-sectional survey-response rate 74%.Patients: Two thousand seven hundred and fifteen LEP Chinese and Vietnamese immigrant adults who received care at 11 community-based health centers across the U.S.Measurements: Five self-reported communication measures and overall rating of care.Results: Patients who used interpreters were more likely than language-concordant patients to report having questions about their care (30.1% vs 20.9%, P<.001) or about mental health (25.3% vs 18.2%, P=.005) they wanted to ask but did not. They did not differ significantly in their response to 3 other communication measures or their likelihood of rating the health care received as "excellent" or "very good" (51.7% vs 50.9%, P=.8). Patients who rated their interpreters highly ("excellent" or "very good") were more likely to rate the health care they received highly (adjusted odds ratio 4.8, 95% confidence interval, 2.3 to 10.1).Conclusions: Assessments of communication and health care quality for outpatient visits are similar for LEP Asian immigrants who use interpreters and those whose clinicians speak their language. However, interpreter use may compromise certain aspects of communication. The perceived quality of the interpreter is strongly associated with patients' assessments of quality of care overall. [ABSTRACT FROM AUTHOR]

Background: Effective mentorship is crucial to career development. Strategies to improve the availability of mentors include mentoring multiple mentees at once, compensating mentors, comentoring, and long-distance mentoring.Objective: To describe current trends in mentorship in general Internal Medicine (GIM).Methods: We conducted a national cross-sectional web-based survey of GIM mentors, GIM fellowship directors, and GIM National Institutes of Health K24 grant awardees to capture their experiences with mentoring, including compensation for mentorship, multiple mentees, comentorship, and long-distance mentorship. We compared experiences by mentorship funding status, faculty type, academic rank, and sex.Results: We collected data from 111 mentors (77% male, 54% full professors, and 68% clinician-investigators). Fifty-two (47%) received funding for mentorship. Mentors supervised a median (25th percentile, 75th percentile) of 5 (3, 8) mentees each, and would be willing to supervise a maximum of 6 (4, 10) mentees at once. Compared with mentors without funding, mentors with funding had more current mentees (mean of 8.3 vs 5.1, respectively; P<.001). Full professors had more current mentees than associate or assistant professors (8.0 vs 5.9 vs 2.4, respectively; P=.005). Ninety-four (85%) mentors had experience comentoring, and two-thirds of mentors had experience mentoring from a distance. Although most mentors found long-distance mentoring to be less demanding, most also said it is less effective for the mentee and is personally less fulfilling.Conclusions: Mentors in GIM appear to be close to their mentorship capacity, and the majority lack funding for mentorship. Comentoring and long-distance mentoring are common. [ABSTRACT FROM AUTHOR]

Purpose: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.Subjects: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital.Methods: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about "problems,""mistakes," and "injuries" that occurred. Physician investigators classified patients' reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events.Results: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4).Conclusion: Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety. [ABSTRACT FROM AUTHOR]

Background: Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure.Objective: To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time.Design: Retrospective cohort study.Setting and Participants: Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program.Outcome: Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer.Main Results: Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P<.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P<.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women.Conclusions: AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad. [ABSTRACT FROM AUTHOR]

Background: While the majority of adults are attempting weight loss at any given time, few engage in optimal diet and exercise. We examined factors associated with being in advanced stages of behavior change for weight loss, diet, and exercise.Methods: We surveyed primary care patients about their health, health habits, and perception and advice about weight as health risk, and about stage of readiness to lose weight, improve diet (control food portions, limit fat intake, increase fruits and vegetables), and increase planned exercise using the Prochaska Stage of Behavior Change model. We conducted bivariable analyses to describe the association between being at the preparation (change in 1 month), action (changing now), and maintenance (maintaining change) stages of change for weight loss and being at 1 of these 3 advanced stages for improving diet and exercise. We also conducted multivariable analyses to examine factors associated with being at these advanced stages of readiness to concurrently lose weight, improve diet, and increase exercise.Results: Of 365 patients (response rate of 60%), 33% were overweight (body mass index [BMI], 25.0-29.9 kg/m(2)) and 27% were obese (BMI, 30.0+kg/m(2)). Of 199 respondents at the preparation, action, or maintenance stage of losing weight, 61% were also at an advanced stage for improving diet and exercise. Those perceiving weight as a health risk were more likely to be at advanced stages of readiness to concurrently lose weight, improve diet, and increase exercise (adjusted odds ratio [AOR], 5.6; 95% CI, 2.5 to 12.5) after adjustment for confounders; this perception was associated with BMI ([AOR, 1.2; 95% CI, 1.1 to 1.3 for each unit increment in BMI]) and being advised by a physician about weight as a health risk (AOR, 6.7; 95% CI, 3.0 to 15.1). Demographic factors, having obesity-related comorbidities, and mental and physical functioning did not appear important.Conclusions: A large proportion of primary care patients are at advanced stages of readiness to lose weight, improve diet, and increase exercise. Future studies should examine the effectiveness of primary care interventions to help patients optimize weight-related behavior. [ABSTRACT FROM AUTHOR]

To determine factors that influence patient willingness to accept a medication change to a unified, restrictive formulary.Prospective cohort study.University-affiliated hospital-based primary care internal medicine practice.Two hundred ninety-seven members of a managed care plan who had received a prescription for a nonformulary medication in the previous 4 months and whose primary care physician approved a conversion to a formulary medication.Clinical nurses invited patients to change to a formulary medication at the time of a telephone refill request based on a standard script.The overall conversion rate to the formulary medication was 59.8%. Seventy-four percent of patients who requested a refill by telephone converted to the formulary (odds ratio[OR], 2.24; 95% confidence interval[CI], 1.02 to 4.72). Patient age (OR, 1.03; CI, 1.01 to 1.05) and male gender (OR, 2.00; CI, 1.09 to 3.67) were each significant correlates of conversion. After adjustment in a multivariable model, only telephone refill request (adjusted OR, 2.31; CI, 1.07 to 4.97) and age (adjusted OR, 1.03; CI, 1.01 to 1.06) remained significant. Among the patients who made a telephone refill request, those who converted were more likely to completely trust their physician's judgment (P= .04) and to trust their physician to put their health over cost concerns (P= .05). Formulary conversion reduced costs beginning 3 months after the conversion date.A protocol for encouraging conversion to a unified formulary at the point of a telephone refill request increases formulary compliance rates and reduces medication costs. Patients who decline to convert medications are less likely to trust their physician.J GEN INTERN MED 2004;19:1212 – 1219. [ABSTRACT FROM AUTHOR]

Background: Modest weight loss of 10% of baseline weight is beneficial and achievable for overweight and obese patients. However, whether primary care patients value modest weight loss is unclear.Objective: To quantify the value patients place on modest weight loss.Design: Cross-sectional telephone survey.Setting: Patients at a large hospital-based primary care practice.Participants: Three hundred sixty-five primary care patients (60% response rate).Measurements: Utilities or value for weight loss estimated from willingness to risk death or trade time in exchange for losing different levels of weight (weight loss in pounds equivalent to a 5%, 10%, and 20% reduction in initial weight or to achieve a body mass index [BMI] of 25 kg/m2) using the standard gamble and time tradeoff formats.Results: Of respondents, 15% of overweight (BMI, 25 to 29.9 kg/m2) and 42% of obese patients (BMI > or = 30 kg/m2) believed they needed to lose more than 10% of their weight to derive any health benefits. However, 18% of overweight and 33% of obese patients were willing to risk death to lose 10% of their weight. Patients with higher BMI valued higher degrees of weight loss. Among the overall sample, the utilities derived using standard gamble were 0.95 for current weight, 0.96 for 5% weight loss, 0.97 for 10% weight loss, and 0.98 for 20% weight loss; among obese patients, utilities were 0.88, 0.91, 0.93, and 0.96, respectively. Utilities derived using time tradeoff were lower but correlated with utilities derived from standard gamble. Utilities did not vary by education, gender, race, having comorbidities, or smoking.Conclusions: Many primary care patients value modest weight loss. The value placed on loss of 10% body weight among obese patients where utility improved from 0.88 to 0.93 is similar to recovery from major depression. Nevertheless, the majority of patients still do not highly value modest weight loss. Clinicians should emphasize the health benefits of modest weight loss when counseling about weight. [ABSTRACT FROM AUTHOR]

Background: Compared to normal weight women, women with obesity have higher mortality from breast cancer but are less often screened.Objectives: To examine the relation between mammography use and weight category and to examine the influence of race, illness burden, and other factors on this relationship.Design and Setting: The 1998 National Health Interview Survey, a U.S. civilian population-based survey.Participants: Five thousand, two hundred, and seventy-seven women ages 50 to 75 years who responded to the Sample Adult and Prevention questionnaires.Measurements: Mammogram use in the preceding 2 years.Results: Among 5277 eligible women, 72% reported mammography use. The rate was 74% among white women and 70% among black women. Among white women, mammogram use was lowest in women with a body mass index (BMI) greater than 35 kg/m(2) (64% to 67%). After adjusting for sociodemographic factors, health care access, medical conditions, hospitalizations, and mobility status, higher BMI was associated with lower screening among white women, P =.02 for trend; the relative risk (RR) for screening in moderately obese white women (BMI, 35 to 40 kg/m(2)) was 0.83 (95% confidence interval [CI], 0.68 to 0.96) compared to normal weight white women. Compared to normal weight black women, mammography use was similar or higher in overweight (BMI, 25 to 30 kg/m(2); RR, 1.19; 95% CI, 1.01 to 1.32), mildly obese (BMI, 30 to 35 kg/m(2); RR, 1.22; 95% CI, 0.98 to 1.39), and moderately obese black women (RR, 1.37; 95% CI, 1.37 to 1.50) after adjustment. The P value for the race-BMI interaction was.001. Results for white and black women were unchanged after additional adjustment for psychological functioning and health habits.Conclusion: Among white women, those with higher BMI were less likely to undergo breast cancer screening than normal weight women. This relationship was not seen in black women. Our findings were not explained by differences in sociodemographic factors, health care access, illness burden, or health habits. More research is needed to determine the reasons for these disparities so that appropriate efforts can be made to improve screening. [ABSTRACT FROM AUTHOR]

Objective: To examine how Asian race/ethnicity affects patients' health care experiences and satisfaction with care.Design: Telephone interview using random-digit dialing, stratified to over-sample adults living in areas with disproportionately large numbers of minorities.Participants and Setting: White (N = 3,205) and Asian-American (N = 521) respondents, weighted to represent all such adults living in the continental U.S. in telephone households.Measurements: Reports of health care experiences and trust in the doctor at the last visit, and overall satisfaction with care and desire to change doctors in the last 2 years.Main Results: Asian Americans were less likely than whites to report that their doctors ever talked to them about lifestyle or mental health issues (P < or =.01). They were more likely to report that their regular doctors did not understand their background and values (P < or =.01). When asked about the last visit, they were more likely to report that their doctors did not listen, spend as much time, or involve them in decisions about care as much as they wanted (all P < or =.0001). In multivariable analyses, Asian Americans were less likely than whites to report that they were very satisfied with care (odds ratio [OR], 0.64, 95% confidence interval [CI], 0.42 to 0.99). However, they were not significantly less likely than whites to trust their doctors (OR, 0.79, 95% CI, 0.52 to 1.20), or to change doctors (OR, 0.93, 95% CI, 0.56 to 1.56).Conclusions: In a national survey, Asian Americans were less likely to receive counseling and less likely to report positive interactions with their doctors than white respondents. More research is needed to determine the reasons for these differences. [ABSTRACT FROM AUTHOR]

To examine how Asian race/ethnicity affects patients’ health care experiences and satisfaction with care. Telephone interview using random-digit dialing, stratified to over-sample adults living in areas with disproportionately large numbers of minorities. White ( N = 3,205) and Asian-American ( N = 521) respondents, weighted to represent all such adults living in the continental U.S. in telephone households. Reports of health care experiences and trust in the doctor at the last visit, and overall satisfaction with care and desire to change doctors in the last 2 years. Asian Americans were less likely than whites to report that their doctors ever talked to them about lifestyle or mental health issues ( P ≤ .01). They were more likely to report that their regular doctors did not understand their background and values ( P ≤ .01). When asked about the last visit, they were more likely to report that their doctors did not listen, spend as much time, or involve them in decisions about care as much as they wanted (all P ≤ .0001). In multivariable analyses, Asian Americans were less likely than whites to report that they were very satisfied with care (odds ratio [OR], 0.64, 95% confidence interval [CI], 0.42 to 0.99). However, they were not significantly less likely than whites to trust their doctors (OR, 0.79, 95% CI, 0.52 to 1.20), or to change doctors (OR, 0.93, 95% CI, 0.56 to 1.56). In a national survey, Asian Americans were less likely to receive counseling and less likely to report positive interactions with their doctors than white respondents. More research is needed to determine the reasons for these differences. J GEN INTERN MED 2004;19:111–119. [ABSTRACT FROM AUTHOR]

Object: Research demonstrating connections between the mind and body has increased interest in the potential of mind-body therapies. Our aim was to examine the use of mind-body therapies, using data available from a national survey.Design: Analysis of a large nationally representative dataset that comprehensively evaluated the use of mind-body therapies in the last year.Setting: United States households.Patients/participants: A total of 2055 American adults in 1997-1998.Interventions: Random national telephone survey.Measures and Main Results: We obtained a 60% weighted overall response rate among eligible respondents. We found that 18.9% of adults had used at least 1 mind-body therapy in the last year, with 20.5% of these therapies involving visits to a mind-body professional. Meditation, imagery, and yoga were the most commonly used techniques. Factors independently and positively associated with the use of mind-body therapies in the last year were being 40 to 49 years old (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.33 to 3.10), being not married (AOR, 1.78; 95% CI, 1.34 to 2.36), having an educational level of college or greater (AOR, 2.21; 95% CI, 1.57 to 3.09), having used self-prayer for a medical concern (AOR, 2.53; 95% CI, 1.87 to 3.42), and having used another complementary medicine therapy in the last year (AOR, 3.77; 95% CI, 2.74 to 5.20). While used for the full array of medical conditions, they were used infrequently for chronic pain (used by 20% of those with chronic pain) and insomnia (used by 13% of those with insomnia), conditions for which consensus panels have concluded that mind-body therapies are effective. They were also used by less than 20% of those with heart disease, headaches, back or neck pain, and cancer, conditions for which there is strong research support. Mind-body therapies were generally used concomitantly with conventional care: 90% of those using a mind-body therapy in the last year had seen a physician and 80% of mind-body therapies used were discussed with a physician.Conclusions: Although mind-body therapies were commonly used, much opportunity exists to increase use of mind-body therapies for indications with demonstrated efficacy. [ABSTRACT FROM AUTHOR]

Research demonstrating connections between the mind and body has increased interest in the potential of mind–body therapies. Our aim was to examine the use of mind–body therapies, using data available from a national survey. Analysis of a large nationally representative dataset that comprehensively evaluated the use of mind–body therapies in the last year. United States households. A total of 2,055 American adults in 1997–1998. Random national telephone survey. We obtained a 60% weighted overall response rate among eligible respondents. We found that 18.9% of adults had used at least 1 mind–body therapy in the last year, with 20.5% of these therapies involving visits to a mind–body professional. Meditation, imagery, and yoga were the most commonly used techniques. Factors independently and positively associated with the use of mind–body therapies in the last year were being 40 to 49 years old (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.33 to 3.10), being not married (AOR, 1.78; 95% CI, 1.34 to 2.36), having an educational level of college or greater (AOR, 2.21; 95% CI, 1.57 to 3.09), having used self-prayer for a medical concern (AOR, 2.53; 95% CI, 1.87 to 3.42), and having used another complementary medicine therapy in the last year (AOR, 3.77; 95% CI, 2.74 to 5.20). While used for the full array of medical conditions, they were used infrequently for chronic pain (used by 20% of those with chronic pain) and insomnia (used by 13% of those with insomnia), conditions for which consensus panels have concluded that mind–body therapies are effective. They were also used by less than 20% of those with heart disease, headaches, back or neck pain, and cancer, conditions for which there is strong research support. Mind–body therapies were generally used concomitantly with conventional care: 90% of those using a mind–body therapy in the last year had seen a physician and 80% of mind–body therapies used were discussed with a physician. Although mind–body therapies were commonly used, much opportunity exists to increase use of mind–body therapies for indications with demonstrated efficacy. J GEN INTERN MED 2004; 19:43–50. [ABSTRACT FROM AUTHOR]

Context: Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace.Objective: To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening.Design, Setting, and Subjects: Cross-sectional study using 1998 data from the National Health Interview Survey.Main Outcome Measures: Completion of cervical, breast, or colorectal cancer screening.Results: Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents.Conclusion: Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born. [ABSTRACT FROM AUTHOR]

Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace. To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening. Cross-sectional study using 1998 data from the National Health Interview Survey. Completion of cervical, breast, or colorectal cancer screening. Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents. Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born. J GEN INTERN MED 2003; 18:1028–1035. [ABSTRACT FROM AUTHOR]

Context: Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality.Objective: To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills.Design: Qualitative study using focus groups and content analysis to determine domains of quality of care.Setting: Four community health centers in Massachusetts.Participants: A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide.Main Outcome Measures: Domains of quality of care mentioned by patients in verbatim transcripts.Results: In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services.Conclusions: Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services. [ABSTRACT FROM AUTHOR]

Patients with obesity experience psychosocial consequences because of their weight and report physician bias. We examined whether obesity is associated with lower patient satisfaction with ambulatory care among 2,858 patients seen at 11 academically affiliated primary care practices in Boston. Compared with normal weight patients (body mass index [BMI], 19.0 to 24.9 kg/M 2), overweight (BMI, 25.0 to 29.9 kg/M 2) and obese patients (BMI > or =30 kg/M 2) reported lower overall satisfaction scores at their most recent visit; the scores were 85.5, 85.0, and 82.6 out a possible 100, respectively (P =.05). After adjustment for potential confounders including illness burden, obese patients reported lower scores but the difference was not statistically significant (mean difference, 1.23 [95% confidence interval -0.67 to 3.12]). Patient satisfaction with their usual provider and their practice did not vary by BMI group. Obesity is associated with only modest decreases in satisfaction scores with the most recent visit, which were explained largely by higher illness burden among obese patients. [ABSTRACT FROM AUTHOR]

Background: Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage.Objective: To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice.Design: Cross-sectional patient survey and medical record review.Setting: Eleven academically affiliated primary care medicine practices in the Boston area.Patients: 2,782 patients with at least one visit in the preceding year.Measurement: Unwillingness to return to the usual health care practice.Results: Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3).Conclusion: Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care. [ABSTRACT FROM AUTHOR]

We surveyed 241 board-certified internists affiliated with a large teaching hospital (Boston, Mass) before implementing a hospitalist service to determine attitudes towards providing inpatient care and the hospitalist model. Of physicians surveyed, 66% responded. Most disagreed that inpatient care is "an inefficient use of my time," only 10% felt a hospitalist service would improve patient satisfaction, and 54% felt it would hurt patient-doctor relationships. Multivariable analyses suggest that physicians physically furthest from their inpatient site were had more favorable attitudes toward the hospitalist model; more experienced and busier physicians were more negative. Future investigations should determine strategies for implementing the hospitalist model which address physicians' concerns. [ABSTRACT FROM AUTHOR]

Objective: To determine the clinical factors associated with delayed protease inhibitor initiation.Design: Chart review and telephone survey.Setting: General medicine practice at an academic medical center in Boston, Mass.Patients: One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml.Measurements and Main Results: The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56).Conclusions: HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness. [ABSTRACT FROM AUTHOR]

This study compares the demographic features and hospital course of all 472 patients discharged against medical advice from the general medicine service of an urban teaching hospital between 1984 and 1995 and 1,113 control patients discharged with physician approval. In the multivariate analysis, younger age (odds ratio [OR] 0.97 per year; 95% confidence interval [CI] 0.96, 0.98), male gender (OR 1.9; 95% CI 1.4, 2.4), lack of health insurance (OR 2.0; 95% CI 1.3, 3.1), Medicaid applicant or recipient status (OR 2.2; 95% CI 1.6, 3.1), admission through the emergency department (OR 2.2; 95% CI 1.4, 3.5), and lack of a personal attending physician at the time of admission (OR 2.1; 95% CI 1.6, 2.8) increased the odds of discharge against medical advice. Fifty-four percent of patients who left against medical advice were readmitted to the hospital during the study period; 98% were then discharged with physician approval. Patients who left the hospital against medical advice included many disadvantaged individuals without ongoing primary care. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of treatment with erythromycin on the resolution of symptoms among adults with pharyngitis not caused by group A streptococcus (GAS).Design: Randomized, double-blind, placebo-controlled trial.Setting: Ambulatory setting (hospital-based general internal medicine practices, walk-in clinic, employee health service, and university health service).Patients: One hundred and eighty-six adults who met eligibility criteria and whose chief complaint included sore throat. Patients with positive cultures for GAS were excluded.Intervention: Ninety-three patients received erythromycin (333 mg three times daily for 10 days) and 93 control patients received placebo.Measurements and Main Results: Major outcome measurements included time to improvement in sore throat, time to improvement in cough, time to improvement in activity level, and subjective sense of well-being. The average age of the patients studied was 26.6 years; 35% were men. Patients given erythromycin had more rapid resolution of sore throat symptoms (hazard ratio 1.43: 95% confidence interval [CI] 1.00, 2.03: p = .049). Cough also resolved more rapidly in patients receiving erythromycin (hazard ratio 2.22: 95% CI 1.01, 4.88: p = .05). There were no differences between the two treatment groups in improvement of activity level or how sick patients felt in general. Most of the benefit in resolution of sore throat was conferred on patients who sought medical care within 2 days of onset.Conclusions: Our results suggest that the benefit of erythromycin treatment for patients with non-GAS pharyngitis is small and of borderline statistical significance. Because of the small size of the effect and because widespread use of erythromycin could promote drug resistance, we do not recommend routine use of erythromycin in adult patients with this type of pharyngitis. [ABSTRACT FROM AUTHOR]

The article focuses on behavioral health integration model such as Collaborative Care Model (CoCM). It states that economic modeling of care implementation requires discernment of resource staffing and reimbursement for costs and reimbursements, not theoretically minimal costs. It states that financing of behavioral healthcare in fee-for-service environment is a critical barrier to adoption and financial viability is directly the target of Medicare's policy change, which prompted our analysis.