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BACKGROUND AND OBJECTIVES: Diabetes is a common chronic illness with potentially severe complications. The risk of complications is reduced through controlling blood sugar, lipids, and blood pressure. While medical intervention is important, substantial selfmanagement on the part of patients is required to achieve good control. Patients often find self-management difficult, particularly diet and exercise modification. Clinicians face barriers as well, including lack of time, poor reimbursement, and difficulty changing their clinical practice patterns. We hypothesized that a strong focus on readily measured disease indicators competes with patients' agendas relating to symptoms and their day-to-day social context. METHODS: We recorded clinical encounters to study communication about self-management in context. Recordings were transcribed verbatim and analyzed, primarily using a grounded theory approach. RESULTS: We found that clinicians often focused their communication on quantitative measures such as blood pressure and glycosylated hemoglobin but that patients found it difficult to relate these measures to how they were feeling physically. Patients' social contexts influenced their self-management activities, in particular heavy caregiving responsibilities and work schedules. CONCLUSIONS: Supporting self-management of patients with diabetes requires providers to link clinical measurements to patients' symptoms and likely outcomes. It is difficult for providers to know what support or assistance their patients need without knowledge of patients' social contexts. [ABSTRACT FROM AUTHOR]

Both senior residents and faculty members evaluate family practice interns (PGY-1) on the inpatient family medicine service at the University of Missouri-Columbia. The purpose of this study was to investigate the content and nature of narrative comments on a clinical evaluation sheet. Objective 1. The authors placed the subjective comments made by faculty and senior residents in their evaluations of PGY-1 residents into 12 distinctive categories. Objective 2. Comments were coded with a positive or negative valence. Objective 3. The genders of the evaluator and learner were recorded. All evaluations made between 1996 and 1999 were analysed. A total of 1341 individual comments were reviewed. Objective 1. Categories used most often were generic comments (20.2%), personal attributes (18%), and clinical competence (14.1%). There was no difference in category use based on the experience level of the evaluator ( P = 0.17). Objective 2. The majority of the comments (81.9%) were positive in nature. Senior faculty members were significantly less likely to make negative comments than were junior faculty members or senior residents ( P = 0.004). Objective 3. There were no differences in category use based on the gender of the evaluator ( P = 0.13). Objective 1. Narrative evaluation comments may be placed into 12 distinctive categories. Most comments are generic and do not help to inform learning. Objective 2. A total of 82% of comments were positive. Residents were more likely to make negative comments than senior faculty members. Objective 3. There was no demonstrable gender bias in writing negative comments. [ABSTRACT FROM AUTHOR]

To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs). Prospective cohort. Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study. NH residents with a LRI (n=1031). Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed. Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49–0.97). DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI. [ABSTRACT FROM AUTHOR]

To assess whether the term "intention to treat" (ITT) predicts Inclusion of all randomized subjects in the analysis, we reviewed 100 randomly selected reports of randomized trials that mentioned analysis by ITT. Only 42 of 100 reports included all randomized subjects in the ITT analysis. We could not determine which categories of participants were excluded from the ITT analysis in 13 trials. The most common categories of excluded subjects were patients who. after randomization, received no follow-up (16/100), received no treatment (14/100), or were found not to meet study entry criteria (12/100). We could determine the number of participants in the ITT analysis for 92 studies. Nineteen of the 92 studies excluded more than 5% of randomized participants, and 10 excluded more than 10%. There is considerable variation in how researchers define and apply the principle of intention to treat. [ABSTRACT FROM AUTHOR]