Anne W. Moulton

Patients' Use of the Internet for Medical Information

AbstractOBJECTIVES: To determine the percentage of patients enrolled in a primary care practice who use the Internet for health information, to describe the types of information sought, to evaluate patients’ perceptions of the quality of this information, and to determine if patients who use the Internet for health information discuss this with their doctors. DESIGN: Self-administered mailed survey. SETTING: Patients from a primary care internal medicine private practice. PARTICIPANTS: Randomly selected patients (N=1,000) were mailed a confidential survey between December 1999 and March 2000. The response rate was 56.2%. MEASUREMENTS AND MAIN RESULTS: Of the 512 patients who returned the survey, 53.5% (274) stated that they used the Internet for medical information. Those using the Internet for medical information were more educated (P<.001) and had higher incomes (P<.001). Respondents used the Internet for information on a broad range of medical topics. Sixty percent felt that the information on the Internet was the “same as” or “better than” information from their doctors. Of those using the Internet for health information, 59% did not discuss this information with their doctor. Neither gender, education level, nor age less than 60 years was associated with patients sharing their Web searches with their physicians. However, patients who discussed this information with their doctors rated the quality of information higher than those who did not share this information with their providers. CONCLUSIONS: Primary care providers should recognize that patients are using the World Wide Web as a source of medical and health information and should be prepared to offer suggestions for Web-based health resources and to assist patients in evaluating the quality of medical information available on the Internet.

Diabetic Myocardial Infarction: Interaction of Diabetes With Other Preinfarction Risk Factors

To assess the effect of diabetes on outcome after acute myocardial infarction (MI), we compared a cohort of 228 type II (non-insulin-dependent) diabetic patients who had sustained acute MI with a similar number of nondiabetic patients with MI. Thirty-day mortality was greater in the diabetic group (27 vs. 17%). However, diabetic patients were older and had more cardiovascular disease before MI. Analyses accounting for such baseline risk revealed a complex effect of diabetes. The relative risk (RR) of dying from MI due to diabetes was greatest among patients with lowest baseline risk (RR 7.3) and least among those at highest baseline risk (RR 0.83). These effects were most striking with transmural MI, which was highly lethal for those with diabetes. Analyses with pulmonary edema as the endpoint support the significant risk conferred by diabetes and its interaction with baseline risk. Diabetes is a risk factor for poor outcome after MI, particularly among patients whose pre-MI cardiovascular status otherwise appears normal.

Risk factors for stroke in patients with nonrheumatic atrial fibrillation : a case-control study

PURPOSE Randomized controlled trials have demonstrated that anticoagulant therapy is very effective at preventing stroke among patients with nonrheumatic atrial fibrillation. However, these trials have reported too few strokes for powerful risk factor analysis. Observational studies may provide additional information. The purpose of this study was to identify risk factors in a larger number of patients with stroke and nonrheumatic atrial fibrillation, using case-control methodology. PATIENTS AND METHODS We identified all patients discharged from one hospital over an 8-year period who met our case definition of nonrheumatic atrial fibrillation and ischemic stroke (n = 134), and compared them with contemporaneous control subjects who were discharged with nonrheumatic atrial fibrillation without stroke (n = 131). RESULTS Cases and controls were similar in terms of duration of atrial fibrillation; proportion with paroxysmal atrial fibrillation; percentage with a past medical history of angina, myocardial infarction, congestive heart failure, diabetes, or smoking; and mean left atrial size. In contrast, cases were significantly older than controls (78.5 versus 74.8 years, p = 0.002) and more likely to have a history of hypertension (55% versus 38%, p = 0.0093). The relative odds for stroke was 1.91 for patients with hypertension, 1.73 for patients older than 75 years, and 3.26 for patients with both factors. CONCLUSIONS Our analysis suggests that age and hypertension should be considered when deciding upon long-term anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation.

Accuracy of dipyridamole SPECT imaging in identifying individual coronary stenoses and multivessel disease in women versus men

The concordance between perfusion image results and cardiac catheterization for individual coronary territories for women was 75%, and for men, it was 65% (P=.09). In women, the presence of disease of the left anterior descending coronary artery was detected more frequently than it was in men, 84% versus 44% (P=.004). The detection of disease in the territories of the left circumflex and right coronary arteries was similar for both groups. For women, the accuracy of perfusion imaging in identifying the presence/absence of multivessel coronary disease was 64%, compared with 71% for men (P=not significant).BackgroundOlder women frequently undergo dipyridamole perfusion imaging and can have advanced coronary artery disease, but little data exist on the accuracy of perfusion imaging in detecting disease in individual vascular territories and multivessel disease in women, compared with men.Methods and ResultsFrom a database of patients undergoing myocardial single photon emission computed tomography (SPECT) perfusion imaging, 107 unselected sequential patients (58 women, 49 men) who underwent sestamibi dipyridamole stress and cardiac catheterization within 6 months of each other were identified. Data were analyzed to compare sensitivities for detection of individual coronary stenoses and multivessel disease.ConclusionsThe accuracy of dipyridamole sestamibi SPECT imaging in detecting multivessel disease was similar for men and women. The sensitivity of dipyridamole sestamibi SPECT imaging in detecting disease of the left anterior descending artery was better in women.

Physicians’ utilization of health care

OBJECTIVE: To describe how physicians attend to their own health care needs.SETTING: Rhode Island.PARTICIPANTS: A random sample of Blue Cross/Blue Shield providers. The 306 respondents (67% of 458) primarily (92%) had MD or DO degrees. The nonphysician providers were chiropractors, dentists, optometrists, and podiatrists.DESIGN: A mailed survey provided data describing the respondents’ medical conditions and utilization of formal and informal care during a three-year period. Questions asked about provider visits, physical examinations, preventive and diagnostic tests, and medication use. The respondents indicated whether services had been initiated by themselves or by another physician.MAIN RESULTS: The physicians’ overall use of formal health services was low; their number of office visits was a fourth of the national average. Two-thirds of the respondents reported having a primary care physician, and one-third had sought informal care. The respondents’ use of preventive services was high. During the three-year period, 82% of the women physicians had received a Pap test, and 81% of the women physicians over the age of 40 years had received mammography. Cholesterol levels were checked for more than two-thirds of all the respondents. Medical examinations and laboratory tests tended to be ordered by another physician, although self-prescribing was not uncommon. Furthermore, 61% of the respondents had self-prescribed at least one medication.CONCLUSIONS: Physicians’ care-seeking behavior covers a broad spectrum, ranging from self-care, to informal consultation, to formal treatment by another physician. Physicians appear to be low users of formal services overall, but high users of preventive care.

Inpatient Management Protocols to Reduce Health Care Costs

A group of 12 internists, members of a university-affiliated hospital, designed and imple mented protocols for the general inpatient management of four medical problems (chest pain, stroke, pneumonia, and upper gastrointestinal hemorrhage). Hospital charges for the 63 cases were compared with charges generated by 64 controls who had been patients admitted to the same physicians with the same diagnoses during the same period of the preceding year, before the project was begun. A group of nonparticipating internists was similarly evaluated during the two time periods to control for changes in practice patterns extraneous to the intervention. Adjustment was made for inflation (6%) and differences in case mix. The program resulted in a 15% reduction in total average charge generated by the cases. Sizeable reductions were achieved in utilization of EKGs (34.8%), x-rays (15.4%), laboratory testing (20.4%), and drugs (11.4%). Given the prevailing attitude that health care costs are too high and that many services are unnecessary, the benefit of altering physician behavior by using standards established by them for themselves could be substantial, es pecially with the threat of more restrictive and less sympathetic modes of controlling costs. Key words: cost containment; inpatient management; protocols; standards of care. (Med Decis Making 6:101-109, 1986)

The Gastrointestinal Tract and Pancreas

Alcohol has pervasive effects on the gastrointestinal tract and pancreas, ranging from subtle microscopic changes to devastating clinical sequelae. As the portal of entry into the body, the digestive tract is vulnerable to the effects of alcohol. The effect of alcohol on the pancreas is mediated by less direct mechanisms. The association between alcohol and liver disease is discussed in Chapter 14 and that with gastrointestinal cancer is discussed in Chapter 18.

MRFIT, MS FIT, and Alcohol Use

Excerpt To the Editors:Suh and colleagues (1) report results from the Multiple Risk Factor Intervention Trial (MRFIT) suggesting that for light- to moderate-drinking middle-aged men, the inverse as...