Arthur J. Bonito

Health status of individuals with mild stroke.

BACKGROUND AND PURPOSE Diminished quality of life and limitations in higher levels of physical functioning are often underestimated in stroke and are not fully captured by measures such as the Barthel Index and the Rankin Outcome Scale. This study used additional measures to assess the health status of 304 persons with mild stroke and to compare these individuals with 184 persons with transient ischemic attack and 654 persons without history of stroke/transient ischemic attack but at elevated risk for stroke (asymptomatic group). METHODS Subjects were recruited from the Academic Medical Center Consortium (inpatients), the Cardiovascular Health Study (population-based sample of community-dwelling persons 65 years and older), and United HealthCare (inpatients and outpatients typically younger than 65 years). Subjects were interviewed by telephone or in person to assess activities of daily living (Barthel Index), depression (Center for Epidemiological Studies Depression Scale), health status (MOS-36), and utility for current health state. RESULTS Most respondents were independent on all Barthel items. The stroke group was more impaired on the MOS-36 than the asymptomatic group but similar to the group with transient ischemic attack. Health-related quality of life was lowest for persons with stroke. While symptom status and Barthel Index score were the strongest predictors of health status, the Barthel Index showed a consistent ceiling effect when compared with the physical function subscale of the MOS-36. CONCLUSIONS The consequences of even mild stroke affect all dimensions of health except pain. Standardized assessment of persons with stroke must evaluate across the entire continuum of health-related functions.

Utilities for major stroke: Results from a survey of preferences among persons at increased risk for stroke

BACKGROUND Patient beliefs, values, and preferences are crucial to decisions involving health care. In a large sample of persons at increased risk for stroke, we examined attitudes toward hypothetical major stroke. METHODS AND RESULTS Respondents were obtained from the Academic Medical Center Consortium (n = 621), the Cardiovascular Health Study (n = 321 ), and United Health Care (n = 319). Preferences were primarily assessed by using the time trade off (TTO). Although major stroke is generally considered an undesirable event (mean TTO = 0.30), responses were varied: although 45% of respondents considered major stroke to be a worse outcome than death, 15% were willing to trade off little or no survival to avoid a major stroke. CONCLUSIONS Providers should speak directly with patients about beliefs, values, and preferences. Stroke-related interventions, even those with a high price or less than dramatic clinical benefits, are likely to be cost-effective if they prevent an outcome (major stroke) that is so undesirable.

US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke: Carotid Endarterectomy

BACKGROUND AND PURPOSE Data from several randomized clinical trials concerning the efficacy of carotid endarterectomy (CE) in patients with symptomatic and asymptomatic stenoses of the extracranial carotid artery are now available. Yet, there are few data concerning the patterns of use of CE by physicians for their patients at risk for stroke. These data are critical for the rational allocation of resources and targeting of educational efforts. METHODS Between August 1993 and February 1994, we surveyed the stroke prevention practices of a stratified random sample of 2000 US physicians. The survey queried the perceived availability and use of diagnostic studies and surgery for specific types of patients who might be considered candidates for CE. RESULTS Of eligible physicians, 67% (n = 1006) completed the survey. Seventy percent reported that they always or often obtain carotid ultrasonography for evaluation of patients with asymptomatic bruits; 89% do so in patients with recent transient ischemic attack or minor stroke (P < .001). For asymptomatic patients, 13% always or often obtain a cerebral angiogram if carotid ultrasonography indicates 50% to 70% stenosis versus 33% if carotid ultrasonography indicates > 70% stenosis (P < .001). For asymptomatic patients with > 70% stenosis, a cerebral angiogram was reported as seldom or never used by 42% of physicians who viewed the test as readily available versus 67% if cerebral angiography was perceived as not readily available (P = .005). Multinomial multiple logistic regression analysis showed that symptom status, the degree of stenosis, perceived availability of CE, and physician specialty independently contributed to the explained variance in the reported use of CE (P < .001). The odds of performing CE were approximately four times greater in patients recent symptoms compared with asymptomatic patients (P < .001) and four times greater in patients with > 70% stenosis compared with patients with 50% to 70% stenosis (P < .001). Physicians who perceived CE as not being readily available were one third as likely to report using the procedure compared with physicians who reported having ready access (P = .004). CE was reported as being always or often used by more than 80% of neurologists and surgeons but by only about half of internists and noninternist primary care physicians for patients with newly symptomatic high-grade stenosis (P < .001). Almost one in four noninternist primary care physicians responded that they would seldom or never use CE for these patients. CONCLUSIONS These data show that (1) symptom status and degree of carotid artery stenosis strongly influence the reported frequency with which CE is used by practicing physicians; (2) the perceived availability of cerebral angiography and CE significantly affects their reported frequency of use; and (3) physician specialty significantly influences the reported frequency of use of CE.

Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries

OBJECTIVES Our understanding of the use of emergency departments (EDs) and physician offices for the management of dental problems is limited. We undertook this study to examine whether there are differences in their use by low-income White and minority adults as compared with higher-income adults. METHODS Participantsincluded White, Black, and Hispanic adults who had experi enced a dental problem during the previous 12 months and who visited a physician, ED, or dentist for treatment. We selected a stratified random sample of 27,002 Maryland households with listed telephones to screen for eligibility. We identified 1,387 households with an eligible adult, selected 423 for interviews, and completed interviews with 401 (94.8%). RESULTS To restore correct proportionality to the sample, and to adjust for nonresponse and the distribution of demographic characteristics, weights were created for use in the analyses. Only 7.1 percent of respondents contacted an ED, while 14.3 percent contacted a physician and 90.2 percent a dentist. The vast majority of respondents who contacted an ED (96.0%) or a physician (92.2%) also contacted a dentist. Lower-income respondents were more likely to seek care from an ED, while higher-income respondents were more likely to seek care from a dentist. Over whelmingly, respondents visiting EDs (89.4%) and physicians (51.7%) were instructed to see a dentist or given prescriptions/samples. Treatment provided by EDs, physicians, and dentists was not associated with the respondents income or race/ethnicity. CONCLUSIONS Respondents visiting EDs and physicians typically did not receive definitive care and subsequently visited a dentist for treatment.

Toothache pain: Behavioral impact and self-care strategies

A computer-assisted telephone interview in Maryland of adults who had low income and were Hispanic, Black, and White and who had experienced a toothache during the previous 12 months was conducted. Respondents reported a high prevalence of toothaches, with 44.3% having experienced more than five toothaches during the preceding 10 years. Pain intensity associated with the most recent toothache was high with 45.1% of the respondents reporting the highest pain possible. Pain interfered with many aspects of normal functioning. Self-care strategies generally took precedence over professional health services. Pain sufferers used a combination of self-care and formal care strategies. Initial strategies most often focused on nonprescription medicines(home remedies and prayer. The majority of respondents ultimately sought pain relief from a dentist. We identified a number of significant differences in the strategies used across racial/ethnic groups.

US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke Medical Therapy in Patients With Carotid Artery Stenosis

BACKGROUND AND PURPOSE Aspirin or other platelet antiaggregants and anticoagulants are commonly used in many types of patients at elevated stroke risk. However, relatively little is known concerning how practicing physicians use these medications in their patients with extracranial carotid artery stenosis. The identification of variations in practice may help to both direct specific educational efforts and guide further research. METHODS Between August 1993 and February 1994, we surveyed the stroke prevention practices of a stratified random sample of 2000 US physicians. The survey included clinical scenarios that probed the use of aspirin or other platelet antiaggregants and anticoagulants in symptomatic and asymptomatic patients with carotid artery stenoses of 50% to 70% or more than 70%, with and without known surgical contraindications. RESULTS Sixty-seven percent of those eligible completed the survey (n = 1006). More than 85% of physicians responded that they always or often prescribe aspirin or other platelet antiaggregants regardless of degree of carotid artery stenosis, symptom status, or presence of surgical contraindications. However, the reported frequency of use of these medications varied independently according to physician specialty (P = .044). In contrast, in addition to physician specialty, the reported frequency of anticoagulant use varied independently with degree of carotid artery stenosis, symptom status, and presence of surgical contraindications (P < .0001 for each variable). Fifteen percent of physicians responded that they always or often use anticoagulants for asymptomatic patients with 50% to 70% carotid artery stenosis versus 43% who reported doing so for symptomatic patients with a similar degree of stenosis (P < .001); 28% often or always prescribe anticoagulants for asymptomatic patients with more than 70% carotid artery stenosis versus 49% who do so if symptoms are present (P < .001). The odds of noninternist primary care physicians responding that they always or often use anticoagulants were more than five times higher (odds ratio, 5.32; 95% confidence interval [CI], 3.79 to 7.45) than surgical specialists. Compared with surgical specialists, the odds ratios for the use of anticoagulants were 3.65 for internists (95% CI, 2.63 to 5.06) and 1.88 (95% CI, 1.40 to 2.53) for neurologists. CONCLUSIONS These data show the following: (1) Aspirin or other platelet antiaggregants are used by most physicians regardless of degree of carotid artery stenosis, symptom status, or presence of surgical contraindications; (2) anticoagulants are prescribed selectively, with each of these variables influencing their use; and (3) the use of both classes of agents varies with physician specialty training.

Assessing the Preparedness of Research Integrity Officers (RIOs) to Appropriately Handle Possible Research Misconduct Cases

Institutions receiving federal funding for research from the U.S.Public Health Service need to have policies and procedures to both prevent research misconduct and to adjudicate it when it occurs. The person who is designated to handle research misconduct is typically referred to as the research integrity officer (RIO). In this interview study we report on 79 RIOs who describe how they would handle allegations of research misconduct. Their responses were compared to two expert RIOs. The responses to the allegations in the scenarios demonstrated that RIOs are not uniformly well prepared to handle activities associated with reported allegations of research misconduct. We recommend greater preparation through directed training, use of check lists of possible behaviors necessary to consider when situations arise, being involved in a network of RIOs so one can discuss options, and the possible need to certify RIOs.

Anticoagulation for atrial fibrillation: Physicians' readiness to change practices:

94 PURPOSE. Determine physicians’ readiness to change anticoagulation practices for patients with non-valvular atrial fibrillation (NVAF). BACKGROUND. Only half of eligible NVAF patients receive warfarin. Interventions to alter physicians’ anticoagulation practices must consider their motivation to change. METHODS. As part of a US national survey (1993–94), physicians were asked their current practices for patients over age 65 with NVAF, and whether they were comfortable, considering change, or expecting to change those practices. RESULTS. Overall, 67% of eligible physicians fully responded to the survey (n=1006). Seventy-three percent (72% of non-internist primary care physicians [PCPs], 76% of internists, 69% of neurologists and 37% of surgeons) responded that they often or always anticoagulate patients over age 65 with NVAF. The majority (73%) indicated they were comfortable with their practices, with the rates differing by specialty (68% PCPs, 76% internists, 82% neurologists, 87% surgeons; p CONCLUSION. Although differing by specialty, these data show that the majority of physicians are not expecting or planning to change their anticoagulation practices for patients over age 65 with NVAF. Although the majority believe they anticoagulate such patients and are comfortable with their practices, their actual treatment patterns may differ as several studies show that high proportions of eligible AF patients do not receive warfarin. Utilization review coupled with the identification of specific practice barriers and tailored educational programs may address this discrepancy. A high proportion of physicians who responded that they seldom or never anticoagulate these patients were also comfortable with their practices. Providing current treatment guidelines reinforced by other educational strategies might motivate them to consider a change in practice.