David R. Calkins

The functional status questionnaire

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients’ functional status. In this study, the FSQ was administered to 497 regular users of Boston’s Beth Israel Hospital’ Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

Rehabilitation for patients with chronic obstructive pulmonary disease: meta-analysis of randomized controlled trials

AbstractOBJECTIVE: To develop a meta-analysis to determine the effectiveness of rehabilitation in patients with chronic obstructive pulmonary disease (COPD). DATA SOURCES: MEDLINE, CINHAL, and Cochrane Library searches for trials of rehabilitation for COPD patients. Abstracts presented at national meetings and the reference lists of pertinent articles were reviewed. STUDY SELECTION: Studies were included if: trials were randomized; patients were symptomatic with forced expiratory volume in one second (FEV1) <70% or FEV1 divided by forced vital capacity (FEV1/FVC) <70% predicted; rehabilitation group received at least 4 weeks of rehabilitation; control group received no rehabilitation; and outcome measures included exercise capacity or shortness of breath. We identified 69 trials, of which 20 trials were included in the final analysis. DATA EXTRACTION: Effect of rehabilitation was calculated as the standardized effect size (ES) using random effects estimation techniques. RESULTS: The rehabilitation groups of 20 trials (979 patients) did significantly better than control groups on walking test (ES=0.71; 95% confidence interval [95% CI], 0.43 to 0.99). The rehabilitation groups of 12 trials (723 patients) that used the Chronic Respiratory Disease Questionnaire had less shortness of breath than did the control groups (ES=0.62; 95% CI, 0.35 to 0.89). Trials that used respiratory muscle training only showed no significant difference between rehabilitation and control groups, whereas trials that used at least lower-extremity training showed that rehabilitation groups did significantly better than control groups on walking test and shortness of breath. Trials that included severe COPD patients showed that rehabilitation groups did significantly better than control groups only when the rehabilitation programs were 6 months or longer. Trials that included mild/moderate COPD patients showed that rehabilitation groups did significantly better than control groups with both short- and long-term rehabilitation programs. CONCLUSION: COPD patients who receive rehabilitation have a better exercise capacity and they experience less shortness of breath than patients who do not receive rehabilitation. COPD patients may benefit from rehabilitation programs that include at least lower-extremity training. Patients with mild/moderate COPD benefit from short- and long-term rehabilitation, whereas patients with severe COPD may benefit from rehabilitation programs of at least 6 months.

Health status assessment for elderly patients. Report of the Society of General Internal Medicine Task Force on Health Assessment.

A brief but systematic assessment of functional status should be incorporated into the routine medical management of elderly patients, because of its demonstrated usefulness.

Functional disability screening of ambulatory patients

The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and social function. The experimental group physicians received reports summarizing their patients’ responses; the control group physicians received no report. At the end of one year the authors found no significant difference between the patients of the experimental and control group physicians on any measure of functional status. Functional disability screening alone does not improve patient function.

A New educational approach for supporting the professional development of third-year medical students

This paper describes a new course designed to support the professional development of third-year medical students. The course runs through the clinical clerkships, and has several additional features: it includes a multidisciplinary faculty; it is centrally based in the medical school; it addresses students’ values and attitudes in addition to their knowledge and skills; and it makes use of small-group learning methods, and faculty, student, and group continuity during the year. The curriculum, which addresses ethical, social, and communicative issues in medicine, plus the evaluation of students and of the course, are described.

Independent clinical correlates of severe alcohol withdrawal

This retrospective cohort study sought to identify clinical variables that independently correlate with severe alcohol withdrawal and to quantify risk in a clinically useful manner. The records of 284 inpatients admitted to an acute detoxification unit at a Veterans Affairs teaching hospital were reviewed. Clinical data were recorded on standardized forms at the time of admission and abstracted by a physician reviewer. Alcohol withdrawal severity was prospectively measured with the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Seventy-one patients (25% of cohort) had severe withdrawal. We identified six independent correlates of severe withdrawal: use of a morning eye-opener (adjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2–25.9), an initial CIWA-Ar score ≥q 10 (OR, 5.1; 95% CI, 2.4–10.6), a serum aspartate aminotransferase ≥ 80 U/L (OR, 4.2; 95% CI, 2.0–8.8), past benzodiazepine use (OR, 3.6; 95% CI, 1.3–9.9), self-reported history of “delirium tremens” (OR, 2.9; 95% CI, 1.3–6.2), and prior participation in two or more alcohol treatment programs (OR, 2.6; 95% CI, 1.3–5.6). Significantly higher risk was observed in subjects with three or more independent correlates. In conclusion, several readily available clinical variables correlate with the occurrence of severe alcohol withdrawal. Ascertainment of these variables early in the course of alcohol withdrawal has the potential to improve triage and treatment decisions.

The costs and financing of ambulatory medical education

MEDICAL EDUCATORS recen t ly h a v e s u g g e s t e d that more of the e d u c a t i o n of m e d i c a l s tudents , res idents , a n d fellows should occur in a m b u l a t o r y settings, l, 2 This r e c o m m e n d a t i o n reflects a shift in the m a n a g e men t of a cu t e illness f rom inpat ient to ou tpa t ien t sett ings a n d i n c r e a s e d a t tent ion b y e d u c a t o r s to preven t ive med ic ine a n d the c a r e of chron ic d i sease , which m a y b e l e a r n e d bes t b y work ing with a m b u l a to ry pat ients . Economic cons ide ra t ions m a y b e a ba r r i e r to a m b u l a t o r y m ed ica l educa t ion , s-s Hospi ta l ou tpa t ient d e p a r t m e n t s s taf fed by res idents a r e be l i e v e d to h a v e h ighe r costs t h a n o ther a m b u l a t o r y settings, a fac tor which could t h r e a t e n their viabili ty in a n inc reas ing ly cos t -conscious hea l th c a r e marke t . Fur thermore , m u c h of the f inanc ing of m e d i c a l educat ion, e spec i a l l y a t the g r a d u a t e level, is ] inked to p a y m e n t for inpat ient services . If the re is to be a n i n c r e a s e in a m b u l a t o r y medi ca l educa t ion , e d u c a t o r s a n d pol icy m a k e r s must a d d r e s s the following quest ions:

Ambulatory care and the poor: tracking the impact of changes in federal policy.

JUST OVER 20 years ago, the Congress adopted Title XIX of the Social Securi ty Act, e s tab l i sh ing the Medicaid program. Over the next 15 years Medicaid payments rose rapidly. Between 1973 and 1980 the annual rate of growth was 14.5%. 1 Federa l spending also increased over the same period for a variety of other public hea l th care programs serving the poor: materna l and child hea l th care, family planning, community and migrant heal th centers, and 2. the National Heal th Service Corps. In 1981, however, the rate of growth in federal spending on hea l th care programs for the poor began to slow. Legislat ion enac ted since 1981 has 3. reduced annua l federal spending on Medicaid by

Unconventional Medicine in the United States -- Prevalence, Costs, and Patterns of Use

700 million and spending on other heal th service programs for the poor by

The functional status questionnaire: Reliability and validity when used in primary care

600 million. 2 What has been the impact of these changes in 4. federal policy on access to ambula tory care for the poor? The answer to this quest ion depends in part upon the measu re of access one chooses. Blendon and Rogers have sugges ted pa ramete r s that should 5. be followed in tracking the impact of changes in public policy on heal th and heal th care. 3 Several are appl icable to a s tudy of access to ambula tory care. They inc lude changes in the f requency of visits to physicians, changes in the location where care is received by the poor, and trends in the utilization of prevent ive services. In the first sect ion of this paper we review stud6. ies examin ing each of these pa ramete r s prior to 1981. We h i g h l i g h t c h a n g e s in u t i l i z a t i o n of ambula tory care by the poor following the establ ishment of Medicaid in 1965 and note gaps in utilization still appa ren t in the late 1970s. In the second section of the pape r we discuss utilization t rends since 1981. Finally, we sugges t addi t ional research 7. s t ra tegies to eva lua t e the impact of recent reductions in federal spending on heal th care programs for the poor.