Dennis Cope

Internal medicine patients’ expectations for care during office visits

AbstractObjective: To describe internal medicine patients’ expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction. Design: Survey of patients and their physicians. Setting: The internal medicine practice of faculty and housestaff at a large academic center in Southern California. Patients: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85% ) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases. Main measurements: The patients’ previsit reports of the elements of care they thought necessary for their physicians to provide; the patients’ and physicians’ postvisit reports of the elements of care actually provided; and the patients’ satisfaction with care. Results: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients’ own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain “necessary” elements of care was associated with lower visit satisfaction. Conclusion: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients’ expectations are carefully elicited and dealt with, the physician-patient relationship may be adversely affected.

Improving patient quality of life with feedback to physicians about functional status.

OBJECTIVE: To improve functional status among primary care patients.INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,” and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians.DESIGN: Randomized controlled trial.SETTING: University primary care clinic.PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients.MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems.RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more actions recommended by the feedback form (p<0.02).CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients.

Factors Associated With Life Satisfaction Among Practicing Internists

The present study explored the relationship between satisfaction with life in general among 211 practicing internists and characteristics of their work, health, and life styles. Using a forced stepwise multiple regression analysis, 67% of the total variance in life satisfaction was accounted for by study variables. More satisfied physicians were more likely to be older, married, engaged in sexual intercourse more often, argued with or emotionally withdrew from family or friends less often, had fewer health problems, were less anxious and depressed, and experienced less job stress and more job satisfaction. Characteristics of the work setting type of work activity (teaching, research, or patient care), number of patients seen, or hours worked per week were unrelated to satisfaction with life. The findings point to the importance of studying family life, mental health, and social relations in addition to work-related variables in order to understand and assess the quality of life among physicians.

Thyroid disorders in elderly patients.

Thyroid disorders are common in the elderly and are associated with significant morbidity if left untreated. Typical symptoms may be absent and may be erroneously attributed to normal aging or coexisting disease. Physical examination of the thyroid gland may not be helpful, as the gland is often shrunken and difficult to palpate. Usually only myxedema coma requires levothyroxine parenterally; all other forms of hypothyroidism can be treated with oral levothyroxine. Low-dose levothyroxine should be initiated and increased gradually over several months. In unstable elderly patients with hyperthyroidism, antithyroid medication can quickly produce a euthyroid state. Radioactive iodine therapy is more definitive and is well tolerated, effective, and preferred. Surgical thyroid ablation may be necessary in patients who fail to respond to radioactive iodine therapy and in patients with multinodular goiter. If there is a suspicion of malignant disease, early biopsy or fine needle aspiration for cytology should be considered.

Attaining resident duty hours compliance: the acute care nurse practitioners program at Olive View-UCLA Medical Center.

The institution of resident duty hours limits by the Accreditation Council for Graduate Medical Education (ACGME) has made it difficult for some programs to cover inpatient teaching services. The medical literature is replete with editorials criticizing the hour limits and the resulting problems but is nearly silent on the topic of constructive solutions to compliance. In this article, the authors describe a new program, initiated in 2003 at the Olive View–UCLA Medical Center, of using acute care nurse practitioners to allow for compliance with the “24 + 6” continuous duty hours limit, as well as the 80-hour workweek limit. Each post-call team is assigned a nurse practitioner for the day, allowing residents to sign out by 2 pm while ensuring quality care for patients. Nurse practitioners participate in evaluation of residents and, in turn, are evaluated by them. Using this system, the authors report 99% compliance with ACGME work-hour restrictions, with average work hours for inpatient ward residents decreasing from 84 to 76 hours per week. Physician satisfaction with the new system is high; anonymous evaluation by residents and faculty returned average scores of 8.8 out of 9 possible points. The authors report that using nurse practitioners on post-call days provides excellent, continuous patient care without impinging on scheduling and without sacrificing responsibility, continuity, or education for the residents. This system has several potential advantages over previously described work-hour solutions. Addition of a nurse practitioner to the post-call team is an effective solution to the problem of compliance with resident duty hours limitations.

Restructuring VA ambulatory care and medical education: the PACE model of primary care.

The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.

Rhabdomyolysis in an HIV-Infected Patient on Anti-Retroviral Therapy Precipitated by High-Dose Pravastatin

Protease inhibitors (PIs) inhibit the cytochrome P450 CYP3A4. Because the metabolism of pravastatin is independent of the cytochrome P450 CYP3A4, this drug has become the preferred statin for treatment of dyslipidemia associated with human immunodeficiency virus (HIV) infection, with no cases of serious toxicity such as rhabdomyolysis reported to date. We report an HIV-infected patient receiving antiretroviral regimen consisting of atazanavir, ritonavir, emtricitabine and tenofovir who developed severe rhabdomyolysis approximately 4 months after increasing his pravastatin dose from 40 to 80 mg daily. His symptoms resolved within 10 days after the discontinuation of pravastatin and antiretroviral therapy. To our knowledge, this is the first case of rhabdomyolysis possibly caused by pravastatin in an HIV-infected patient.

Dementia Care Management in an Underserved Community The Comparative Effectiveness of Two Different Approaches

Objectives: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. Methods: We randomized 151 patient–caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient–caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. Results: Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. Discussion: Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

Cost-effectiveness of a hospitalist service in a public teaching hospital.

Purpose The authors report implementing an academic hospitalist team as a cost-effective solution to the problem of an inpatient census that exceeds their public hospitals teaching service limits. Medi-Cal (Californias Medicaid program) per diem reimbursement was the primary source of revenue, which rendered moot some traditional advantages of hospitalist services. Method The authors assessed cost-effectiveness by comparing average inpatient census, payment denial rate, and Medi-Cal reimbursement for internal medicine in 2008 and in 2007. They also focused on Medi-Cal patients admitted with low-risk chest pain in 2008, comparing the length-of-stay and denied-day rate data with data from 2005. Results Overall Medi-Cal reimbursement was

Management Strategies for Type 2 Diabetes: Focus on Vildagliptin

2,310,000 higher in 2008 than in 2007. Overall payment denial rate fell from 29% to 27.4%, while yearly admissions increased from 8,069 to 8,643, and the average daily census increased from 97.7 to 107.1 patients. For low-risk chest pain admissions, length of stay decreased from 2.48 to 1.92 days, denial rate decreased from 43.8% to 31.8%, and average reimbursement per inpatient day increased from