Jennifer S. Haas

Is the Professional Satisfaction of General Internists Associated with Patient Satisfaction

AbstractBACKGROUND: The growth of managed care has raised a number of concerns about patient and physician satisfaction. An association between physicians’ professional satisfaction and the satisfaction of their patients could suggest new types of organizational interventions to improve the satisfaction of both. OBJECTIVE: To examine the relation between the satisfaction of general internists and their patients. DESIGN: Cross-sectional surveys of patients and physicians. SETTING: Eleven academically affiliated general internal medicine practices in the greater-Boston area. PARTICIPANTS: A random sample of English-speaking and Spanish-speaking patients (n=2,620) with at least one visit to their physician (n=166) during the preceding year. MEASUREMENTS: Patients’ overall satisfaction with their health care, and their satisfaction with their most recent physician visit. MAIN RESULTS: After adjustment, the patients of physicians who rated themselves to be very or extremely satisfied with their work had higher scores for overall satisfaction with their health care (regression coefficient 2.10; 95% confidence interval 0.73–3.48), and for satisfaction with their most recent physician visit (regression coefficient 1.23; 95% confidence interval 0.26–2.21). In addition, younger patients, those with better overall health status, and those cared for by a physician who worked part-time were significantly more likely to report better satisfaction with both measures. Minority patients and those with managed care insurance also reported lower overal satisfaction. CONCLUSIONS: The patients of physicians who have higher professional satisfaction may themselves be more satisfied with their care. Further research will need to consider factors that may mediate the relation between patient and physician satisfaction.

Drug Complications in Outpatients

OBJECTIVE: Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction. DESIGN: Retrospective chart reviews and patient surveys. SETTING: Eleven Boston-area ambulatory clinics. PATIENTS: We randomly selected 2,248 outpatients, 20 to 75 years old. MEASUREMENTS AND MAIN RESULTS: Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.05 to 1.30), failure to explain side effects (OR 1.65; 95% CI, 1.16 to 2.35), and primary language other than English or Spanish (OR 1.40; 95% CI, 1.01 to 1.95). Patient satisfaction was lower among patients who reported drug complications (P < .0001). In addition, 48% of those reporting drug complications sought medical attention and 49% experienced worry or discomfort. On chart review, 3 (5%) of the patients with an adverse drug event required hospitalization and 8 (13%) had a documented previous reaction to the causative drug. CONCLUSIONS: Drug complications in the ambulatory setting were common, although most were not documented in the medical record. These complications increased use of the medical system and correlated with dissatisfaction with care. Our results indicate a need for better communication about potential side effects of medications, especially for patients with multiple medical problems.

Changes in the use of Postmenopausal hormone therapy after the publication of clinical trial results

Context Since 1998, 2 large trials have drastically changed the evidence for the preventive health benefits of postmenopausal hormone replacement therapy. However, changes in practice often lag behind changes in evidence. Contribution Among mammography recipients in San Francisco, California, the use of hormone replacement therapy decreased 1% per quarter after publication of the Heart and Estrogen/progestin Replacement Study and 18% per quarter after publication of results from the Womens Health Initiative (WHI). Reduction in use was unrelated to a womans age, hysterectomy status, or race or ethnicity. Implications The WHI resulted in more dramatic changes in practice than are often associated with changes in evidence. The vigorous media coverage of the WHI may have contributed to rapid changes in practice. The Editors In 1995, approximately 38% of postmenopausal women in the United States were taking hormone therapy (1). At that time, several observational studies had suggested that hormone therapy offered women some protection against coronary heart disease and osteoporosis (2-5). A decision analysis published in 1997 concluded that the benefits of hormone therapy outweighed its risks for nearly all women (6). More recently, the results from 2 large randomized clinical trials, the Heart and Estrogen/progestin Replacement Study (HERS) (7) and the Womens Health Initiative (WHI), have been published (8). These clinical trials demonstrated that the risks associated with hormone therapy outweigh the benefits for women taking continuous estrogen and progestin regimens. As a result of these trial results, the U.S. Food and Drug Administration required new warning labels for all estrogen products (9), and the U.S. Preventive Services Task Force revised its assessment of hormone therapy to recommend against the routine use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women (10). It is important to understand whether this new scientific evidence is changing the use of hormone therapy. Of note, the results of the WHI were widely disseminated. Despite this publicity, differential access to new information, varied interpretations of study findings, and individual perceptions of menopausal symptoms and hormone side effects may have resulted in different patterns of use. An understanding of how use is changing over time provides important information about the dissemination of clinical trial results to women. We designed our analysis to examine whether the use of hormone therapy has changed among postmenopausal women as a result of the publication of the results from HERS and the WHI. We were also interested in examining whether patterns of use differ by patient characteristics. Because HERS examined the outcomes of older women, we hypothesized that there would be earlier and more substantial declines in hormone therapy use among this group. We also expected that there would be variation in use by race or ethnicity because white women may have better access to new information (11). Finally, because the WHI study results were specific to women taking continuous estrogen plus progestin, we hypothesized that hormone use would be more stable among women who had had hysterectomies because such women typically take only estrogen and may believe that the findings do not apply to them. Methods Sample The San Francisco Mammography Registry is a population-based registry of women undergoing mammography in San Francisco, California. It is 1 of 7 registries participating in the National Cancer Institute Breast Cancer Surveillance Consortium (12). This registry began to prospectively collect patient data and mammography results in 1995 and currently captures about 90% of mammography examinations performed in San Francisco. Data from 11 mammography facilities are included in this analysis. Women were eligible for this analysis if they were between the ages of 50 to 74 years, were postmenopausal, did not report a personal history of breast cancer, and underwent screening or diagnostic mammography between January 1997 and 19 May 2003. Women 55 years of age and older were assumed to be menopausal. Women 50 to 54 years of age were considered to be menopausal if both ovaries had been removed or if they reported that their periods had stopped permanently. For women who had mammography more than once in any calendar year, we included only the first instance of mammography in that year to prevent overrepresentation of women undergoing an evaluation of an abnormal mammogram because this experience may influence use of hormone therapy. Our final sample included 15 1862 mammograms received by 71 219 women. Data At the facilities that participate in the San Francisco Mammography Registry, each woman completes a brief, scannable questionnaire at the time of mammography. This questionnaire collects information about current use of hormone therapy and several personal characteristics, including race or ethnicity (categorized as white, African American, Latina, Chinese, Filipina, other Asian, other), family history of breast cancer (including mother, sisters, and daughters), history of childbirth, whether the woman had undergone a hysterectomy, menopausal status, history of breast biopsy (including fine-needle aspiration, core biopsy, and surgical biopsy). Information about age at the time of mammography, date of mammography, and ZIP code of residence is reported by the facility. Data from the year 2000 U.S. Census was used to assign median income for each womans ZIP code of residence as a proxy for socioeconomic status. Variables Our outcome variable for this analysis was the current use of hormone therapy. Date of mammography was represented as a linear term. Binary variables were created for the publication dates of HERS (before 19 August 1998 vs. that date or later) and the publication of the principal findings from the WHI (before 17 July 2002 vs. that date or later). Other independent variables examined were age at the time of mammography, race or ethnicity, median income of the ZIP code of residence, history of childbirth, family history of breast cancer, history of breast biopsy, and previous hysterectomy. Statistical Analysis Because some of the women in this sample had more than 1 mammogram represented in this data set, which spanned a 7-year period, we conducted a repeated-measures logistic regression to adjust the variance estimates for clustering of hormone therapy use over time for individual women and for the clustering of women within mammography facilities (13). Generalized estimating equations were implemented by using the SUDAAN statistical package, version 8.0.0 (Research Triangle Institute, Research Triangle Park, North Carolina) assuming an exchangeable correlation matrix. These models included a linear term indicating quarter from January 1997 to the first quarter of 2003 to control for temporal trends (the last quarter included mammograms through 19 May 2003), the variables specified above to indicate the dates of publication of HERS and the WHI, and an interaction term between each of these publication indicators and the time (in quarters) following each of these publications to measure changes in use after the publication of these clinical trials. These models also controlled for the individual characteristics described earlier (that is, age, race or ethnicity, history of childbirth, family history of breast cancer, history of breast biopsy, previous hysterectomy, median income for the ZIP code of residence). To specifically test our hypotheses about differential changes in the use of hormone therapy for subgroups of women on the basis of age, hysterectomy status, and race or ethnicity, we examined interaction terms to test for effect modification. For the main effects, a P value less than 0.05 was considered statistically significant, and for the interaction terms, a P value less than 0.01 was considered to be statistically significant. The likelihood ratio test compared the null model with the fitted model. Role of the Funding Source This work was supported by a National Cancer Institutefunded Breast Cancer Surveillance Consortium agreement. The funding source did not participate in the design, conduct, or reporting of this analysis or in the decision to submit the manuscript for publication. Results The Table shows the characteristics of the sample for each of the study years. Over the time period of the study, the median age decreased from 61 years to 59 years. The racial and ethnic composition of the sample also changed somewhat across the study years. Fewer women undergoing mammography in 2003 reported a history of childbirth (71.7% vs. 75.2%) or hysterectomy than did women undergoing mammography in 1997. Conversely, more women reported a family history of breast cancer (17.1% vs. 11.8%) or a personal history of a previous breast biopsy or aspiration. The average number of mammograms obtained for each woman in our sample across the 7-year study period was 2.1 (range, 1 to 7). Table. Description of the Sample (151 862 Mammograms) The Figure shows the unadjusted rates of current hormone therapy use by month for all of the women in the sample. Among menopausal women who had received mammography, we estimated that the average proportion reporting the current use of hormone therapy was 41% in 1997. In 1997, hormone use was highest among white women (52.6%) and lowest among African-American women (34.1%), Latina women (33.9%), Chinese women (32.2%), and Filipina women (29.6%). In 1997, hormone use was higher among younger women than older women (48.7% vs. 28.7%; P < 0.001) and among women who had had a hysterectomy compared with women who had not had a hysterectomy (60.0% vs. 36.4%; P < 0.001). Figure. Rates of hormone therapy use among postmenopausal women, 1997 to 2003 HERS WHI The adjusted multivariate model estimates that before the publication of HERS, the use of hormone thera

Housing Instability and Food Insecurity as Barriers to Health Care Among Low-Income Americans

BACKGROUND: Homelessness and hunger are associated with poor health outcomes. Housing instability and food insecurity describe less severe problems securing housing and food.OBJECTIVE: To determine the association between housing instability and food insecurity and access to ambulatory health care and rates of acute health care utilization.DESIGN: Secondary data analysis of the National Survey of American Families.PARTICIPANTS: 16,651 low-income adults.MEASUREMENT: Self-reported measures of past-year access: (1) not having a usual source of care, (2) postponing needed medical care, or (3) postponing medication; and past-year utilization: (1) not having an ambulatory care visit, (2) having emergency department (ED) visits, or (3) inpatient hospitalization.RESULTS: 23.6% of subjects had housing instability and 42.7% had food insecurity. In multivariate logistic regression models, housing instability was independently associated with not having a usual source of care (adjusted odds ratio [AOR] 1.31, 95% confidence interval [CI] 1.08 to 1.59), postponing needed medical care (AOR 1.84, 95% CI 1.46 to 2.31) and postponing medications (AOR 2.16, 95% CI 1.70 to 2.74), increased ED use (AOR: 1.43, 95% CI 1.20 to 1.70), and hospitalizations (AOR 1.30, 95% CI 1.01 to 1.67). Food insecurity was independently associated with postponing needed medical care (AOR 1.74, 95% CI 1.38 to 2.21) and postponing medications (AOR 2.15, 95% CI 1.62 to 2.85), increased ED use (AOR 1.39, 95% CI 1.17 to 1.66), and hospitalizations (AOR 1.42, 95% CI 1.09 to 1.85).CONCLUSIONS: Housing instability and food insecurity are associated with poor access to ambulatory care and high rates of acute care. These competing life demands may lead to delays in seeking care and predispose to acute care.

Trends in Prescription Drug Use Among Adults in the United States From 1999-2012

IMPORTANCE It is important to document patterns of prescription drug use to inform both clinical practice and research. OBJECTIVE To evaluate trends in prescription drug use among adults living in the United States. DESIGN, SETTING, AND PARTICIPANTS Temporal trends in prescription drug use were evaluated using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Participants included 37,959 noninstitutionalized US adults, aged 20 years and older. Seven NHANES cycles were included (1999-2000 to 2011-2012), and the sample size per cycle ranged from 4861 to 6212. EXPOSURES Calendar year, as represented by continuous NHANES cycle. MAIN OUTCOMES AND MEASURES Within each NHANES cycle, use of prescription drugs in the prior 30 days was assessed overall and by drug class. Temporal trends across cycles were evaluated. Analyses were weighted to represent the US adult population. RESULTS Results indicate an increase in overall use of prescription drugs among US adults between 1999-2000 and 2011-2012 with an estimated 51% of US adults reporting use of any prescription drugs in 1999-2000 and an estimated 59% reporting use of any prescription drugs in 2011-2012 (difference, 8% [95% CI, 3.8%-12%]; P for trend <.001). The prevalence of polypharmacy (use of ≥5 prescription drugs) increased from an estimated 8.2% in 1999-2000 to 15% in 2011-2012 (difference, 6.6% [95% CI, 4.4%-8.2%]; P for trend <.001). These trends remained statistically significant with age adjustment. Among the 18 drug classes used by more than 2.5% of the population at any point over the study period, the prevalence of use increased in 11 drug classes including antihyperlipidemic agents, antidepressants, prescription proton-pump inhibitors, and muscle relaxants. CONCLUSIONS AND RELEVANCE In this nationally representative survey, significant increases in overall prescription drug use and polypharmacy were observed. These increases persisted after accounting for changes in the age distribution of the population. The prevalence of prescription drug use increased in the majority of, but not all, drug classes.

Potential Savings from Substituting Generic Drugs for Brand-Name Drugs: Medical Expenditure Panel Survey, 1997–2000

Context The cost of prescription drugs is of great concern to Americans. The substitution of cheaper generic drugs for more expensive brand-name drugs might reduce prescription drug costs. Contribution Using data from the 19972000 Medical Expenditure Panel Survey Household Component, the researchers estimated that substitution of a generic for a brand-name drug whenever available would have saved approximately

Body Mass Index, Provider Advice, and Target Gestational Weight Gain

46 per year for adults younger than 65 years of age and approximately

The Association of Race, Socioeconomic Status, and Health Insurance Status With the Prevalence of Overweight Among Children and Adolescents

78 per year for older adults. Implication While the per capita savings of generic substitution appear modest, national savings would be substantial: about

Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain

6 billion for adults younger than age 65 years and about

Changes in the Health Status of Women During and After Pregnancy

3 billion for older adults. The Editors Prescription drug spending is increasing at a rate of over 10% per year and currently represents 11% of all health care expenditures (1). In 2001, expenditures for prescription drugs in the United States were