Lawrence L. Kupper

Communication, compliance, and concordance between physicians and patients with prescribed medications.

Forty-six practicing physicians and 357 patients with diabetes mellitus or congestive heart failure were the subjects for this study, which focuses on the impact of medication regimen and doctor-patient communication in affecting patient medication-taking behavior and physician awareness of these behaviors. Four types of medication errors were defined: omissions, commissions, scheduling misconceptions and scheduling non-compliance. The average error rates were 19 per cent, 19 per cent, 17 per cent and 3 per cent, respectively. The combined average error was 58 per cent; scheduline non-compliance on the part of the patient was a minor component. Specific aspects of the medication regimen were associated with increased errors: (1) the more drugs involved between the doctor-patient pair, the greater the errors of omission and commission; and (2) the greater the complexity of the scheduling, the greater the errors of commission and scheduling misconceptions. If the patient did not know the function of all his drugs, errors of commission and scheduling misconception increased. Neither characteristics of patients nor the severity of disease were influential in determining the extent of medication errors. For patients with congestive heart failure, good communication of instructions and information from physician to patient was associated with low levels of all types of errors.

Partner Violence Among Adolescents in Opposite-Sex Romantic Relationships: Findings From the National Longitudinal Study of Adolescent Health

OBJECTIVES This report examines (1) the prevalence of psychological and minor physical violence victimization in a nationally representative sample of adolescents and (2) associations between sociodemographic factors and victimization. METHODS Analyses are based on 7500 adolescents who reported exclusively heterosexual romantic relationships in the National Longitudinal Study of Adolescent Health. Items from the Conflict Tactics Scale were used to measure victimization. Associations between victimization patterns and sociodemographic characteristics were assessed with polytomous logistic regression. RESULTS One third of adolescents reported some type of victimization, and 12% reported physical violence victimization. Although most sociodemographic characteristics were significantly associated with victimization, patterns varied by sex and type of victimization. CONCLUSIONS Psychological and minor physical violence victimization is common in opposite-sex romantic relationships during adolescence. The sex-specific associations between sociodemographic characteristics and patterns of partner violence victimization underscore the importance of pursuing longitudinal, theory-driven investigations of the characteristics and developmental histories of both partners in a couple to advance understanding of this public health problem.

Meta-Analyses of the Relation between Silicone Breast Implants and the Risk of Connective-Tissue Diseases

BACKGROUND The postulated relation between silicone breast implants and the risk of connective-tissue and autoimmune diseases has generated intense medical and legal interest during the past decade. The salience of the issue persists, despite the fact that a great deal of research has been conducted on this subject. To provide a stronger quantitative basis for addressing the postulated relation, we applied several techniques of meta-analysis that combine, compare, and summarize the results of existing relevant studies. METHODS We searched data bases and reviewed citations in relevant articles to identify studies that met prestated inclusion criteria. Nine cohort studies, nine case-control studies, and two cross-sectional studies were included in our meta-analyses. We conducted meta-analyses of the results of these studies, both with and without adjustment for confounding factors, and a separate analysis restricted to studies of silicone-gel-filled breast implants. Finally, we estimated the annual number of new cases of connective-tissue disease that could be attributed to breast implants. RESULTS There was no evidence that breast implants were associated with a significant increase in the summary adjusted relative risk of individual connective-tissue diseases (rheumatoid arthritis, 1.04 [95 percent confidence interval, 0.72 to 1.51]; systemic lupus erythematosus, 0.65 [95 percent confidence interval, 0.35 to 1.23]; scleroderma or systemic sclerosis, 1.01 [95 percent confidence interval, 0.59 to 1.73]; and Sjögrens syndrome, 1.42 [95 percent confidence interval, 0.65 to 3.11]); all definite connective-tissue diseases combined (0.80; 95 percent confidence interval, 0.62 to 1.04); or other autoimmune or rheumatic conditions (0.96; 95 percent confidence interval, 0.74 to 1.25). Nor was there evidence of significantly increased risk in the unadjusted analyses or in the analysis restricted to silicone-gel-filled implants. CONCLUSIONS On the basis of our meta-analyses, there was no evidence of an association between breast implants in general, or silicone-gel-filled breast implants specifically, and any of the individual connective-tissue diseases, all definite connective-tissue diseases combined, or other autoimmune or rheumatic conditions. From a public health perspective, breast implants appear to have a minimal effect on the number of women in whom connective-tissue diseases develop, and the elimination of implants would not be likely to reduce the incidence of connective-tissue diseases.

GRADE guidelines: 13. Preparing Summary of Findings tables and evidence profiles—continuous outcomes

Presenting continuous outcomes in Summary of Findings tables presents particular challenges to interpretation. When each study uses the same outcome measure, and the units of that measure are intuitively interpretable (e.g., duration of hospitalization, duration of symptoms), presenting differences in means is usually desirable. When the natural units of the outcome measure are not easily interpretable, choosing a threshold to create a binary outcome and presenting relative and absolute effects become a more attractive alternative. When studies use different measures of the same construct, calculating summary measures requires converting to the same units of measurement for each study. The longest standing and most widely used approach is to divide the difference in means in each study by its standard deviation and present pooled results in standard deviation units (standardized mean difference). Disadvantages of this approach include vulnerability to varying degrees of heterogeneity in the underlying populations and difficulties in interpretation. Alternatives include presenting results in the units of the most popular or interpretable measure, converting to dichotomous measures and presenting relative and absolute effects, presenting the ratio of the means of intervention and control groups, and presenting the results in minimally important difference units. We outline the merits and limitations of each alternative and provide guidance for meta-analysts and guideline developers.

The use of a correlated binomial model for the analysis of certain toxicological experiments.

In certain toxicological experiments with laboratory animals, the outcome of interest is the occurrence of dead or malformed fetuses in a litter. Previous investigations have shown that the simple one-parameter binomial and Poisson models generally provide poor fits to this type of binary data. In this paper, a type of correlated binomial model is proposed for use in this situation. First, the model is described in detail and is compared to a beta-binomial model proposed by Williams (1975). These two-parameter models are then contrasted for goodness of fit to some real-life data. Finally, numerical examples are given in which likelihood ratio tests based on these models are employed to assess the significance of treatment-control differences.

Statistical age-period-cohort analysis: A review and critique

Descriptive and statistical age-period-cohort (APC) analysis methods have received considerable attention in the literature. The statistical modeling of APC data often involves the popular multiple classification model, a model containing the effects of age groups (rows), periods of observation (columns), and birth cohorts (diagonals of the age-by-period table). The identifiability problem inherent to this model is discussed, and its adverse effects on the results of APC modeling exercises are illustrated numerically. Potential problems attendant with the use of two-factor models are described, and other possible modeling approaches currently in use are discussed. Interpretational limitations due to certain innate characteristics of typical APC data sets are also detailed. Given all the documented potential sources for error, the current state-of-the-art regarding the statistical modeling of APC data should be considered to be at an early stage of development.

Patterns of intimate partner violence victimization from adolescence to young adulthood in a nationally representative sample.

PURPOSE To determine the prevalence of patterns of intimate partner violence (IPV) victimization from adolescence to young adulthood, and document associations with selected sociodemographic and experiential factors. METHODS We used prospective data from the National Longitudinal Study of Adolescent Health to group 4134 respondents reporting only opposite-sex romantic or sexual relationships in adolescence and young adulthood into four victimization patterns: no IPV victimization, adolescent-limited IPV victimization, young adult onset IPV victimization, and adolescent-young adult persistent IPV victimization. RESULTS Forty percent of respondents reported physical or sexual victimization by young adulthood. Eight percent experienced IPV only in adolescence, 25% only in young adulthood, and 7% showed persistent victimization. Female sex, Hispanic and non-Hispanic black race/ethnicity, an atypical family structure (something other than two biologic parents, step-family, single parent), more romantic partners, experiencing childhood abuse, and early sexual debut (before age 16) were each associated with one or more patterns of victimization versus none. Number of romantic partners and early sexual debut were the most consistent predictors of violence, its timing of onset, and whether victimization persisted across developmental periods. These associations did not vary by biological sex. CONCLUSIONS Substantial numbers of young adults have experienced physical or sexual IPV victimization. More research is needed to understand the developmental and experiential mechanisms underlying timing of onset of victimization, whether victimization persists across time and relationships, and whether etiology and temporal patterns vary by type of violence. These additional distinctions would inform the timing, content, and targeting of violence prevention efforts.

Medication use and misuse: Physician-patient discrepancies☆

INTRODUCTION DURING recent years a substantial literature has developed on the subjects of physician prescribing patterns [IA], medication use by various population groups [5-71, and patient compliance with taking prescribed medications [S-15]. Physician-patient communication has been reviewed under the assumption that compliant behavior can only occur as the result of appropriate communication [I 1, 12, 151. Methodological studies have been done to compare the accuracy of various methods for measuring patient compliance [13, 14, 16-201. The present paper introduces a quantitative method for analyzing data on medication use and misuse among patients with either adult onset diabetes mellitus or congestive heart failure. This study was undertaken within the context of a more comprehensive research effort. Representatives from two organizations, the American Academy of Family Physicians and the Department of Epidemiology at the University of North Carolina, undertook the development of a research design, which was both original in concept and feasible to implement, as a method of assessment of primary medical care [21]. Two of the areas for assessment are physician-patient communication and patient compliance. Communication represents the extent to which the physician is successful in transmitting information and instructions to the patient, while compliance measures the extent to which the patient’s behavior is modified by these instructions. Medicationtaking behavior is an important indicator of both communication and compliance. Study of medication use has the potential for introducing another concept into the evaluation scheme; that is, the recognition that communication is a two-way phenomenon. Not only should the patient take drugs as recommended by the

Violence and substance use among North Carolina pregnant women.

OBJECTIVES Prenatal patients were studied to examine the proportion of women who had been violence victims, womens patterns of substance use (cigarettes, alcohol, and illegal drugs) before and during pregnancy, and relationships between violence and substance use. METHODS More than 2000 prenatal patients in North Carolina were screened for violence and substance use. Relationships between violence and patterns of substance use before and during pregnancy were examined, as well as womens continuation of substance use during pregnancy as a function of violence and sociodemographic factors. RESULTS Twenty-six percent of the women had been violence victims during their lives. Before pregnancy, 62% of the women had used one or more substances; during pregnancy, 31% had used one or more substances. Both before and during pregnancy, violence victims were significantly more likely to use multiple substances than nonvictims. Continuation of substance use during pregnancy was significantly more likely among violence victims than nonvictims. CONCLUSIONS Care providers should screen women for violence as well as for substance use and should ensure that women are provided with appropriate interventions.

Correlates of Satisfaction and Dissatisfaction with Medical Care: A Community Perspective

The attitude of the public toward physicians and medical services is an issue of current concern and debate. To address this problem, an instrument was developed using Thurstone scaling methods in conjunction with a Likert format and a modified scoring technique. Following pretesting of the instrument among both patient and population samples, a survey was conducted among the residents of a probability sample of households in a city of 200,000 people. The attitude questionnaire was completed by 1,713 adults in 1,112 households. Overall, attitudes were favorable toward the professional competency and the personal qualities of physicians. Accessibility, including costs and convenience, were less highly regarded. Men were less satisfied than women and blacks less satisfied than whites. Particularly negative attitudes were expressed toward the personal qualities of physicians by young blacks, whereas among blacks over 60 the negative effect was toward costs and convenience. Having a regular physician and long attendance with that physician were correlated with positive attitudes. The most negative sentiment was expressed by women without a regular source of care. Medical services are being sought and obtained by a large segment of society, but problems of costs and acceptability for the elderly, low social class persons, members of large families, and for blacks still remain.