Lisa K. Sharp

Specialty board certification and clinical outcomes: the missing link.

Purpose Specialty board certification status is often used as a standard of excellence, but no systematic review has examined the link between certification and clinical outcomes. The authors evaluated published studies tracking clinical outcomes and certification status. Method Data sources consisted of studies cited between 1966 and July 1999 in OVID—Medline, psychological abstracts (PsycLit), and the Educational Research Information Clearinghouse (ERIC). Screening criteria included: only U.S. patients and physicians used as subjects; verified specialty board certification status by an American Board of Medical Specialties (ABMS) member board using the ABMS database or derivative sources; described selection criteria for patients and physicians; selected nationally recognized standards of care for outcomes; and nested patient data by individual physician. The computerized searches that were conducted in 1999 identified 1,204 papers; one author and a research assistant selected 237 papers based on subject relevance, and reduced the list to 56 based on study quality. The authors independently applied inclusion and exclusion criteria to identify 13 of the 56 papers containing 33 separable relevant findings. Results Of the 33 findings, 16 demonstrated a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes for certified physicians, and 14 showed no association. Three negative findings and one finding of no association were identified in two papers with insufficient case-mix adjustments in the analyses. Meta-analytic statistics were not feasible due to variability in outcome measures across studies. Conclusions Few published studies (5%) used research methods appropriate for the research question, and among the screened studies more than half support an association between board certification status and positive clinical outcomes.

Comparison of perspectives on prostate cancer: analyses of survey data.

OBJECTIVESnProstate cancer will account for 334,500 new cases and 41,800 deaths among men in the United States in 1997. Patients and physicians are faced with many concerns related to benefits and side effects of alternative treatments, educational needs, emotional support, and costs of care. Support groups for prostate cancer patients have been established to help satisfy needs in these areas. Therefore, we addressed three issues among patients who belong to a prostate cancer support group as well as among a second group of urologists who treat prostate cancer: (1) goals for prostate cancer treatment, (2) information that is given and recalled about the disease and therapy, and (3) extent to which educational and emotional needs are being met.nnnMETHODSnRandom telephone surveys were made of 1000 men with prostate cancer who belong to the prostate cancer support group US TOO, the largest prostate cancer support group in the United States, and 200 urologists who provide care to men with prostate cancer. The surveys were conducted by the Louis Harris & Associates survey research firm.nnnRESULTSnAbout four fifths of patients and urologists prefer aggressive therapy for prostate cancer. Patient goals with therapy included preservation of quality of life (45%), extension of life (29%), and delaying disease progression (13%), whereas physicians overwhelmingly focused on treatment efficacy (86%), with side effects (43%) and costs (29%) being secondary considerations. Urologists and patients differed markedly in the description of the patient-physician discussion. Whereas almost 100% of physicians stated that they always discussed important considerations such as options for no therapy, life expectancy with and without therapy, patient preferences, costs, and changes in sexual function, only about one fifth of patients recalled similar discussions. Patients and physicians both believed that physicians were an excellent source of educational support, but often did not report provision of emotional support. Although support groups were viewed as good providers of educational and emotional support by 85% to 90% of patients, physicians appeared to underestimate the benefit of support groups in these areas.nnnCONCLUSIONSnPatients who belong to US TOO have many emotional and educational needs that are not currently being fulfilled by physicians. Although the goals of therapy are viewed similarly by patients and physicians, much of the important cancer- and treatment-related information that physicians report they have provided is not recalled by patients. Policy makers would be wise to devise systematic strategies such as shared decision-making tools and better linkages to support groups to ensure that patients needs are being met.

Increased use of selective serotonin reuptake inhibitors in patients admitted with gastrointestinal haemorrhage: a multicentre retrospective analysis

Background Selective serotonin reuptake inhibitors (SSRIs) can adversely affect platelet function and impair haemostasis. Various bleeding complications have been reported in persons taking SSRIs including an increased risk of gastrointestinal haemorrhage (GIH).

Psychosocial Correlates of Symptoms in Functional Dyspepsia

BACKGROUND & AIMSnPsychosocial factors may influence both symptom generation and reporting in functional dyspepsia. We determined the presence and severity of these factors as well as their relationship to dyspeptic symptoms in patients with functional dyspepsia and healthy subjects.nnnMETHODSnA total of 151 consecutive patients with functional dyspepsia referred chiefly from primary care clinics and 90 healthy subjects rated 15 dyspeptic symptoms. Participants completed the Medical Outcomes Study SF-36 and Symptom Checklist-90-revised.nnnRESULTSnFunctional dyspepsia patients reported significantly higher symptom scores, poorer quality of life, and greater psychiatric distress than healthy subjects. For both patients and healthy subjects, increasing symptom scores were associated with significant decreases in the Physical but not the Mental Components Summary of the Medical Outcomes Study SF-36. Although functional dyspepsia patients showed significantly greater psychiatric distress than healthy subjects, symptoms were correlated only modestly with scores on the Symptom Checklist-90-revised. A number of symptoms showed significant but modest correlations ( r s < .30) with the somatization scale with chest burning correlating most strongly ( r s = .48). Chest burning also was correlated significantly with depression, anxiety, and phobic anxiety. Functional dyspepsia patients at a secondary level of care have greater symptom severity, poorer quality of life, and greater psychiatric distress than healthy subjects. Increasing symptom severity is associated with poorer quality of life primarily in the areas of physical and social functioning. With the exception of chest burning, symptoms are not correlated highly with psychiatric distress.nnnCONCLUSIONSnThese data suggest that although functional dyspepsia patients experience increased psychiatric distress, symptom severity and psychiatric distress are not associated strongly.

Quality of life in metastatic prostate cancer among men of lower socioeconomic status : Feasibility and criterion related validity of 3 measures

PURPOSEnIdentification of metastatic disease progression is often difficult but important. Previous studies of quality of life in metastatic disease have been limited by the small number of respondents who were not white or of lower socioeconomic status. Quality of life assessment is generally done using self-administration techniques but this method is of limited usefulness for patients of low socioeconomic status, many of whom have limited reading abilities. We evaluated the feasibility and validity of interviewer administration of 3 quality of life instruments for patients of low socioeconomic status with metastatic prostate cancer.nnnMATERIALS AND METHODSnWe used instruments previously validated with self-administration methodology, including the European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire-30, Functional Assessment of Cancer Therapy-General Scale and Quality of Life Index. Subjects were men with metastatic prostate cancer with stable (78) or progressive (32) disease at 4 Veterans Affairs medical centers and 1 other site. Of the patients 94% were Veterans Affairs patients and more than 60% were black.nnnRESULTSnEach quality of life instrument required less than 10 minutes of interviewer administration and was able to discriminate between patients with stable versus progressive disease on several health status domains.nnnCONCLUSIONSnThese data support the feasibility and validity of quality of life measurement in patients of low socioeconomic status with metastatic prostate cancer. Consideration should be given to adding quality of life instruments to patient encounter even among low socioeconomic status, low literacy populations.

Impact of Vaginal Antifungal Products on Utilization of Health Care Services: Evidence from Physician Visits

Background: Recently many medications fonnerly available only by prescription have been approved for over-the-counter (OTC) status. In 1990, clotrimazole became the first available OTC drug to treat candidal vaginitis. Subsequently several other prescription antifungal medications have also been available in OTC products. One proposed benefit of these switches from prescription to OTC status is a reduction in the utilization of health care services. Metbods: Using National Ambulatory Medical Care Survey data, the average numbers of annual visits for vaginal complaints were estimated for 1985, 1990, and 1994. These years were chosen because they represented periods before, close to, and after the approval of the OTC antifungal preparations. The estimated visits for each year were compared using a chi-square analysis with a sample weight correction. Results: There was a 15% decline in the number of vaginitis visits from 1990 to 1994 that potentially could be attributed to the availability of the OTC antifungal preparations. The decrease in physician visits results in approximately

Quality of life in low-income patients with metastatic prostate cancer: Divergent and convergent validity of three instruments

45 million in direct cost savings and another

Continuing Medical Education and Attitudes of Health Care Providers toward Treating Diabetes.

18.75 million in indirect savings by reducing time lost from work. Conclusions: It appears that the availability of OTC anticandidal fungal preparations reduces the number of physician visits for vaginitis, resulting in cost savings.

Spouse ratings of quality of life in patients with metastatic prostate cancer of lower socioeconomic status: an assessment of feasibility, reliability, and validity.

Few studies have evaluated Quality Of Life (QOL) among low-income patients with cancer. Information is needed about the feasibility and psychometric characteristics of QOL instruments in these populations. The purpose of this study was to examine the convergent and discriminant relationships between scales of three QOL instruments: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC), Functional Assessment of Cancer Therapy – General (FACT), and Quality of Life Index (QLI). Participants included 110 men with metastatic prostate cancer of whom 94% were low income and 62% were African-American. Interviewers administered the questionnaires. Cronbach α internal consistency reliabilities were 0.57 to 0.90 for the EORTC, 0.65 to 0.86 for the FACT, and 0.63 for the QLI. Convergent validity was supported for the EORTC and FACT scales measuring emotional, physical, and role/functional dimensions (r = 0.54 to 0.72), but not on scales measuring social function (r = 0.12). Divergent validity was supported between dissimilar scales (r = 0.14 to 0.38). Analysis with receiver operating characteristics curves provided empirical support for the EORTC and FACT as multidimensional measures. These findings suggest that, even in busy clinical settings with low literacy patients, interviewer-administered EORTC and FACT QOL instruments can provide valid and reliable information.

Coping with asthma in immigrant Hispanic families: a focus group study

Introduction: Continuing medical education (CME) is an important tool in improving the care provided to patients with type 2 diabetes. Health behavior models suggest that attitudes are important factors in changing behavior. The aim of this study was to evaluate the immediate and 3‐month impact of a diabetes educational program on the attitudes of health care providers toward treating diabetes. Methods: Health care providers (including physicians, physician assistants, nurse practitioners, and nurses were attending a 7‐hour CME program on type 2 diabetes in one of eight states in the United States between May and September 1999. Attitudes were assessed using the Diabetes Attitudes Scale‐3 (DAS‐3), which was given immediately before the program, immediately after the program, and 3 months after the program. A convenience sample of 315 providers completed pre‐ and post‐CME measurement. Three‐month follow‐ups were completed by 146 (46%) of the 315 providers. Results: Following the CME program, physicians had significantly more positive attitudes on two of five DAS subscales. At 3 months, the change persisted on one subscale that measured beliefs related to type 2 being a serious disease. Allied professionals had significantly more positive attitudes on five subscales following the program; however, the change did not persist at 3 months. Discussion: This CME program resulted in different patterns of attitude change for physicians as compared to allied professionals. In both groups, more positive attitudes toward treating diabetes were detected following the CME; however, the change tended to diminish by 3 months after the program. These findings mimic much of the research on knowledge retention following CME.