Melissa McNeil

An empirical investigation of the factor structure of the AUDIT

This study investigated the Alcohol Use Disorders Identification Tests (AUDIT) factor structure and psychometric properties. The factor structure was derived from a sample of 7,035 men and women primary care patients. A principal components analysis identified 2 factors in the AUDIT data and was supported in a confirmatory factor analysis (CFA). The 2 factors were Dependence/Consequences and Alcohol Consumption. The CFA also provided support for a 3-factor model whose factors (Alcohol Consumption, Alcohol Dependence, and Related Consequences) matched those proposed by the AUDITs developers. Psychometric indexes were determined by use of the baseline and 12-month follow-up data of 301 men and women who entered a clinical trial. The results showed that the 2 factors had good reliability. Validity tests supported the interpretation of what the 2 factors measure, its implications for relationships to other variables, and the comparability of the 2- and 3-factor models.

Understanding Turning Points in Intimate Partner Violence: Factors and Circumstances Leading Women Victims Toward Change

OBJECTIVE When counseling women experiencing intimate partner violence (IPV), healthcare providers can benefit from understanding the factors contributing to a womens motivation to change her situation. We wished to examine the various factors and situations associated with turning points and change seeking in the IPV situation. METHODS We performed qualitative analysis on data from 7 focus groups and 20 individual interviews with women (61 participants) with past and/or current histories of IPV. RESULTS The turning points women identified fell into 5 major themes: (1) protecting others from the abuse/abuser; (2) increased severity/humiliation with abuse; (3) increased awareness of options/access to support and resources; (4) fatigue/recognition that the abuser was not going to change; and (5) partner betrayal/infidelity. CONCLUSIONS Women experiencing IPV can identify specific factors and events constituting turning points or catalyst to change in their IPV situation. These turning points are dramatic shifts in beliefs and perceptions of themselves, their partners, and/or their situation that alter the womens willingness to tolerate the situation and motivate them to consider change. When counseling women experiencing IPV, health providers can incorporate understanding of turning points to motivate women to move forward in their process of changing their IPV situation.

A computer-assisted medical diagnostic consultation service. Implementation and prospective evaluation of a prototype.

STUDY OBJECTIVE To evaluate the accuracy of a computer-aided consultation service using academic general internists and the Quick Medical Reference (QMR) diagnostic program: and to study the impact of the consultation on the diagnostic behavior of physicians caring for patients. DESIGN Prospective study of the diagnostic accuracy of computer-aided consultation in 31 cases, as well as a prospective study of ward team diagnoses and opinions before and after consultation. SETTING General medicine wards of two tertiary care centers. PARTICIPANTS Thirty-one patients identified as posing a diagnostic challenge and meeting eligibility criteria, as well as the housestaff caring for these patients. MEASUREMENTS AND MAIN RESULTS After 6 months follow-up, diagnoses were established in 20 of 31 cases. The diagnostic sensitivity of the computer-assisted diagnoses, 85% (95% CI, 56% to 97%), was similar to that of the consult service physicians, 80% (95% CI, 55% to 94%), but better than that of the ward teams, 60% (95% CI, 33% to 81%; P = 0.03 using the binomial test). The consultation influenced the postconsultation differential diagnoses of the ward teams in 26 of the 31 cases (95% CI, 92% to 95%). House officers rated the consultation service as being educationally helpful in 25 of the 31 cases (95% CI, 62% to 94%). CONCLUSIONS Computer-aided diagnostic consultation, when provided by physicians familiar with the limitations of the system and capable of overriding inappropriate suggestions, was both accurate and educationally helpful in most cases. The system provided reasonable diagnostic suggestions not previously considered by the ward teams and these suggestions were valued sufficiently to cause alteration of the original differential diagnoses.

Trends in women's health services by type of physician seen: data from the 1985 and 1997-98 NAMCS.

As managed care enrollment has increased, controversy has arisen about the role of internists (IM), family physicians (FP), and obstetrician/gynecologists (ob/gyns) in the provision of womens health care. Efforts to improve training in womens health needs have also increased. Yet it is unclear how these trends have affected practice. We used the National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based medical visits, to examine by physician specialty a) trends in the proportion of visits for womens health care and b) the content of nonillness care. Between 1985 and 1997-98, market share of reproductive health services increased for IMs (e.g., from 3.7% to 10.5% of contraceptive visits, p <.05) and decreased for FPs (from 30.5% to 20.5% for contraceptive visits, p <.05). Ob/Gyns increased their share of womens health care visits, with reproductive health visits increasing from 56.2% to 65.9% (p <.0001). The trend in hormone replacement therapy visits differed, with nonsignificant gains in market share for IMs and decreases for ob/gyns. Nonillness care (1997-98 data only) differed predictably by specialty, with IMs and FPs more often providing cholesterol screening while ob/gyns more often provided reproductive health services. Compared with IMs and FPs, ob/gyns were more likely to counsel women on reproductive health topics and equally likely to counsel on general health topics, but additional time spent in counseling was lower. Specialty differences in the provision of womens health services continue, though the scope of care provided by IMs has broadened. Still, women are unlikely to obtain a full range of preventive services in a single nonillness visit. Ensuring adequate coordination among physicians providing primary care to women continues to be a critical concern.

Comparison of Consumption Effects of Brief Interventions for Hazardous Drinking Elderly

We sought to determine if Brief Interventions [BIs, Motivational Enhancement (ME), and Brief Advice (BA)] reduced alcohol consumption among hazardous alcohol drinking elderly (65 years or older) and whether the elderly responded similarly to younger populations. In 12 primary care offices from 10 1995 to 12 1997, we screened 13,438 patients of whom 2702 were elderly (180 were hazardous drinkers). Forty-five elderly enrollees were randomized to receive ME (n = 18), BA (n = 12), and Standard Care (SC, n = 12). At baseline, the elderly drank more alcohol and abstained fewer days than the younger cohort (p<0.05). During the year, the elderly in ME, BA, and SC intervention arms increased the number of days abstained, decreased the number of drinks per day, and reduced the number of total days per month drinking. There were trends toward decreases in the alcohol consumption measures in the ME and BA treatment arms compared to SC. The elderlys response to all interventions was similar to that of the younger cohort. This study suggests that hazardous alcohol consumption in the elderly is common and that BIs reduce alcohol consumption in the elderly similar to younger populations.

Patient satisfaction in women's clinics versus traditional primary care clinics in the Veterans Administration.

AbstractOBJECTIVE: To compare patient satisfaction in women’s clinics (WCs) versus traditional primary care clinics (TCs). DESIGN: Anonymous, cross-sectional mailed survey. SETTING: Eight Department of Veterans Affairs (VA) medical centers in 3 states. PATIENTS: A random sample of women stratified by site and enrollment in WC versus TC (total response rate = 61%). MEASURES: Overall satisfaction and gender-specific satisfaction as measured by the Primary Care Satisfaction Survey for Women (PCSSW). ANALYSIS: We dichotomized the satisfaction scores (excellent versus all other), and compared excellent satisfaction in WCs versus TCs using logistic regression, controlling for demographics, health status, health care use, and location. RESULTS: Women enrolled in WCs were more likely than those in TCs to report excellent overall satisfaction (odds ratio, 1.42; 95% confidence interval, 1.00 to 2.02; P=.05). Multivariate models demonstrated that receipt of care in WCs was a significant positive predictor for all 5 satisfaction domains (i.e., getting care, privacy and comfort, communication, complete care, and follow-up care) with the gender-specific satisfaction instrument (PCSSW). CONCLUSIONS: This study is the first to consistently show higher satisfaction in WCs versus TCs despite age and race differences and comparable health status. Since these WCs show better quality in terms of satisfaction, other quality indicators should be evaluated. If WCs reduce fragmentation and improve health care delivery, the model will be applicable in VA and non-VA outpatient settings.

Contraceptive care in the VA health care system.

BACKGROUND Little is known about contraceptive care within the Veterans Affairs (VA) health care system. This study was conducted to assess the prevalence of documented contraception by race/ethnicity within the VA and to examine the association between receiving primary care in womens health clinics (WHCs) and having a documented contraceptive method. STUDY DESIGN We examined national VA administrative and pharmacy data for 103,950 female veterans aged 18-45 years who made at least one primary care clinic visit in 2008. Multivariable regression models were used to examine the associations between race/ethnicity and receipt of care in a WHC with having a method of contraception while controlling for confounders. RESULTS Only 22% of women veterans had a documented method of contraception during 2008. After adjusting for potential confounders, Hispanic and African-American women were significantly less likely to have a method compared to whites [odds ratio (OR): 0.82; 95% confidence interval (CI): 0.76-0.88 and OR: 0.85; 95% CI: 0.81-0.89, respectively]. Women who went to WHCs were significantly more likely to have a method of contraception compared to women who went to traditional primary care clinics (OR: 2.05; 95% CI: 1.97-2.14). CONCLUSIONS Overall contraceptive prevalence in the VA is low, but receiving care in a WHC is associated with a significantly higher likelihood of having a contraceptive method.

Professionalism in Residency Training: Is There a Generation Gap?

Background: Teaching and evaluating professionalism is part of the Accreditation Council for Graduate Medical Educations training requirements for postgraduate education. Defining what constitutes professional behavior is the first step in this endeavor. Difficulty in teaching and evaluating professionalism may stem from generational differences between teachers and trainees in their definition of professional behavior. Purpose: We sought to explore the magnitude of generational differences by asking faculty and residents to evaluate behaviors along a continuum of professionalism. Methods: A questionnaire composed of 16 vignettes describing unprofessional behaviors was distributed to a sample of internal medicine trainees and faculty. For each specific behavior described, participants were asked to rate the severity of the infraction on a 4-point scale. Results: Within each group, responses were distributed across severity categories for most vignettes. There were no significant differences in the responses of trainees versus faculty for any of the vignettes except two. Conclusion: There is little consensus for determining the severity of unprofessional behaviors among faculty and trainees at one urban university training program. However, this lack of consensus does not appear to have a generational basis. Attributing difficulties in teaching and assessing professionalism cannot be blamed on differences between the generations.

Once Is Not Enough: Effective Strategies for Medical Student Education on Intimate Partner Violence

Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort regarding IPV; the optimal training frequency and format is unknown. We assessed how various types and amounts of IPV education for medical students affected knowledge and attitudes. Medical students at a large, urban university completed a survey concerning IPV-related knowledge and attitudes and participation in didactic and experiential IPV training activities. This was a one-time assessment. Of 586 students, 279 (48%) completed the survey. IPV-related knowledge increased with increased number of training activities. Knowledge and attitude scores were higher (p < .001) for respondents with experiential, versus only didactic, activities.

Health services research in the privacy age

AbstractBACKGROUND: Strengthened regulations concerning privacy of health information are affecting large-scale health outcomes research. OBJECTIVE: To create a data collection system that would facilitate outcomes research, avoid selection bias, and fulfill obligations to protect privacy. DESIGN: We created a web-based system that uses touch-screen computer technology for longitudinal collection of data. The system provides access to information in deidentified form, enables it to be linked to health services and outcomes data, and allows patients to join a research registry project (RRP) and be placed on a prospective subject list (PSL). PARTICIPANTS, MEASUREMENTS, AND RESULTS: Pilot testing in 86 consecutive patients who were seen at a large, urban, university-based general medicine practice and had a mean age of 50 years showed that 81 patients had no difficulty, 5 had some difficulty, and none had considerable difficulty using the computer technology to complete a health survey. No patients refused to complete the survey and all patients completed the entire survey. Forty-seven (55%) joined the RRP and 42 of these 47 (89%) joined the PSL. RRP participants were less likely than RRP nonparticipants to be divorced or widowed (P=.03) and less likely to have hypertension (P=.03) but had no other significant differences in sociodemographic or clinical characteristics. PSL participants did not differ from PSL nonparticipants. CONCLUSIONS: The new system ensures privacy and appears to facilitate research recruitment and avoid selection bias.