Paul D. Cleary

Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores.

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

RACIAL DISPARITIES IN ACCESS TO RENAL TRANSPLANTATION: Clinically Appropriate or Due to Underuse or Overuse?

BACKGROUND Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care. METHODS We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. RESULTS Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). CONCLUSIONS Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.

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.

Quality collaboratives: lessons from research

Quality improvement collaboratives are increasingly being used in many countries to achieve rapid improvements in health care. However, there is little independent evidence that they are more cost effective than other methods, and little knowledge about how they could be made more effective. A number of systematic evaluations are being performed by researchers in North America, the UK, and Sweden. This paper presents the shared ideas from two meetings of these researchers. The evidence to date is that some collaboratives have stimulated improvements in patient care and organisational performance, but there are significant differences between collaboratives and teams. The researchers agreed on the possible reasons why some were less successful than others, and identified 10 challenges which organisers and teams need to address to achieve improvement. In the absence of more conclusive evidence, these guidelines are likely to be useful for collaborative organisers, teams and their managers and may also contribute to further research into collaboratives and the spread of innovations in health care.

Sex differences in psychological distress among married people

This study examines the influence of various factors, including role responsibilities and satisfaction, on depressive mood. Various competing hypotheses concerning the factors related to depression are explored using data from a study of psychological distress in a representative sample of a Midwestern community (N = 1,026). Although women reported more distress than men, the largest difference among married people was between employed married men and housewives. Employed married women experienced slightly less distress than housewives, but having minor children in the household was especially stressful for these women and counteracted the advantage of employment. The effects of children in the household on distress were strongest among working women with lower family incomes. These data support the hypothesis that the strain of working and doing the majority of the work associated with raising children increases distress among married women.

Social class and psychological distress.

Although a negative relationship between socioeconomic position and psychological distress has consistently been documented in community surveys, we know very little about the determinants of this relationship. The dominant interpretation argues that distress is caused by exposure to stressful life experiences, that lower status people are highly exposed to this sort of experience, and that statistical adjustment for differential exposure can account for the higher rates of distress among lower status people. In this paper, a different interpretation is emphasized. It is shown that differential exposure to stress, while clearly of some importance, accounts for only a minor part of the status/distress relationship, and that a far more central role is played by class differences in responsiveness to stress-that is, by the fact that lower status people are more likely than middle and upper status people to develop symptoms of distress when exposed to problematic life experience. Several plausible interpretations of this differential responsiveness are presented and an analysis strategy developed to evaluate their relative contributions. Results of an empirical evaluation document the importance of social origins and mobility experiences as determinants of differential responsiveness to stress.

Use of Hormone Replacement Therapy by Postmenopausal Women in the United States

Postmenopausal hormone replacement therapy (HRT) is a subject of major interest in the field of womens health. Although HRT has a clear role in the treatment of menopausal symptoms (1), uncertainty exists about its long-term use to prevent disease and prolong life (2). In randomized, controlled trials, HRT has been shown to improve lipid profiles (3) and increase bone density in postmenopausal women (4) but not to decrease the rate of subsequent coronary events in women with established coronary artery disease (5). Observational studies have shown that women who use HRT have a substantially decreased risk for coronary artery disease (6-8), osteoporosis and fractures (8-10), and death (12), but they may also have an increased risk for breast cancer (13). In 1992, guidelines from the American College of Physicians advised that postmenopausal women who have had hysterectomy and women at risk for coronary heart disease are likely to benefit from preventive HRT (14, 15). A more recent decision analysis suggested that almost all postmenopausal women will benefit from HRT, especially those with risk factors for coronary heart disease (16). Despite these recommendations, the benefits and risks of HRT are not fully defined. The decision to use preventive HRT is usually not simple and is probably influenced by the personal characteristics and beliefs of women and their physicians. Previous studies have sought to characterize women who use postmenopausal HRT (17-27), but most of these studies examined local or highly selected cohorts of patients. A recent report on HRT use in a national sample of women in the United States analyzed past and current use together and last collected data in 1992 (26). To our knowledge, only one study has assessed psychological factors that may influence the decision to use HRT (27). Therefore, we examined patterns of HRT use in a national sample of postmenopausal women during 1995 to understand how sociodemographic, clinical, and psychological characteristics were associated with current use of this treatment. We also assessed patterns of use in women at risk for cardiovascular disease who may benefit most from this therapy. Finally, we sought to identify potential selection effects that may be present in observational studies while randomized clinical trials of this therapy are in progress (28). Methods Study Sample In 1995, the John D. and Catherine T. MacArthur Foundation Research Network on Successful Midlife Development conducted a random-digit telephone survey of a probability sample of adults in the United States from 25 to 74 years of age to identify physical, psychological, and social factors that promote good health, psychological well-being, and social responsibility. The study protocol was approved by the human subjects committee of Harvard Medical School. The survey was conducted by using a multistage sampling design. For the first stage, an equal probability sample of telephone numbers, stratified by county in proportion to population, was selected from more than 70 million directory-listed residential numbers. After determining household eligibility, respondents were selected on the basis of age and sex and were offered a stipend for participation. The response rate for this telephone survey was 70%. United States Census data from 1990 for each telephone exchange were used to assess for response bias, and no statistically significant differences were found between eligible households for which the telephone interview was completed and other households by age, education, income, Hispanic ethnicity, other ethnicity, and residence in a Metropolitan Statistical Area. Participants who completed the telephone interview were also mailed a self-administered questionnaire. We limited our cohort to women 50 to 74 years of age; 93% of these women also completed the self-administered questionnaire and were eligible for our sample, yielding an estimated response rate of 65% for the combined telephone survey and questionnaire. Compared with women who responded to the telephone interview only, these women were younger (mean age, 60.1 compared with 62.7 years; P=0.02), more likely to be married (56% compared with 35%; P=0.004), and more likely to have completed at least 12 years of education (84% compared with 61%; P=0.001). From this cohort (n=668), we identified all postmenopausal women with no personal history of breast cancer (n=495). A woman was considered postmenopausal if she reported that her menses had stopped permanently. Because by 50 years of age, most women with a uterus in our sample had undergone natural menopause, women who had undergone hysterectomy were considered postmenopausal whether or not they had undergone bilateral salpingo-oophorectomy. Data Collection Current users of HRT were women who reported use of hormone replacement, such as estrogen, in the past 30 days. Women were also asked about sociodemographic, clinical, and psychological factors that had previously been associated with use of HRT in other studies or that we postulated might influence its use. Sociodemographic variables included age (denoted by indicator variables for 5-year increments), ethnicity (white or nonwhite), education (<12 years, high school graduate or general education diploma, or college graduate), household income (in quartiles), marital status (currently married), children (one or more), employment status (full-time job), rural residence (not living in a Metropolitan Statistical Area), and geographic region (Northeast, Midwest, South, and West) as defined by the U.S. Census. Clinical variables included a history of hysterectomy, having a regular physician, use of supplemental calcium, physical activity (vigorous activity one or more times per week), and a waist-to-hip ratio of 0.85 or less as a measure of body habitus; all of these factors were previously associated with use of HRT. We also examined self-report of diabetes, cigarette smoking (current, former, or never smoker), family history of myocardial infarction, hypertension, high cholesterol level, personal history of myocardial infarction or angina (based on the Rose criteria [29]), sexual activity, alcohol use, multivitamin use, and use of alternative therapies. Psychological variables included perceived risk for heart disease and cancer (above average compared with average or below), self-perceived physical and mental health (excellent, very good, or good compared with fair or poor), depression (based on the Composite International Diagnostic Interview [30]), self-report of depression or anxiety, perceived control over health, and thought and effort put into health. Women were also asked whether they worry about becoming less attractive or developing illness as they age. Measures of six major personality characteristicsagency (self-confident, forceful, assertive, outspoken, and dominant), agreeableness (helpful, warm, caring, softhearted, and sympathetic), openness (creative, imaginative, intelligent, curious, sophisticated, and adventurous), neuroticism (moody, worrying, nervous, and not calm), extroversion (outgoing, friendly, lively, active, and talkative), and conscientiousness (organized, responsible, hardworking, and not careless)were adapted from standard scales (31-34). Finally, we used the Somatic Amplification Scale (35) to assess somatosensory amplification (experiencing somatic sensation as intense, noxious, and disturbing). Statistical Analysis Data were weighted to adjust for differing probabilities of contacting households, sampling persons within each household, and obtaining completed surveys from designated participants (36) and to approximate the U.S. population on the basis of the Current Population Survey (October 1995). First, we adjusted for differing probabilities of successfully contacting households in geographic areas by mapping 1990 U.S. Census data on age, ethnicity, income, education, and urban location to telephone exchanges. Second, we adjusted for the higher probability of sampling persons in smaller households when their household was contacted. Third, we adjusted for differing probabilities of obtaining self-administered questionnaires from persons who completed the telephone interview by using numerous variables from the telephone interview. Finally, we created post-stratification weights so that the sample more closely approximated the U.S. population on the basis of 1995 Current Population Survey data. Thus, the weighted sample resembles the U.S. population by geographic region, ethnicity, age, education, marital status, and residence in a Metropolitan Statistical Area. We used the Pearson chi-square test to compare rates of HRT use by categorical variables and the Mantel-Haenszel chi-square test for the same comparison after stratifying by hysterectomy status (37). We converted values of each continuous psychological variable to ranks and compared users and nonusers of HRT by using two-way analysis of variance to control for hysterectomy status. We conducted multivariable logistic regression analyses in two stages. Because we had large numbers of sociodemographic, clinical, and psychological variables, we first created three separate models for each of these types of variables. Each model included all variables of a particular type with a P value of 0.2 or less in bivariable analyses. Finally, all variables with P values of 0.2 or less in the intermediate models were included in a final composite main-effects model. Because we also wished to ensure that the final model controlled for key demographic and clinical variables that might confound the effect of statistically significant variables, we also forced the following select variables to enter the final model: ethnicity, marital status, waist-to-hip ratio, income, hypertension, high cholesterol, family history of myocardial infarction, smoking, and personal history of coronary artery disease . Only this final composite multivariable logi

The functional status questionnaire

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients’ functional status. In this study, the FSQ was administered to 497 regular users of Boston’s Beth Israel Hospital’ Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV cost and services utilization study

PURPOSE To measure health-related quality of life among adult patients with human immunodeficiency virus (HIV) disease; to compare the health-related quality of life of adults with HIV with that of the general population and with patients with other chronic conditions; and to determine the associations of demographic variables and disease severity with health-related quality of life. SUBJECTS AND METHODS We studied 2,864 HIV-infected adults participating in the HIV Cost and Services Utilization Study, a probability sample of adults with HIV receiving health care in the contiguous United States (excluding military hospitals, prisons, or emergency rooms). A battery of 28 items covering eight domains of health (physical functioning, emotional well-being, role functioning, pain, general health perceptions, social functioning, energy, disability days) was administered. The eight domains were combined into physical and mental health summary scores. SF-36 physical functioning and emotional well-being scales were compared with the US general population and patients with other chronic diseases on a 0 to 100 scale. RESULTS Physical functioning was about the same for adults with asymptomatic HIV disease as for the US population [mean (+/- SD) of 92+/-16 versus 90+/-17) but was much worse for those with symptomatic HIV disease (76+/-28) or who met criteria for the acquired immunodeficiency syndrome (AIDS; 58+/-31). Patients with AIDS had worse physical functioning than those with other chronic diseases (epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes) for which comparable data were available. Emotional well-being was comparable among patients with various stages of HIV disease (asymptomatic, 62+/-9; symptomatic, 59+/-11; AIDS, 59+/-11), but was significantly worse than the general population and patients with other chronic diseases except depression. In multivariate analyses, HIV-related symptoms were strongly associated with physical and mental health, whereas race, sex, health insurance status, disease stage, and CD4 count were at most weakly associated with physical and mental health. CONCLUSIONS There is substantial morbidity associated with HIV disease in adults. The variability in health-related quality of life according to disease progression is relevant for health policy and allocation of resources, and merits the attention of clinicians who treat patients with HIV disease.

Patients' Trust in Their Physicians: Effects of Choice, Continuity, and Payment Method

OBJECTIVE: To evaluate the extent to which physician choice, length of patient-physician relationship, and perceived physician payment method predict patients’ trust in their physician.DESIGN: Survey of patients of physicians in Atlanta, Georgia.PATIENTS: Subjects were 292 patients aged 18 years and older.MEASUREMENTS AND MAIN RESULTS: Scale of patients’ trust in their physician was the main outcome measure. Most patients completely trusted their physicians “to put their needs above all other considerations” (69%). Patients who reported having enough choice of physician (p<.05), a longer relationship with the physician (p<.001), and who trusted their managed care organization (p<.001) were more likely to trust their physician. Approximately two thirds of all respondents did not know the method by which their physician was paid. The majority of patients believed paying a physician each time a test is done rather than a fixed monthly amount would not affect their care (72.4%). However, 40.5% of all respondents believed paying a physician more for ordering fewer than the average number of tests would make their care worse. Of these patients, 53.3% would accept higher copayments to obtain necessary medical tests.CONCLUSIONS: Patients’ trust in their physician is related to having a choice of physicians, having a longer relationship with their physician, and trusting their managed care organization. Most patients are unaware of their physician’s payment method, but many are concerned about payment methods that might discourage medical use.