Peter D. Friedmann

Patients' Use of the Internet for Medical Information

AbstractOBJECTIVES: To determine the percentage of patients enrolled in a primary care practice who use the Internet for health information, to describe the types of information sought, to evaluate patients’ perceptions of the quality of this information, and to determine if patients who use the Internet for health information discuss this with their doctors. DESIGN: Self-administered mailed survey. SETTING: Patients from a primary care internal medicine private practice. PARTICIPANTS: Randomly selected patients (N=1,000) were mailed a confidential survey between December 1999 and March 2000. The response rate was 56.2%. MEASUREMENTS AND MAIN RESULTS: Of the 512 patients who returned the survey, 53.5% (274) stated that they used the Internet for medical information. Those using the Internet for medical information were more educated (P<.001) and had higher incomes (P<.001). Respondents used the Internet for information on a broad range of medical topics. Sixty percent felt that the information on the Internet was the “same as” or “better than” information from their doctors. Of those using the Internet for health information, 59% did not discuss this information with their doctor. Neither gender, education level, nor age less than 60 years was associated with patients sharing their Web searches with their physicians. However, patients who discussed this information with their doctors rated the quality of information higher than those who did not share this information with their providers. CONCLUSIONS: Primary care providers should recognize that patients are using the World Wide Web as a source of medical and health information and should be prepared to offer suggestions for Web-based health resources and to assist patients in evaluating the quality of medical information available on the Internet.

Classification and regression tree analysis in public health: Methodological review and comparison with logistic regression

Background: Audience segmentation strategies are of increasing interest to public health professionals who wish to identify easily defined, mutually exclusive population subgroups whose members share similar characteristics that help determine participation in a health-related behavior as a basis for targeted interventions. Classification and regression tree (C&RT) analysis is a nonparametric decision tree methodology that has the ability to efficiently segment populations into meaningful subgroups. However, it is not commonly used in public health.Purpose: This study provides a methodological overview of C&RT analysis for persons unfamiliar with the procedure.Methods and Results: An example of a C&RT analysis is provided and interpretation of results is discussed. Results are validated with those obtained from a logistic regression model that was created to replicate the C&RT findings. Results obtained from the example C&RT analysis are also compared to those obtained from a common approach to logistic regression, the stepwise selection procedure. Issues to consider when deciding whether to use C&RT are discussed, and situations in which C&RT may and may not be beneficial are described.Conclusions: C&RT is a promising research tool for the identification of at-risk populations in public health research and outreach.

Screening and Intervention for Alcohol Problems

OBJECTIVE: To describe adult primary care physicians’ and psychiatrists’ approach to alcohol screening and treatment, and to identify correlates of more optimal practices. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry. MEASUREMENTS: Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales. MAIN RESULTS: Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object. CONCLUSIONS: Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols of offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians’ screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement

Barriers to Screening for Domestic Violence

AbstractCONTEXT: Domestic violence has an estimated 30% lifetime prevalence among women, yet physicians detect as few as 1 in 20 victims of abuse. OBJECTIVE: To identify factors associated with physicians’ low screening rates for domestic violence and perceived barriers to screening. DESIGN: Cross-sectional postal survey. PARTICIPANTS: A national systematic sample of 2,400 physicians in 4 specialties likely to initially encounter abused women. The overall response rate was 53%. MAIN OUTCOME MEASURE: Self-reported percentage of female patients screened for domestic violence; logistic models identified factors associated with screening less than 10%. RESULTS: Respondent physicians screened a median of only 10% (interquartile range, 2 to 25) of female patients. Ten percent reported they never screen for domestic violence; only 6% screen all their patients. Higher screening rates were associated with obstetrics-gynecology specialty (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.31 to 0.78), female gender (OR, 0.51; CI, 0.35 to 0.73), estimated prevalence of domestic violence in the physician’s practice (per 10%, OR, 0.72; CI, 0.65 to 0.80), domestic violence training in the last 12 months (OR, 0.46; CI, 0.29 to 0.74) or previously (OR, 0.54; CI, 0.34 to 0.85), and confidence in one’s ability to recognize victims (per Likert-scale point, OR, 0.71; CI, 0.58 to 0.87). Lower screening rates were associated with emergency medicine specialty (OR, 1.72; CI, 1.13 to 2.63), agreement that patients would volunteer a history of abuse (per Likert-scale point, OR, 1.60; CI, 1.25 to 2.05), and forgetting to ask about domestic violence (OR, 1.69; CI, 1.42 to 2.02). CONCLUSIONS: Physicians screen few female patients for domestic violence. Further study should address whether domestic violence training can correct misperceptions and improve physician self-confidence in caring for victims and whether the use of specific intervention strategies can enhance screening rates.

Operative blood loss, blood transfusion, and 30-day mortality in older patients after major noncardiac surgery.

Objective:Anemia and operative blood loss are common in the elderly, but evidence is lacking on whether intraoperative blood transfusions can reduce the risk of postoperative death. Methods:We analyzed retrospective data from 239,286 patients 65 years of older who underwent major noncardiac surgery in 1997 to 2004 at veteran hospitals nationwide. Propensity-score matching was used to adjust for differences between patients who received intraoperative blood transfusions (9.4%) and those who did not, and data were used to determine the association between intraoperative blood transfusion and 30-day postoperative mortality. Results:After propensity-score matching, intraoperative blood transfusion was associated with mortality risk reductions in patients with preoperative hematocrit levels of <24% (odds ratio: 0.60, 95% CI: 0.41–0.87), and in patients with hematocrit of 30% or greater when there is substantial (500–999 mL) blood loss (odds ratio: 0.35, 95% CI: 0.22–0.56 for hematocrit levels between 30%–35.9% and 0.78, 95% CI: 0.62–0.97 for hematocrit levels of 36% or greater). When operative blood loss was <500 mL, transfusion was not associated with mortality reductions for patients with hematocrit levels of 24% or greater, and conferred increased mortality risks in patients with preoperative hematocrit levels between 30% to 35.9% (odds ratio 1.29, 95% CI: 1.04–1.60). Conclusions:Intraoperative blood transfusion is associated with a lower 30-day postoperative mortality among elderly patients undergoing major noncardiac surgery if there is substantial operative blood loss or low preoperative hematocrit levels (<24%). Transfusion is associated with increased mortality risks for those with preoperative hematocrit levels between 30% and 35.9% and <500 mL of blood loss.

Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure.

ObjectiveTo quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.DesignSurvey of a national systematic sample of physicians.ParticipantsFive hundred family practitioners, 500 general internists, and 500 cardiologists.Measurements and main resultsPhysicians’ choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p≤.01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%); and asymptomatic, post-myocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely (p≤.05) to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less (43% vs 15%).ConclusionsCompared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasize the dosages demonstrated to lower mortality and morbidity in the trials.

Buprenorphine retention in primary care.

AbstractBACKGROUND: This study assesses the rate and predictors of treatment retention for primary care patients with opioid dependence-prescribed buprenorphine, a long-acting partial opioid agonist. METHODS: Observational cohort study of patients prescribed buprenorphine/naloxone and followed for 6 months in the period after the adoption of buprenophine/naloxone by a primary care practice in Rhode Island. Practice policy precluded patient discharges due to continuing drug use. RESULTS: Patients (n=41) had a mean duration of opioid use of 15.7 years and most had a history of heroin use (63.4%). Thirty-nine percent of patients transferred from methadone maintenance. At 24 weeks, 59% remained in treatment. Nearly half of dropouts occurred in the first 30 days. Participants with opiate-positive toxicologies at week 1 were more likely to drop out of the program (P<.01) and had a significantly shorter retention time (P<.01) on average. Among other drug use and drug treatment variables, employment and addiction counseling during treatment were significantly associated with treatment retention (P=.03). CONCLUSION: Retention rates in a real world, primary care-based buprenorphine maintenance practice reflect those reported in clinical trials. Abstinence during the first week of treatment and receipt of counseling were critical to patient retention.

Effect of Primary Medical Care on Addiction and Medical Severity in Substance Abuse Treatment Programs

AbstractOBJECTIVE: To examine whether the availability of primary medical care on-site at addiction treatment programs or off-site by referral improves patients’ addiction severity and medical outcomes, compared to programs that offer no primary care. DESIGN: Secondary analysis of a prospective cohort study of patients admitted to a purposive national sample of substance abuse treatment programs. SETTING: Substance abuse treatment programs in major U.S. metropolitan areas eligible for demonstration grant funding from the federal Substance Abuse and Mental Health Services Administration. RESPONDENTS: Administrators at 52 substance abuse treatment programs, and 2,878 of their patients who completed treatment intake, discharge, and follow-up interviews. MEASUREMENTS: Program administrators reported whether the program had primary medical care available on-site, only off-site, or not at all. Patients responded to multiple questions regarding their addiction and medical status in intake and 12-month follow-up interviews. These items were combined into multi-item composite scores of addiction and medical severity. The addiction severity score includes items measuring alcohol and drug use, employment, illegal activities, legal supervision, family and other social support, housing, physical conditions, and psychiatric status. The medical severity score includes measures of perceived health, functional limitations, and comorbid physical conditions. MAIN RESULTS: After controlling for treatment modality, geographic region, and multiple patient-level characteristics, patients who attended programs with on-site primary medical care experienced significantly less addiction severity at 12-month follow-up (regression coefficient, −25.9; 95% confidence interval [95% CI], −43.2 to −8.5), compared with patients who attended programs with no primary medical care. However, on-site care did not significantly influence medical severity at follow-up (coefficient, −0.28; 95% CI, −0.69 to 0.14). Referral to off-site primary care exerted no detectable effects on either addiction severity (coefficient, −9.0; 95% CI, −26.5 to 8.5) or medical severity (coefficient, −0.03; 95% CI, −0.37 to 0.44). CONCLUSIONS: On-site primary medical care improves substance abuse treatment patients’ addiction-related outcomes, but not necessarily their health-related outcomes. Further study is needed to discern the mechanism through which on-site primary care might improve the addiction-related outcomes of substance abuse treatment.

Attitudes and practices regarding the use of methadone in US State and federal prisons

In the United States, vigorous enforcement of drug laws and stricter sentencing guidelines over the past 20 years have contributed to an expanded incarcerted population with a high rate of drug use. One in five state prisoners reports a history of injection drug use, and many are opiate dependent. For over 35 years, methadone maintenance therapy has been an effective treatment for opiate dependence; however, its use among opiate-dependent inmates in the United States is limited. In June 2003, we conducted a survey of the medical directors of all 50 US states and the federal prison system to describe their attitudes and practices regarding methadone. Of the 40 respondents, having jurisdiction over 88% (n=1,266,759) of US prisoners, 48% use methadone, predominately for pregnant inmates or for short-term detoxification. Only 8% of respondents refer opiate-dependent inmates to methadone programs upon release. The results highlight the need to destigmatize the use of methadone in the incarcerated setting, expand access to methadone during incarceration, and to improve linkage to methadone treatment for opiate-dependent offenders who return to the community.

Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders

BACKGROUND Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. METHODS In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78. RESULTS A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02). CONCLUSIONS In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).