Sidna M. Scheitel

Underreporting the Use of Dietary Supplements and Nonprescription Medications Among Patients Undergoing a Periodic Health Examination

OBJECTIVEnTo compare the use of dietary supplements and nonprescription medications as reported on a written medical questionnaire with use reported during a structured interview.nnnDESIGNnWe conducted a prospective study of 200 subjects randomly selected among patients undergoing a periodic health examination in two divisions of the Department of Internal Medicine at Mayo Clinic Rochester--100 patients from a national cohort of executives and 100 community patients.nnnMATERIAL AND METHODSnWritten information on self-reported use of supplements and nonprescription medications was obtained as part of a comprehensive medical questionnaire. Subjects were then interviewed and asked about the use of supplements and nonprescription medications. In addition, the reason for using supplements was elicited and recorded.nnnRESULTSnThe prevalence of use of dietary supplements was 30.5% by written self-report in comparison with 61.0% reported during the structured interview. The results were consistent between executive and community patients. In response to questions about taking nonprescription medications, 24.5% of patients reported such use on the medical questionnaire in comparison with 42.5% when interviewed. The most common dietary supplements taken were multivitamins (41.5%), followed by vitamin E (24.0%) and vitamin C (23.0%). The most common nonprescription medications taken were aspirin (16.5%) and ibuprofen (13.0%). Most frequently, patients indicated that they were using supplements to promote health.nnnCONCLUSIONnIn this study, half the patients who took dietary supplements and almost half who took nonprescription medications did not report them to their healthcare provider on a written questionnaire, even though this information was requested. Patients should be specifically asked about use of dietary supplements and nonprescription medications, even if written information about such use is provided.

A Randomized Trial of Three Diabetes Registry Implementation Strategies in a Community Internal Medicine Practice

BACKGROUNDnDisease registries are powerful tools with the potential to transform the way chronic diseases are managed. To date, however, little work has been done to determine how to optimize the implementation of a chronic disease registry in practice.nnnMETHODSnTwenty-nine physicians and their nurse teams in a large community internal medicine practice participated in this 6-month prospective randomized trial in 2000. Teams were assigned to one of three implementation strategies using information from a diabetes registry. Process and outcome measures for diabetes management were analyzed. Process measures included the percentage of patients completing glycosylated hemoglobin (Hgb) testing within 6 months and low-density lipoprotein (LDL) testing within 12 months. Outcome measures included the percentage of patients with a glycosylated Hgb > 9.3% (equivalent to a HgbA1c > 8.0%), the percentage of patients with an LDL cholesterol > 130 mg/dl, and the percentage of patients with controlled blood pressure, defined as < 130/85 millimeters of mercury. Mean change in LDL and glycosylated Hgb values was also measured.nnnRESULTSnTeams randomized to an intervention strategy that included direct letters to patients showed significant improvement across a number of measures. The improvement was most apparent among patients without recent testing or with poorly controlled disease. The two interventions that did not include direct patient letters resulted in limited improvement.nnnDISCUSSIONnDisease registries can be used to improve outcomes in the management of diabetes and other chronic diseases. Better outcomes were seen in patients who received letters based on registry-generated data. This strategy should be included as part of a comprehensive chronic disease management plan. Further refinements in the use of registries should result in further incremental improvement.

Colorectal Cancer Screening: A Community Case-Control Study of Proctosigmoidoscopy, Barium Enema Radiography, and Fecal Occult Blood Test Efficacy

OBJECTIVEnTo examine the effectiveness of screening proctosigmoidoscopy, barium enema radiography, and the fecal occult blood test (FOBT) in decreasing colorectal cancer mortality in a community setting.nnnPATIENTS AND METHODSnIn this population-based case-control study, cases comprised 218 Rochester, Minn, residents who died of colorectal cancer between 1970 and 1993. Controls were 435 age- and sex-matched residents who did not have a diagnosis of colorectal cancer. Screening proctosigmoidoscopy, barium enema radiography, and FOBT results were documented for the 10 years prior to and including the date of diagnosis of fatal colorectal cancer in cases and for the same period in matched controls. History of general medical examinations and hospitalizations was also recorded.nnnRESULTSnWithin the 10 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening proctosigmoidoscopy were 23 (10.6%) of 218 cases vs 43 (9.9%) of 435 controls; at least 1 screening barium enema radiographic study was done in 12 (5.5%) of 218 vs 25 (5.7%) of 435. Within 3 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening FOBT were 27 (12.4%) of 218 vs 44 (10.1%) of 435. Adjusted odds ratios were 1.04 (95% confidence interval [CI], 0.21-5.13) for proctosigmoidoscopy (distal rectosigmoid cancers only), 0.67 (95% CI, 0.31-1.48) for barium enema radiography, and 0.83 (95% CI, 0.45-1.52) for FOBT over the above time periods.nnnCONCLUSIONnIn this case-control study within a community setting, a colorectal cancer-specific mortality benefit could not be demonstrated for screening by FOBT, proctosigmoidoscopy, or barium enema radiography. Screening frequency was low, which may have contributed to the lack of measurable effects.

Patient-physician agreement about medical diagnoses and cardiovascular risk factors in the ambulatory general medical examination.

OBJECTIVEnTo describe the spectrum of medical diagnoses and cardiovascular risk factors identified by physicians during the comprehensive medical examination in ambulatory patients, to assess how accurately patients report the health problems identified by their physicians, and to determine the characteristics associated with patient and physician agreement.nnnMATERIAL AND METHODSnWe conducted a prospective study of ambulatory patients at Mayo Clinic Rochester. All 64 internists in the general internal medicine divisions who perform comprehensive medical examinations were invited to enroll 10 adult patients each; 57 physicians and 566 eligible patients participated. Complete physician and patient information on diagnosed health problems was available for 458 patient visits (81%). Diagnosed health problems were collected from both the patients and the physicians by questionnaire after the examination and classified into medical diagnoses and cardiovascular risk factors.nnnRESULTSnOf the diagnosed health problems, 63% involved four organ system categories: (1) nutritional, endocrine, or metabolic (20%); (2) cardiovascular (18%); (3) musculoskeletal (13%); and (4) digestive (12%). Patients failed to report 68% of all health problems and 54% of the most important health problems diagnosed by the physician. Major health problems, new diagnoses, and distant residence were associated with the highest level of patient-physician agreement for diagnosed health problems.nnnCONCLUSIONnBecause patients failed to report more than half of their most important health problems identified by their physicians, practitioners might consider giving problem lists or summary letters to patients to improve and reinforce communication and management of health problems.

Patient-physician agreement on reasons for ambulatory general medical examinations.

OBJECTIVEnTo evaluate the physicians ability to identify patients reasons for visits (RFVs) for a general medical examination (GME), to assess predictors of agreement between patient and physician on the RFV, and to determine whether agreement about the RFVs was associated with patient satisfaction with the visit.nnnDESIGNnWe conducted a prospective study involving patients scheduled for a GME and internists in a multispecialty group practice.nnnMATERIAL AND METHODSnPatient-physician agreement on the RFV was independently assessed by two internists. Logistic regression was used to identify predictors of low agreement.nnnRESULTSnThe 458 patients reported a total of 848 RFVs for their GME. Patient-physician agreement on the patients RFV was low in 20% of the visits. Female gender (odds ratio, 2.02; 95% confidence interval [CI], 1.11 to 3.66), multiple RFVs (odds ratio, 2.03; 95% CI, 1.06 to 3.91), and previous GME (odds ratio, 2.18; 95% CI, 1.07 to 4.44) were independent predictors of low agreement. Patient-physician agreement for RFVs was not associated with patient satisfaction with the medical visit.nnnCONCLUSIONnIn this study, physicians correctly identified the patients main RFV in a majority of the visits. Failures to identify the patients main RFV occurred more frequently in female patients, in patients with multiple RFVs, and in patients with a previous comprehensive GME. Surprisingly, patient-physician agreement was not associated with patient satisfaction.

Geriatric Health Maintenance

OBJECTIVEnTo highlight articles pertaining to geriatric health maintenance and provide clinicians with current evidence supportive of or opposed to screening or treatment for various diseases and conditions.nnnMETHODnWe conducted a computer-assisted search of the relevant medical literature and summarized the results of pertinent studies in the elderly population.nnnRESULTSnThe geriatric population is progressively increasing in numbers. Unfortunately, no consensus exists about health maintenance in this population. To date, the United States Preventive Services Task Force has made several recommendations about preventive services; however, they did not specifically focus on the geriatric age-group. We outline their guidelines and discuss our clinical practices in a wide variety of encounters with geriatric patients.nnnCONCLUSIONnThe efficacy of many screening tests and interventions for preventing illness in elderly patients is unclear. As the general population continues to age, further research in this area will be important.