Stephen J. Zyzanski

Coronary heart disease in the Western Collaborative Group Study

Abstract A prospective study of coronary heart disease (CHD) was initiated in 1960–1961 in 39–59 year old men. Some of the relevant findings observed during a mean four and one-half year period of follow-up of 3182 subjects are presented. A significantly increased incidence of CHD was found to be associated with parental history of CHD, elevated systolic or diastolic blood pressure, cigarette smoking, higher serum levels of cholesterol, triglyceride and beta lipoproteins, and the Type A behavior pattern. The association of the Type A behavior pattern with a significantly increased rate of CHD was not found to be ascribable to an association of the behavior pattern with other risk factors.

Progress toward validation of a computer-scored test for the type A coronary-prone behavior pattern.

&NA; A self‐administered, machine‐scored test questionnaire to discriminate between men with the Type A coronary‐prone behavior pattern and those without that pattern (Type B) was taken twice by over 2800 men in the Western Collaborative Group Study in 1965 and 1966. Optimal weighting, discriminant function, and factor analytic procedures were applied to these test items to produce scales measuring Behavior Type A, Speed and Impatience, Job Involvement, and Hard‐Driving traits, respectively. In a retrospective study, 83 men who had sustained a first attack of CHD before taking the test in 1965 were compared with 468 random control subjects. The mean Type A score was significantly higher for cases than for controls (P=0.01). The mean Factor H score showed cases to be more hard‐driving, competitive and responsible than controls (P=0.01). Contingency tables also supported these discriminations. The other two factor scales did not discriminate significantly.

Prediction of Clinical Coronary Heart Disease by a Test for the Coronary-Prone Behavior Pattern

Abstract Prospective study of 2750 employed men who completed a computer-scored test questionnaire measuring the coronary-prone Type A behavior pattern showed that high scorers had twice the incide...

HOW VALID ARE MEDICAL RECORDS AND PATIENT QUESTIONNAIRES FOR PHYSICIAN PROFILING AND HEALTH SERVICES RESEARCH? A COMPARISON WITH DIRECT OBSERVATION OF PATIENT VISITS

OBJECTIVES This study was designed to determine the optimal nonobservational method of measuring the delivery of outpatient medical services. METHODS As part of a multimethod study of the content of primary care practice, research nurses directly observed consecutive patient visits to 138 practicing family physicians. Data on services delivered were collected using a direct observation checklist, medical record review, and patient exit questionnaires. For each medical service, the sensitivity, specificity, and Kappa statistic were calculated for medical record review and patient exit questionnaires compared with direct observation. Interrater reliability among eight research nurses was calculated using the Kappa statistic for a separate sample of videotaped visits and medical records. RESULTS Visits by 4,454 patients were observed. Exit questionnaires were returned by 74% of patients. Research nurse interrater reliabilities were generally high. The specificity of both the medical record and the patient exit questionnaire was high for most services. The sensitivity of the medical record was low for measuring health habit counseling and moderate for physical examination, laboratory testing, and immunization. The patient exit questionnaire showed moderate to high sensitivity for health habit counseling and immunization and variable sensitivity for physical examination and laboratory services. CONCLUSIONS The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.

Physician Noncompliance With the 1993 National Cholesterol Education Program (NCEP-ATPII) Guidelines

BACKGROUND We sought to determine the frequency with which physicians follow National Cholesterol Education Program (NCEP-ATPII) guidelines in screening for cardiovascular risk factors and treating hyperlipidemia. METHODS AND RESULTS We conducted a retrospective chart review on randomly sampled charts of 225 patients admitted to the coronary care unit between January and June 1996. The main outcome measures were rates of physician screening for coronary heart disease risk factors; rates of counseling for cigarette cessation, diet, and exercise; and extent of use of NCEP algorithms for obtaining LDL cholesterol values and treating hypercholesterolemia. Screening rates for interns (who performed best) were: cigarette use (89%), known coronary heart disease (74%), hypertension (68%), hyperlipidemia (59%), family history (56%), diabetes (37%), postmenopausal hormone therapy (11%), and premature menopause (1%). Four percent of smokers were counseled to quit, 14% of patients were referred to dietitians, and 1% were encouraged to exercise. A full lipid panel was obtained in 50% of patients in whom it was indicated on the basis of NCEP criteria. Patients were more likely to receive lipid-lowering treatment if NCEP criteria indicated that they should, but 36% of hospitalized patients and 46% of patients who should have been treated on discharge were not. CONCLUSIONS Physicians are poorly compliant with NCEP guidelines for risk factor assessment and counseling, even in patients at high risk for coronary heart disease. Physicians follow NCEP-ATPII algorithms for obtaining an LDL value, a key step in evaluating the need for treatment, only 50% of the time. NCEP criteria seem to influence the decision to initiate lipid-lowering therapy, but significant numbers of eligible patients remain untreated.

Risk of new myocardial infarction in middle-aged men with manifest coronary heart disease.

Men incurring coronary heart disease (CHD) during surveillance of an employed population were studied for risk factors associated with additional myocardial infarctions. The coronaryprone Type A behavior pattern measured by a test score, number of cigarettes smoked daily, and serum cholesterol were significant discriminators between the 67 men with recurrent CHD and the 220 with but a single clinical CHD event. Diastolic blood pressure and fasting serum triglycerides were not significant discriminators. Statistical analyses directed to possible sources of bias occasioned by the combined retrospective-prospective study design revealed that these problems are negligible and do not alter the findings observed. Type A score appears relatively unaffected by whether the measure was made before or after the initial CHD event. Multivariable discriminant function equations showed Type A score to be the strongest single predictor of recurrent CHD among the variables available. Number of cigarettes smoked and serum cholesterol accounted for additional variance. Future field trials for the secondary prevention of myocardial infarction would be strengthened by consideration of the possible role of Type A behavior.

A clinical trial of tailored office systems for preventive service delivery: The Study to Enhance Prevention by Understanding Practice (STEP-UP)

BACKGROUND The potential of primary care practice settings to prevent disease and morbidity through health habit counseling, screening for asymptomatic disease, and immunizations has been incompletely met. This study was designed to test a practice-tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling. DESIGN Group randomized clinical trial and multimethod process assessment. SETTING/PARTICIPANTS Seventy-seven community family practices in northeast Ohio. INTERVENTION After a 1-day practice assessment, a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aimed at increasing preventive service delivery. MAIN OUTCOME MEASURE Summary scores of the health habit counseling, screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during randomly selected chart review days. RESULTS A significant increase (p=0.015) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group (31% to 42%) compared to the control group (35% to 37%). Rates specifically for health habit counseling (p=0.007) and screening services (p=0.048) were increased, but not for immunizations. CONCLUSIONS An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates.

The Association of Attributes of Primary Care With the Delivery of Clinical Preventive Services

OBJECTIVES Evidence is building that primary care is associated with quality of care and cost effectiveness. Still, little is known of the contribution of specific attributes of primary care to important health outcomes, such as the delivery of preventive services. This study tests the association of specific attributes of primary care with a comprehensive measure of the delivery of preventive services. METHODS A cross-sectional multimethod study design was used to examine 2,889 patient visits to 138 community-based primary care physicians. Four primary care attributes were measured: patient preference for their regular physician, interpersonal communication, physicians accumulated knowledge of the patient, and coordination of care. Delivery of US Preventive Service Task Force-recommended services were based on data collected from direct observation and medical record review. Hierarchical linear regression models (HLM) were used to test the association of each of the primary care attributes with being up to date on screening, immunization, and health habit counseling preventive services. Each regression model was adjusted for patient age, race, health status, and insurance type. RESULTS Interpersonal communication and coordination of care scale scores were associated with being more up to date on screening services and health habit counseling. Accumulated knowledge and preference for regular physician were associated with being more up to date on immunizations. CONCLUSIONS The attributes of primary care measured in this study are associated with the receipt of preventive services. Fostering the tenets of primary care may have an impact on the delivery of preventive services and possibly other important health outcomes.

Basic dimensions within the coronary-prone behavior pattern

Recent studies have demonstrated the relation of the “coronary-prone behavior pattern (Type A)” to prevalence and incidence of coronary heart disease (CHD). A self-administered, computer-scored questionnaire—The Jenkins Activity Survey (JAS)—has been shown to identify men having this coronary-prone behavior pattern with over 70 per cent accuracy. To resolve the question of whether this behavior pattern is a single unified set of responses or an aggregation of distinct traits, independent factor analyses were performed on JAS responses from four large samples of employed men. These analyses all concurred that the coronary-prone behavior pattern is actually composed of at least three major, conceptually independent behavioral syndromes: I. Hard Driving, II. Job Involvement, and III. Speed and Impatience. A system was constructed for deriving factor scores for individuals on these dimensions, and these scores were demonstrated to be reliable across forms of the test and stable over time. The 3 scores were uncorrelated with each other. The behavioral factors defined and measured here are in concordance with variables found to be associated with coronary heart disease by numerous other investigators using other methods.

Sustainability of a practice-individualized preventive service delivery intervention.

BACKGROUND The long-term effect of most interventions has not been studied. Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends. This analysis reports the 24-month follow-up of a practice-tailored intervention to increase preventive service delivery rates. DESIGN Group randomized clinical trial with 24-month follow-up of intervention sites. SETTING/PARTICIPANTS Seventy-seven community family practices in northeast Ohio. INTERVENTION Practice-individualized facilitation of implementation of tools and approaches. MAIN OUTCOME MEASURES Summary scores of health habit counseling, screening, and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during randomly selected chart review days. RESULTS Previously reported increases in global preventive service delivery rates, health habit counseling, and screening rates at 12 months were sustained after 24 months. CONCLUSIONS A practice-individualized approach can result in sustainable increases in rates of preventive service delivery, even 1 year after the outside intervention stimulus ends. Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes.