Stuart J. Cohen

Reminders to physicians from an introspective computer medical record: a two-year randomized trial

We developed a computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12 467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p less than 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indication predicted their response to the indications (p less than 0.03, r2 = 0.33). The intentions of the control residents did not.

The Diabetes Education Study: A Controlled Trial of the Effects of Diabetes Patient Education

The Diabetes Education Study (DIABEDS) was a randomized, controlled trial of the effects of patient and physician education. This article describes a systematic education program for diabetes patients and its effects on patient knowledge, skills, self-care behaviors, and relevant physiologic outcomes. The original sample consisted of 532 diabetes patients from the general medicine clinic at an urban medical center. Patients were predominantly elderly, black women with non-insulin-dependent diabetes mellitus of long duration. Patients randomly assigned to experimental groups (N = 263) were offered up to seven modules of patient education. Each content area module contained didactic instruction (lecture, discussion, audio-visual presentation), skill exercises (demonstration, practice, feedback), and behavioral modification techniques (goal setting, contracting, regular follow-up). Two hundred seventy-five patients remained in the study throughout baseline, intervention, and postintervention periods (August 1978 to July 1982). Despite the requirement that patients demonstrate mastery of educational objectives for each module, postintervention assessment 11–14 mo after instruction showed only rare differences between experimental and control patients in diabetes knowledge. However, statistically significant group differences in self-care skills and compliance behaviors were relatively more numerous. Experimental group patients experienced significantly greater reductions in fasting blood glucose (−27.5 mg/dl versus −2.8 mg/dl, P < 0.05) and glycosylated hemoglobin (−0.43% versus + 0.35%, P < 0.05) as compared with control subjects. Patient education also had similar effects on body weight, blood pressure, and serum creatinine. Continued follow-up is planned for DIABEDS patients to determine the longevity of effects and subsequent impact on emergency room visits and hospitalization.

Evaluation of Biochemical Validation Measures in Determination of Smoking Status

This study was designed to evaluate the use of salivary cotinine, salivary thiocyanate, and expired-air carbon monoxide as biochemical validation measures for assessing the smoking status of adults. The participants were 20 known non-smokers plus 216 admitted smokers and 102 proclaimed quitters participating in a clinical trial of approaches to facilitate smoking cessation. Conventional analytical procedures were utilized. By use of data from known non-smokers and admitted smokers, the sensitivity and specificity of the validation measures were as follows: salivary cotinine, 99% and 100%; expired-air carbon monoxide, 96% and 100%; and salivary thiocyanate, 67% and 95%, respectively. The salivary cotinine and expired-air carbon monoxide tests confirmed smoking cessation for 55% and 74%, respectively, of the proclaimed quitters. The length of time since quitting was significantly related to the results observed with the latter measures. Consideration of these observations along with various practical factors suggests that expired-air carbon monoxide assays may be the validation measure of choice for most clinical trials.

Quality of care for secondary prevention for patients with coronary heart disease: results of the Hastening the Effective Application of Research through Technology (HEART) trial.

Abstract Background Effective therapies for reducing mortality rates in persons with coronary heart disease (CHD) remain underused. We report the results of an effectiveness trial of a quality improvement effort to increase the use of 3-hydroxy-3methylglutaryl coenzyme A (HMG CoA) reductase inhibitors, β-blockers, and angiotensin-converting enzyme (ACE) inhibitors in patients with CHD in a network-model managed-care setting. Methods Patients with CHD were identified by searching a claims database. The use of therapies was assessed by linkage with a pharmacy database. An intervention, consisting of a guideline summary, peer comparison performance feedback, and patient specific chart reminders was evaluated in a randomized, practice-based effectiveness trial. Results Data were available for >700 patients per year (1999–2002) in 131 practices. At baseline (1999), 55% of patients were receiving HMG CoA reductase inhibitors, 39% of patients were receiving β-blockers, and 24% of patients were receiving ACE inhibitors. The use of all 3 types of medications increased steadily with time, with the exception of a decrease in the use of HMG CoA reductase inhibitors in the final year (2002). No difference in medication use was observed between randomized groups. Conclusions The observed pattern of care supports the contention that the quality of outpatient care for secondary prevention of CHD improved from 1999 to 2002 in this setting. The basis for the inconsistent pattern of use of HMG CoA reductase inhibitors is not certain, but may relate to concerns about toxicity. Centralized mailings of guideline summaries, performance feedback reports, and chart reminders had no observable impact on quality of care in this setting. More intensive intervention may be required to improve the quality of outpatient care for the secondary prevention of CHD.

The diabetes education study

The Diabetes Education Study was a controlled trial of the effects of physician and patient education. This article describes an educational program for internal medicine residents and its effects on ambulatory diabetes management practices. Forty-five of 86 residents practicing in the general medicine clinic of a university-affiliated city/county hospital were assigned randomly to receive a multifaceted program intended to 1) provide specific care recommendations, 2) teach necessary skills, and 3) make the professional and institutional environment more supportive. During the subsequent 11 months, 323 diabetic patients were interviewed and their records audited for evidence of changes in care. Experimental residents utilized fasting blood glucose determinations more often than controls (i.e., during 40% of visits vs. 31%, p=0.004). Experimental residents also engaged more frequently in a variety of recommended dietary management recommendations. Isolated differences in monitoring/management of chronic complications also were found (e.g., lipid screening: 70% of experimental residents’ patients vs. 58%, p=0.016). Intensive, multifaceted programs of this nature are concluded to result in improvements in diabetes care, over and above that which is attainable through routine methods of clinical training for residents.

Heritable aspects of salt sensitivity

Dietary salt reduction is an important nonpharmacologic remedy for mild hypertension as well as a useful adjunct to drug treatment. However, a reduced salt intake diet is not effective in reducing the blood pressure of all hypertensive patients. Several lines of evidence indicate that some patients are salt-sensitive whereas others are salt-resistant. A series of investigations have been conducted showing that the blood pressure responses to either acute salt and volume loading or to a reduced dietary salt intake are normally distributed. Blood pressure, humoral regulators of blood pressure and renal sodium handling are each found to be influenced by genetic variance. The change in blood pressure from dietary salt reduction is influenced by genetic variance as well. Definitions of salt sensitivity and resistance were formulated, and salt sensitivity of blood pressure was found to occur significantly more often in black than in white Americans. Furthermore, preliminary data suggest that measurement of phenotypes of haptoglobin in blood may assist in identifying salt-sensitive and salt-resistant subjects. Trials of a reduced salt intake diet in pharmacologically treated hypertensive patients are currently being conducted. The data suggest that at least half of the patients are salt-sensitive and that their medications may be reduced in response to the intervention. Results of this study may be of relevance to many of the 60 million Americans with hypertension, particularly to those who are black and elderly.

The effect of a household partner and home urine monitoring on adherence to a sodium restricted diet

To evaluate the effects of social support and home urine monitoring on success with dietary sodium reduction, 114 essential hypertensive adults and a household partner were recruited. One of the pair was required to be the food preparer. Patients with their partners were randomly assigned to either an active or passive partner condition. During dietary counseling in the active condition, both patient and partner were involved in instructions to change their diet to reduce their daily sodium intake to 80 mmol or less. In the passive condition, the partners were present during the dietary counseling, but no effort was made to involve them directly in the instruction or to encourage them to make personal dietary changes. Patients and active partners collected two 24-hr urine collections between each of the first two counseling sessions and received feedback on the sodium results by a telephone call. In the passive partner condition, only patients collected urine for feedback. At the end of the 6 week instructional period, all patients and partners collected a 24-hr urine and had their blood pressure assessed. Half of each group was also randomly assigned to have access to a system for periodic home-monitoring of urine for sodium content during a 3-month period beginning at week 6 of the study (immediate). The delayed feedback group received the home-monitoring three months after completion of the dietary instruction. All patients, but only active partners, used the feedback system during their assignment periods and collected a 24-hr urine monthly between 6 and 30 weeks of the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Perceived influence of different information sources on the decision-making of internal medicine house staff and faculty

To determine the extent to which different sources of information are perceived to influence common medical decisions, 10 interns, 22 senior residents and 9 faculty general internists rated the degree of influence of house staff, general internists, subspecialists, conferences, journal reading and past experience on their decisions concerning primary prevention (vaccination), secondary prevention (screening) and drug therapy. Analysis of variance of their questionnaire data supports the following conclusions: physicians at different stages of training rely on different sources of information; as physicians advance in training the influence of generalists wanes while that of subspecialists increases; subspecialists and past experience are perceived as primarily affecting therapeutic decisions; primary prevention appears least subject to influence by prevailing information sources; and the preference for reading begins early and increases as physicians advance in training. These data suggest that designing effective medical education requires considering the level of the physicians training and the nature of the medical decision.

Overreporting of Smokeless Tobacco Use by Adolescent Males

This study evaluates the impact of a pipeline assessment (salivary cotinine determination) on the accuracy of self-reported use of cigarettes and smokeless tobacco by 160 rural seventh-and eighth-grade males ranging in age from 12 to 16. Half of them were randomly assigned to complete a questionnaire on tobacco use prior to revealing the biochemical validation materials and collecting samples. The others had the samples collected prior to receiving and completing the questionnaires. The questionnaire-first group reported significantly greater smokeless tobacco use than did the pipeline-first group. Only for the latter were their self-reports significantly corroborated by the cotinine results. These results suggest that the utilization of a biochemical pipeline not only can improve self-reported tobacco use but also may help identify perceptions about the social desirability of using harmful substances.

Concept acquisition and the perception of meaning

Abstract The assumptions underlying the classification rule-learning description of concept acquisition are critically examined. It is argued that categorizing is an outcome of perceiving an entitys meaning, and that neither natural pattern recognition nor comprehension requires that persons must first abstract common features from concept exemplars. An alternative characterization of what it means to have a concept is proposed. The theoretical framework derives from Nelsons functional primacy hypothesis and Gibsons position that knowledge of the world is a product of direct perception. The focus of the discussion ranges from metatheoretical issues to practical implications.