Thomas C. Jackson

Comparative Effectiveness of 5 Smoking Cessation Pharmacotherapies in Primary Care Clinics

BACKGROUND Randomized efficacy clinical trials conducted in research settings may not accurately reflect the benefits of tobacco dependence treatments when used in real-world clinical settings. Effectiveness trials (eg, in primary care settings) are needed to estimate the benefits of cessation treatments in real-world use. METHODS A total of 1346 primary care patients attending routine appointments were recruited by medical assistants in 12 primary care clinics. Patients were randomly assigned to 5 active pharmacotherapies: 3 monotherapies (nicotine patch, nicotine lozenge, and bupropion hydrochloride sustained release [SR]) and 2 combination therapies (patch + lozenge and bupropion SR + lozenge). Patients were referred to a telephone quit line for cessation counseling. Primary outcomes included 7-day point prevalence abstinence at 1 week, 8 weeks, and 6 months after quitting and number of days to relapse. RESULTS Among 7128 eligible smokers (> or =10 cigarettes per day) attending routine primary care appointments, 1346 (18.9%) were enrolled in the study. Six-month abstinence rates for the 5 active pharmacotherapies were the following: bupropion SR, 16.8%; lozenge, 19.9%; patch, 17.7%; patch + lozenge, 26.9%; and bupropion SR + lozenge, 29.9%. Bupropion SR + lozenge was superior to all of the monotherapies (odds ratio, 0.46-0.56); patch + lozenge was superior to patch and bupropion monotherapies (odds ratio, 0.56 and 0.54, respectively). CONCLUSIONS One in 5 smokers attending a routine primary care appointment was willing to make a serious quit attempt that included evidence-based counseling and medication. In this comparative effectiveness study of 5 tobacco dependence treatments, combination pharmacotherapy significantly increased abstinence compared with monotherapies. Provision of free cessation medications plus quit line counseling arranged in the primary care setting holds promise for assisting large numbers of smokers to quit. Trial Registration clinicaltrials.gov Identifier: NCT00296647.

Beyond advocacy: A review of the active patient concept

In this paper we critically review the active patient concept and place it in a broader social and historical context. We argue that as a reflection of core, Western European values, the active patient concept has not been adequately scrutinized. Very little research has been done that explicitly tests the claims that have been advanced on behalf of this ideal model of the clinician-patient relationship. The research that is available is far from definitive and does not support many of the assertions made by advocates of this approach to patienthood. We urge investigators to substitute theory driven research programs for those motivated by advocacy of a particular ideological stance.

Educational characteristics of ambulatory morning report

The educational characteristics of ambulatory morning report were compared with those of the inpatient morning report sessions over a five-month period. Ambulatory morning report had fewer total participants and was more likely to cover general internal medicine topics (p<0.05), the medical interview (6.8% vs 1.2%, p=0.02), and social issues (9.6% vs 1.2%, p=0.02). Morning report conference can be replicated in the ambulatory setting, thus providing an opportunity to discuss general medicine topics not usually addressed in the inpatient setting.

What do senior internal medicine residents do in their continuity clinics

Objective: To describe the activities of second- and third-year internal medicine residents during their outpatient continuity clinics.Design: Descriptive observational study.Setting: Medical school-affiliated community hospital primary care clinic.Patients/participants: All second-year (n=15) and third-year (n=14) residents enrolled in the internal medicine training program were observed at one-minute intervals during their routine half-day continuity clinics.Measurements and main results: An average of 203 observations were recorded for each resident. The distribution of resident activities was as follows: 1) direct interaction with patients (29.5%); 2) charting or writing prescriptions (24.0%); 3) social interactions with staff (13.7%); 4) attending conferences or reviewing medical literature (9.4%); 5) waiting or transiting (8.2%); 6) ward responsibilities (4.9%); 7) reviewing cases with attending physician (4.4%); and 8) miscellaneous activities (4.9%). Analysis of variance procedures revealed that the following variables significantly (p<0.05) affected the residents’ activities: 1) the actual number of patients seen produced predictable increases in direct and indirect patient care activities; and 2) the year of training had an impact on the mean number of observations of interactions with the supervising attending physician (PGY-2=11.4, PGY-3=3.8).Conclusions: These results suggest that this senior resident continuity experience is clinically intensive, yet provides surprisingly infrequent direct resident supervision. Further analysis of the educational activities occurring on these half-days is necessary to judge whether they are quantitatively and qualitatively adequate.

Selegiline Transdermal System (STS) as an Aid for Smoking Cessation

INTRODUCTION This study examined the efficacy and safety of selegiline transdermal system (STS) and brief repeated behavioral intervention (BRBI) for smoking cessation in heavy smokers. We hypothesized that the quit rate of subjects who received STS and BRBI would be significantly greater than that of those who received placebo patch and BRBI. METHODS This was a double-blind, placebo-controlled parallel-group study in which 246 men and women were randomized to receive either STS (n = 121) or placebo patch (n =125) for 9 weeks. Recruitment targeted heavy smokers, defined as individuals with self-reported use of ≥15 cigarettes/day in the 30 days prior to enrollment, who had smoked cigarettes for the past 5 years, and had an expired CO level ≥9 ppm during screening. RESULTS Although STS was well tolerated, the overall results indicated that STS with BRBI was not more effective than placebo plus BRBI for smoking cessation (p = .58). CONCLUSIONS The results are discussed in relation to interventions for heavy smokers. Although 2 trials using oral selegiline both showed trends toward improved abstinence, these results indicate that STS with BRBI was not an effective aid for smoking cessation at the end of treatment (10 weeks), 14, or 26 weeks.