Thomas L. Delbanco

Through the Patientʼs Eyes: Understanding and Promoting Patient-Centered Care

1. Introduction: Medicine and Health from the Patients Perspective(Margaret Gerteis, Susan Edgman-Levitan, Jennifer Daley, Thomas L. Delbanco). Part One: The Dimensions of Patient-Centered Care. 2. Treating Patients as Individuals(Kimberly D. Allshouse). 3. Coordinating Care and Integrating Services(Margaret Gerteis). 4. Overcoming the Barrier of Words(Jennifer Daley). 5. Innovations in Patient-Centered Education(Beth Ellers). 6. Enhancing Physical Comfort(Janice D. Walker). 7. Providing Effective Emotional Support(Susan Edgman-Levitan). 8. Involving and Supporting Family and FriAnds(Beth Ellers). 9. Facilitating the Transition Out of the Hospital(Beth Ellers, Janice D. Walker). Part Two: Promoting a Patient-Centered Health Care Environment. 10. Culture, Leadership, and Service in the Patient-Centered Hospital(Margaret Gerteis, Marc J. Roberts). 11. Promoting the Doctors Involvement in Care(Thomas L. Delbanco). 12. Rebuilding Public Trust and Confidence(Thomas W. Moloney, Barbara Paul).

The functional status questionnaire

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients’ functional status. In this study, the FSQ was administered to 497 regular users of Boston’s Beth Israel Hospital’ Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

Discussing cardiopulmonary resuscitation: a study of elderly outpatients.

Decisions about when to perform cardiopulmonary resuscitation (CPR) are frequently made without knowing the wishes of the patient. To evaluate the feasibility of outpatient discussions about CPR, the authors surveyed 22 male and 53 female, mentally competent, ambulatory patients 65 years of age and older. Only 7% of those interviewed had an accurate understanding of what CPR meant before hearing a standardized description. Eighty-seven per cent thought discussions about CPR should take place routinely, but only 3% had previously discussed this issue with their physicians. Seventy per cent felt such discussions should take place during periods of health, and 84% felt their views should be part of the medical record. When asked about three terminal illnesses, a minority of patients wanted CPR: 25% felt CPR was indicated in the presence of irreversible coma, 28% for terminal cancer, and 41% for irreversible heart failure. More patients felt they would request CPR if they had irreversible heart failure than if in a coma (p<0.002) or for terminal cancer (p=0.002). The majority of elderly outpatients have clearly defined opinions about the application of CPR and wish to discuss them with their physicians.

The rheumatoid factor : an analysis of clinical utility

The rheumatoid factor (RF) is a frequently ordered diagnostic test, yet it possesses significant limitations in sensitivity, specificity, and predictive value. Recognition of these limitations could improve the tests utility by encouraging more selective test ordering and more circumspect interpretation of test results. An analysis of 563 requests for RF from a teaching hospital revealed a positive predictive value of only 24% to 34%. The RF performs best under conditions of moderate pretest likelihood of rheumatoid arthritis, and otherwise has rather limited clinical utility.

Prevalence and recognition of alcohol abuse in a primary care population

PURPOSE The purpose of this study was to assess the prevalence, physician recognition, and treatment of alcohol abuse among patients of 19 senior medical residents practicing in a hospital-based, primary care setting. PATIENTS AND METHODS Interviews of 242 outpatients were conducted, and alcohol abuse and dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), were determined using the Diagnostic Interview Schedule. RESULTS Twenty percent of the patients studied had abused or were dependent on alcohol at some time in their lives and 5 percent reported abuse or dependence within the last year. Of the techniques studied, a short screening questionnaire (Short Michigan Alcohol Screening Test [SMAST]) was the most accurate way of identifying patients who abused alcohol, and physician assessments were more accurate than laboratory tests. Although the physicians were aware of serious alcohol problems among 77 percent of their patients who met DSM-III criteria for alcohol abuse or dependence in the previous year, they identified only 36 percent of their patients with less serious problems or past alcohol abuse. They had only discussed alcohol abuse with 67 percent of the patients they identified as alcohol abusers. CONCLUSION We conclude that a short screening questionnaire (SMAST) is an accurate means of identifying alcohol abuse. Despite the recognition of serious alcohol problems by the physicians, the problem is not addressed routinely even among patients that are recognized as alcoholic.

Using patient reports to improve medical care: a preliminary report from 10 hospitals.

This article describes the early activities of the Picker/Commonwealth Program for Patient-Centered Care and reports results from a study of 10 hospitals trying to develop better ways of providing patient-centered care. Reported problems were relatively infrequent, but several problems occurred as often as in an earlier national study of acute care hospitals. Academic medical centers and other teaching hospitals tended to have more problems than nonteaching hospitals, but there was great variability within hospital types. The article discusses ways patient reports can be used to improve the quality of hospital care.

Should Young Adults with a Positive Tuberculin Test Take Isoniazid

We used decision analysis to determine the benefits and risks of preventive therapy with isoniazid for young adults whose only risk factor for the development of active tuberculosis was a positive tuberculin skin test. We assumed that the risk of developing active tuberculosis over the next 20 years ranged from 0.56% to 1.30% for such persons; that isoniazid can reduce this risk by 30% to 70%; and that the risk of developing isoniazid-related hepatitis ranged from 0.3% to 1.1%. Among 100 000 such persons, treatment with isoniazid could prevent from 168 to 910 cases of tuberculosis over 20 years. However, from 300 to 1100 cases of isoniazid-related hepatitis would occur in the year of treatment. The benefits of preventive therapy in this group do not appear clearly to outweigh the risks. We disagree with the recommendation of the American Thoracic Society and the Centers for Disease Control that all such patients take isoniazid.

Functional disability screening of ambulatory patients

The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and social function. The experimental group physicians received reports summarizing their patients’ responses; the control group physicians received no report. At the end of one year the authors found no significant difference between the patients of the experimental and control group physicians on any measure of functional status. Functional disability screening alone does not improve patient function.

Predicting emergency readmissions for patients discharged from the medical service of a teaching hospital.

Emergency readmissions among patients discharged from the medical service of an acute-care teaching hospital were analyzed. Using the multivariate technique of recursive partitioning, the authors developed and validated a model to predict readmission based on diagnoses and other clinical factors. Of the 4,769 patients in the validation series, 19% were readmitted within 90 days. Twenty-six per cent of the readmissions occurred within ten days of discharge, and 57% within 30 days. Readmitted patients were older, had longer hospitalizations, and had greater hospital charges (p<0.01). The discharge diagnoses of AIDS, renal disease, and cancer were associated with increased risks of read-mission regardless of patients’ demographics or test results. The relative risks (95% confidence interval) associated with these diagnoses were: AIDS, 3.3 (1.4–7.8); renal disease, 2.3 (1.7–3.0); cancer, 2.8 (2.4–3.4). Other patients at increased risk were those with diabetes, anemia, and elevated creatinine (2.1; 1.6–2.8) and those with heart failure and elevated anion gaps (2.2; 1.7–2.8). For patients without one of these diagnoses, a normal albumin and no prior admission within 60 days identified patients at reduced risk for readmission (0.4; 0.3–0.4). Thus, commonly available clinical data identify patients at increased risk for emergency readmission. Risk factor profiles should alert physicians to these patients, as intensive intervention may be appropriate. Future studies should test the impacts of clinical interventions designed to reduce emergency readmissions.

Alcohol Abuse in Women Seeking Gynecologic Care

&NA; In several retrospective studies, alcoholic women have reported menstrual problems significantly more often than nonalcoholic women. There is no information, however, comparing the prevalence of alcohol abuse in women who receive periodic gynecologic care and those who seek care for menstrual disorders such as the premenstrual syndromes. This question was studied in two private practice settings. Women seeking periodic care were obtained from a suburban, general gynecology practice. Women seeking treatment for premenstrual syndrome (PMS) were obtained from a practice that specialized in the care of PMS. Ninetyfive patients with PMS and 147 patients seeking periodic care were screened with the CAGE questions—a mnemonic for attempts to Cut back on drinking, being Annoyed at criticism about drinking, feeling Guilty about drinking, and using alcohol as an Eye‐opener. Women who gave affirmative responses to one or more of the CAGE questions were evaluated for the presence of alcohol abuse. In the women seeking periodic care, 33% were CAGE positive and 12% were alcohol abusers. In the PMS practice, 51% were CAGE positive and 21% were alcohol abusers. Alcohol abuse is a common problem in gynecologic practice. Women who seek medical care for PMS are at much greater risk to be alcohol abusers. (Obstet Gynecol 68:322, 1986)