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Biomedical subjects

G Caleb Alexander

Publications and source records attributed to G Caleb Alexander.

At least 19 recordsLinked to original sources
PubMed2006

Physicians' preparedness for bioterrorism and other public health priorities.

OBJECTIVES: Potential bioterrorism challenges policy makers to balance competing public health priorities. Earlier surveys showed low physician bioterrorism preparedness but did not assess physicians' general public health preparedness, compare the preparedness of emergency and primary care physicians, or assess temporal trends. METHODS: This was a national, cross-sectional, random-sample survey conducted in 2003. RESULTS: Overall, 744 of 1,200 eligible physicians responded (response rate, 62%). Of these, 58% of emergency physician respondents and 48% of primary care physician respondents reported having learned a lot about responding to bioterror since September 11, 2001 (p < 0.01). However, only 43% of emergency physicians and 21% of primary care physicians agreed they are generally "well prepared to play a role in responding to a bioterror attack" (p < 0.001). Beliefs about balancing public health priorities were similar among emergency and primary care respondents. Seventy-eight percent of respondents believed that local health care systems need to be prepared for bioterrorism, and 92% believed that local health care systems need to be prepared for natural epidemics. By contrast, only 23% and 46% of respondents reported that their local health care systems are well prepared for bioterrorism and natural epidemics, respectively. Meanwhile, 77% agreed that "influenza is a greater threat to public health than bioterrorism," and 21% reported that bioterrorism preparedness efforts are diverting resources from more important public health problems. CONCLUSIONS: In 2003, most emergency and primary care physicians reported that they and their local health care systems were not yet well prepared to respond to a bioterror attack, and many believed that more resources should go toward preparing for natural epidemics. These findings highlight the importance of expanding bioterrorism preparedness efforts to improve the public health system more broadly.

Attitude of Health Personnel↗
PubMed2006

Exploring patient preferences for infrainguinal bypass operation.

BACKGROUND: Surgical risk and outcomes for patients undergoing infrainguinal bypass operation vary by identifiable patient characteristics, yet little is known about whether patients understand the risks, benefits, and alternatives to operation. STUDY DESIGN: Cross-sectional surveys administered to 50 patients undergoing infrainguinal bypass operation at one institution an average of 7 days (median 4 days) before operations. RESULTS: Most patients rated their health as fair or poor (53%) or good (35%), and the majority reported their vascular disease was associated with difficulty doing activities they enjoyed (71%), leg pain (86%), and difficulty walking (98%). About one-half of patients (54%) thought they would require additional operations, 21% reported being at risk for postoperative myocardial infarction and 24% believed they would require a major amputation despite operations. Over two-thirds of patients (69%) believed their overall health would improve postoperatively, although more than four-fifths (80% to 86%) believed their ability to perform activities, leg pain, and walking would improve. Eighty-eight percent of patients reported willingness to have the operation even with a 10% postoperative mortality rate and 96% of patients reported a preference for operations if the chance of successful outcomes was only 75%. CONCLUSIONS: Although patients appear to be willing to undertake considerable postoperative risk, expectations for benefits from infrainguinal bypass operation appear greater than outcomes suggested by earlier research. These findings, if confirmed in larger studies, challenge how patient preferences should optimally be used to inform decisions about whether to undertake infrainguinal bypass operations.

Aged↗
PubMed2006

Design and evaluation of a workplace intervention to promote organ donation.

BACKGROUND: A number of efforts have been made to improve rates of deceased organ donation. However, few have been specifically designed for implementation in the workplace. OBJECTIVES: To design and evaluate a workplace intervention to increase documentation of intention to be posthumous organ donors, communication of donation intention to families, and family members' documentation of their donation intentions. METHODS: The study was a randomized controlled trial of corporate employees. Within each corporation, worksites were randomized to a control condition or 1 of 2 educational interventions. Measures included baseline and 1-month postintervention measures of stage of organ donation intention, stage of family notification, and family members' organ donation intention. RESULTS: Across 12 corporations, 40 worksites with a total of 754 participants were randomized. At 1-month follow-up, 495 participants (66%) completed a posttreatment questionnaire. The percentage of participants who signed organ donor cards increased in the 2 intervention groups (29%, P < .001, and 31%, P < .002) but not in the control group (17%, P = .454). The percentage who discussed their donation intentions with family members increased significantly across all 3 arms (39%-47%, P < .001). The mean percentage of participants' family members who signed organ donor cards increased by 14% in the control group (P = .016) and by 17% in the 2 intervention groups (P < .001). CONCLUSIONS: Educational interventions in the corporate workplace setting can be effective in increasing organ donation intention, family notification, and recruitment of family members as potential organ donors.

Adult↗
PubMed2006

Should our well-child care system be redesigned? A national survey of pediatricians.

OBJECTIVE: The goal was to examine pediatricians' views about whether and how well-child care for children 0 to 5 years of age should be changed. METHODS: A mail survey of a national random sample of 1000 general pediatricians was performed with a survey instrument that examined pediatricians' attitudes and behaviors toward our current way and an ideal way of providing well-child care. Results were analyzed for the following 3 major domains of change in well-child care: provider type, visit format, and visit location. RESULTS: Sixty percent (n = 502) of eligible subjects responded to the survey. Nearly all respondents (97%) rated the current US system as excellent or good in providing well-child care. Most pediatricians (85%-91%) reported that they are currently the main providers of anticipatory guidance, developmental screening, and psychosocial screening. However, a majority (54%-60%) reported that, in an ideal system that maximized the effectiveness and efficiency of care, nonphysicians would provide these services. Fewer pediatricians (24%) reported that ideally nonphysicians should provide the physical examination. The majority of respondents (79%-93%) reported that at least some anticipatory guidance, minor acute care, and chronic care services could be conducted through telephone or e-mail communication, and 55% stated that at least some well-child care services should be provided in alternative locations, such as day care centers. In multivariate analysis, support for these changes was distributed widely across pediatricians with varying personal and practice characteristics. CONCLUSIONS: Although most pediatricians are generally satisfied with our current way of providing well-child care, a majority think that a system that is less reliant on physicians and face-to-face office visits would be a more effective and efficient way to provide care.

Child Health Services↗
PubMed2006

A practical physicians' guide to the Medicare drug benefit plan.

Recent commentaries on Medicare Part D highlight both the early failings and the successes of the program. However, regardless of one's opinions about the program, Part D is a reality that millions of Medicare beneficiaries must address now and in the future. The ultimate economic, policy, and clinical success of the Medicare drug benefit plan depends on its transparency and ability to be navigated together by patients, physicians, and other parties. Although Medicare Part D is likely to evolve considerably in the future, it will continue to present elderly adults with numerous plan options and rules and therefore present persistent challenges for patients and physicians. By focusing on a few crucial aspects of Part D and taking advantage of available resources, physicians can simplify Part D for their patients, help them make informed decisions about enrollment and plan selection, and possibly help them save money with their current PDP. This may, in turn, reduce beneficiaries' out-of-pocket prescription costs, thereby improving patients' access to medications and possibly their medication adherence and health outcomes as well.

Decision Making↗
PubMed2006

Screening and treatment of hypercholesterolemia for prevention of coronary heart disease.

Undertreatment of hypercholesterolemia for secondary prevention of coronary heart disease has been widely documented. Less is known about screening and treatment for primary prevention. To evaluate recent trends, the rates of low-density lipoprotein (LDL) cholesterol screening and treatment for primary and secondary prevention of coronary heart disease in 1999 and 2003 were quantified from the National Disease and Therapeutic Index and compared. Data were used to examine LDL level reporting, rates at which target levels were attained, and drug therapy among National Cholesterol and Education Panel (NCEP) risk groups. The rate of LDL level reporting increased with greater NCEP risk, ranging from 6% to 7% for visits without risk factors to 31% to 42% for secondary prevention. Rates of meeting LDL targets decreased with greater NCEP risk, ranging from 87% to 88% for visits without risk factors to 29% to 43% for secondary prevention. Drug therapy recommendation also decreasedwith greater NCEP risk. Despite improvements, underscreening and undertreatment of hypercholesterolemia persists in outpatient visits.

Adult↗
PubMed2005

A conceptually based approach to understanding chronically ill patients' responses to medication cost pressures.

Prescription medications enhance the well-being of most chronically ill patients. Many individuals, however, struggle with how to pay for their treatments and as a result experience problems with self-care and health maintenance. Although studies have documented that high out-of-pocket costs are associated with medication non-adherence, little research on prescription cost sharing has been theoretically grounded in knowledge of the more general determinants of patients' self-management behaviors and chronic disease outcomes. We present a conceptual framework for understanding the influence of patient, medication, clinician, and health system factors on individuals' responses to medication costs. We review what is known about how these factors influence medication adherence, identify possible strategies through which clinicians, health systems, and policy-makers may assist patients burdened by their medication costs, and highlight areas in need of further research. Although medication costs represent a burden to chronically ill patients worldwide, most patients report using their medication as prescribed despite the costs, and others report cost-related underuse despite an apparent ability to afford those treatments. The cost-adherence relationship is modified by contextual factors, including patients' characteristics (e.g., age, ethnicity, and attitudes toward medications), the type of medications they are using (e.g., the complexity of dosing and the drug's clinical target), clinician factors (e.g., choice of first-line agent and communication about medication costs), and health system factors (e.g., efforts to influence clinicians' prescribing and to help patients apply for financial assistance programs). Understanding these relationships will enable clinicians and policy-makers to better design pharmacy benefits and assist patients in taking their medication as prescribed. The next generation of studies examining the consequences of prescription drug costs should expand our knowledge of the ways in which these co-factors influence patients' responses to medication cost pressures.

Chronic Disease↗
PubMed2005

Physician strategies to reduce patients' out-of-pocket prescription costs.

BACKGROUND: Physicians often do not communicate with patients about out-of-pocket costs, although research indicates that physicians and patients value such discussion. METHODS: Cross-sectional national random sample mail survey of 1400 cardiologists and general internists to quantify barriers to communication about out-of-pocket costs and strategies used to assist patients in order of likelihood (from 5 [extremely likely] to 1 [not at all likely]). RESULTS: Overall, 519 (39.1%) of 1328 eligible physicians responded to the survey. The most common barriers were lack of habit, insufficient time, and concern over patient discomfort. The most common strategies used to assist patients were switching to a generic drug (mean, 4.34; SD, 0.86), using office samples (mean, 4.16; SD, 1.22), and discontinuing nonessential medicines (mean, 4.03; SD, 0.99). There were no statistically significant differences between cardiologists and general internists in barriers or strategies examined (P<.05). CONCLUSIONS: Our findings suggest that patient-physician communication about out-of-pocket costs is a problem affecting specialists and generalists nationwide. Despite barriers, physicians use multiple strategies that may vary in efficacy to assist patients burdened by these costs.

Adult↗
PubMed2005

National trends in cyclooxygenase-2 inhibitor use since market release: nonselective diffusion of a selectively cost-effective innovation.

BACKGROUND: The withdrawal of rofecoxib has highlighted concerns regarding the safety of cyclooxygenase-2 (COX-2) inhibitors. In some patients COX-2 inhibitors may be safer than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs); however, the public health benefit of COX-2 inhibitors depends on their use in patients at higher than normal risk from NSAIDs. We examined trends in COX-2 inhibitor use based on risk for adverse events from NSAIDs. METHODS: We analyzed data from the National Ambulatory Medical Care Survey (1999-2002) and National Hospital Ambulatory Medical Care Survey (1999-2001), nationally representative surveys of community and hospital-based outpatient practices. The main outcome measure was the proportion of patient visits in which COX-2 inhibitors were prescribed, stratified by risk of adverse gastrointestinal (GI) events from NSAIDs. RESULTS: Of the visits in which either a COX-2 inhibitor or NSAID was prescribed, the frequency of COX-2 inhibitor use increased from 35% (1999) to 55% (2000) to 61% (2001 and 2002). Among patients with the lowest risk for adverse events from NSAIDs, the proportion receiving a COX-2 inhibitor increased from 12% in 1999 to 35% in 2002. Overall, increases in COX-2 inhibitor use among patients in whom NSAIDs could be used accounted for more than 63% of the growth in COX-2 inhibitor use during the period examined. CONCLUSIONS: Marked increases in COX-2 inhibitor use have occurred since their release, primarily among patients at low risk for adverse events from NSAIDs. These findings demonstrate the challenge of limiting innovative therapies to the settings in which they are initially targeted and maximally beneficial.

Adult↗
PubMed2005

New technologies meeting old professional boundaries: the emergence of carotid artery stenting.

BACKGROUND: Carotid artery stenosis is common and costly. Opinions differ in regard to the impact that carotid angioplasty and stenting (CAS) will have. Vascular surgeons, cardiologists, interventional radiologists, and neurologists all have a stake in the uptake of CAS. We sought to explore physicians' views about the safety and efficacy of CAS and the negotiation of professional boundaries in the treatment of carotid stenosis. STUDY DESIGN: We performed a qualitative analysis of key informant interviews with 15 physicians, including four internationally renowned key opinion leaders, representing five medical centers with differing experience adopting CAS. RESULTS: Variation in beliefs about the safety and efficacy of CAS within specialties was overshadowed by variation across the specialties examined. Most informants emphasized the strengths of their specialty in adopting CAS, including frequent patient care (vascular surgery, cardiology, and neurology), extensive catheter experience (cardiology, interventional radiology), and intimate knowledge of the anatomy of vascular and neurovascular disease (vascular surgery, neurology). Several themes were mentioned in regard to the diffusion of CAS, including risks of premature diffusion into low risk populations and the role of patient preferences in CAS uptake. The most common theme in regard to local management of CAS was the strength of interdisciplinary collaboration in the management of patients with carotid artery stenosis. CONCLUSIONS: CAS challenges physicians from several specialties to safely and effectively manage the uptake of an emerging technology crossing traditional specialty lines. Local collaboration of individual physicians and the departments and professional organizations they comprise, will have an important impact on how this technology is adopted.

Adult↗
PubMed2005

Assessing competence of residents to discuss end-of-life issues.

BACKGROUND: Residents are often responsible for eliciting patients' treatment preferences at the end of life (EOL), yet we have a limited understanding of their competence in this task. OBJECTIVE: To assess the competence of medical residents to discuss advance directives (AD) with patients using two measures: self-assessment (perceived competence) and self-reported behaviors (behavioral competence). To examine the relationship between educational experiences and these two measures of competence. DESIGN: Cross-sectional self-report questionnaire. SUBJECTS: Internal medicine residents from two university- and one community-based program. RESULTS: The 282 respondents (84% response) had an average of 6.2 EOL discussions per month. Few residents reported having received useful feedback from a resident (8%) or an attending (7%) about their ability to discuss ADs. Even fewer reported that work rounds (4%) or attending rounds (5%) were frequently forums for learning about EOL care. Mean perceived competence was 3.8 (range, 1-5). In multivariable analyses, greater perceived competence was significantly associated with higher postgraduate year (p < 0.001), having residents demonstrate exemplary AD discussions (p < 0.001), and less formal education (p < 0.01). Behavioral competence was significantly associated with reporting that work rounds were useful for learning about EOL care (p = 0.002), less formal education (p = 0.02) and a greater number of EOL discussions per ward month (p = 0.009). The correlation between perceived and behavioral competence (r = 0.25, p = 0.001) was modest but statistically significant. CONCLUSIONS: Many residents view themselves as competent to discuss ADs with patients but fail to engage in recommended behaviors for such discussions. Increasing experiential learning may be the most promising means of enhancing residents' abilities to discuss EOL issues with patients.

Adult↗
PubMed2005

Physicians in retainer ("concierge") practice. A national survey of physician, patient, and practice characteristics.

BACKGROUND: Retainer practices represent a new model of care whereby physicians charge an up-front fee for services that may not be covered by health insurance. The characteristics of these practices are largely unknown. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional mail survey of 144 retainer physicians (58% response rate) and a national random sample of 463 nonretainer physicians (50% response rate) to compare retainer and nonretainer practices. Outcomes of interest included physician demographics, size and case-mix of patient panel, services offered and, for retainer practices, characteristics of practice development. RESULTS: Retainer physicians have much smaller patient panels (mean 898 vs 2303 patients, P<.0001) than their nonretainer counterparts, and care for fewer African-American (mean 7% vs 16%, P<.002), Hispanic (4% vs 14%, P<.001), or Medicaid (5% vs 15%, P<.001) patients. Physicians in retainer practices are more likely to offer accompanied specialist visits (30% vs 1%), house calls (63% vs 26%), 24-hour direct physician access (91% vs 40%), and several other services (all P values <.05). Most retainer physicians (85%) converted from nonretainer practices but kept few of their former patients (mean 12%). Most retainer physicians (84%) provide charity care and many continue to see some patients (mean 17%) who do not pay retainer fees. CONCLUSIONS: Despite differences between retainer and nonretainer practices, there is also substantial overlap in services provided. These findings, in conjunction with the scope of patient discontinuity when physicians transition to retainer practice, suggest that ethical and legal debates about the standing of these practices will endure.

Attitude to Health↗