Biomedical subjects

Mark A Moskowitz

Publications and source records attributed to Mark A Moskowitz.

5 recordsLinked to original sources

PubMed2003

Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study.

BACKGROUND: Screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented. OBJECTIVE: To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use. DESIGN: Cluster randomized, controlled trial. SETTING: Urban academic primary care practice. PARTICIPANTS: 41 faculty and resident primary care physicians and 312 patients with hazardous drinking. INTERVENTIONS: Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit. MEASUREMENTS: Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later. RESULTS: Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.7] versus 11.6 [CI, 5.4 to 17.7]). CONCLUSIONS: Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.

Adult↗

PubMed2003

Early antidepressant therapy for elderly patients.

PURPOSE: We studied factors affecting the management of depression in older patients, especially the use of early antidepressant therapy. METHODS: We recruited 128 primary care physicians to view one version of a 5-minute videotape of an elderly patient with somatic symptoms that were suggestive of depression, and to complete an interview that assessed decision making. Using an experimental factorial design, 16 versions of the videotape were produced, holding constant the clinical features of the case, while varying the patient's age, race, sex, and socioeconomic status. Dependent variables were the physicians' probability assessment of depression and the recommendation of antidepressant medication after the first visit. RESULTS: Depression was considered a possible diagnosis by 121 physicians (95%) and the most likely diagnosis by 69 (54%). Sixteen physicians (13%) recommended antidepressant therapy after the first visit, and they were less likely than other physicians to order initial laboratory tests to assess the possibility of other conditions. Recommendations for antidepressant therapy was not associated with patient age, sex, race, or socioeconomic status, or with physician sex, race, or experience. Family physicians were more likely than internists to recommend an antidepressant (19% [12/64] vs. 6% [4/64], P = 0.04). CONCLUSION: Based on a 5-minute vignette, physicians were likely to recognize depression, independent of patient characteristics. Those recommending early antidepressant therapy were more likely to be in family medicine and less likely to investigate other diagnoses initially.

Adult↗

PubMed2003

Quality improvement implementation in the nursing home.

OBJECTIVE: To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. DATA SOURCES/STUDY SETTING: Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. STUDY DESIGN: A cross-sectional analysis of the association among the different measures was performed. DATA COLLECTION/EXTRACTION METHODS: Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database. PRINCIPAL FINDINGS: Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. CONCLUSIONS: Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.

Aged↗

PubMed2002

Profiling nursing homes using Bayesian hierarchical modeling.

OBJECTIVES: New methods developed to improve the statistical basis of provider profiling may be particularly applicable to nursing homes. We examine the use of Bayesian hierarchical modeling in profiling nursing homes on their rate of pressure ulcer development. DESIGN: Observational study using Minimum Data Set data from 1997 and 1998. SETTING: A for-profit nursing home chain. PARTICIPANTS: Residents of 108 nursing homes who were without a pressure ulcer on an index assessment. MEASUREMENTS: Nursing homes were compared on their performance on risk-adjusted rates of pressure ulcer development calculated using standard statistical techniques and Bayesian hierarchical modeling. RESULTS: Bayesian estimates of nursing home performance differed considerably from rates calculated using standard statistical techniques. The range of risk-adjusted rates among nursing homes was 0% to 14.3% using standard methods and 1.0% to 4.8% using Bayesian analysis. Fifteen nursing homes were designated as outliers based on their z scores, and two were outliers using Bayesian modeling. Only one nursing home had greater than a 50% probability of having a true rate of ulcer development exceeding 4%. CONCLUSIONS: Bayesian hierarchical modeling can be successfully applied to the problem of profiling nursing homes. Results obtained from Bayesian modeling are different from those obtained using standard statistical techniques. The continued evaluation and application of this new methodology in nursing homes may ensure that consumers and providers have the most accurate information regarding performance.

Bayes Theorem↗

PubMed2002

Professional satisfaction experienced when caring for substance-abusing patients: faculty and resident physician perspectives.

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients' family history. Physicians were less likely (P <.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions.

Adult↗