Biomedical subjects

Neil R Powe

Publications and source records attributed to Neil R Powe.

At least 55 records · Page 3Linked to original sources

PubMed2004

Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis.

CONTEXT: In light of conflicting evidence of differential effects of dialysis modality on survival, patient experience becomes a more important consideration in choosing between hemodialysis and peritoneal dialysis. OBJECTIVE: To compare patient satisfaction with hemodialysis and peritoneal dialysis in a cohort of patients who have recently begun dialysis. DESIGN AND SETTING: Cross-sectional survey at enrollment in a prospective inception cohort study of patients who recently started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998. PATIENTS: Of 736 enrolled incident dialysis patients, 656 (89%) returned a satisfaction questionnaire after an average of 7 weeks of dialysis. MAIN OUTCOME MEASURE: Data collected from a patient-administered questionnaire including 3 overall ratings and 20 items rating specific aspects of dialysis care. RESULTS: Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85% vs 56%, respectively; relative probability, 1.46 [95% confidence interval, 1.31-1.57]) and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69% excellent] vs hemodialysis [30% excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist, response to pain, amount of fluid removed, and staff availability in an emergency. Adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis did not reduce the differences between peritoneal dialysis and hemodialysis patients. CONCLUSIONS: After several weeks of initiating dialysis, patients receiving peritoneal dialysis rated their care higher than those receiving hemodialysis. These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.

Adult↗

PubMed2004

Association between cholesterol level and mortality in dialysis patients: role of inflammation and malnutrition.

CONTEXT: Total cholesterol level is inversely associated with mortality in dialysis patients, a group at high risk of cardiovascular disease (CVD). This paradox may be explained by systemic inflammation and/or malnutrition, which are associated with lower cholesterol levels and higher mortality. OBJECTIVE: To determine the relationship between cholesterol level and outcome in patients undergoing dialysis, accounting for inflammation and malnutrition. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of 823 patients enrolled from October 1995 to June 1998 who recently initiated dialysis, from 79 clinics, classified by absence or presence of inflammation and/or malnutrition (defined as serum albumin levels <3.6 mg/dL, C-reactive protein > or =10 mg/L, or interleukin 6 > or =3.09 pg/mL). MAIN OUTCOME MEASURES: All-cause and cardiovascular disease mortality. RESULTS: During a median follow-up of 2.4 years, 324 deaths (159 CVD deaths), 153 renal transplantations, and 10 losses to follow-up occurred. Average serum cholesterol level was lower in the presence of inflammation/malnutrition than in its absence. In a Cox model adjusted for age, race, and sex, a 40-mg/dL (1.0-mmol/L) increment in baseline total serum cholesterol level was associated with a decreased risk of all-cause mortality overall (relative hazard [RH], 0.92; 95% confidence interval [CI], 0.87-0.98) and in the presence of inflammation/malnutrition (RH, 0.89; CI, 0.84-0.95). In contrast, serum cholesterol level was associated with an increased risk in the absence of inflammation/malnutrition (RH, 1.32; 95% CI, 1.07-1.63). For CVD mortality, an inverse trend was not statistically significant in the presence of inflammation/malnutrition, and a positive association was evident in the absence of inflammation/malnutrition (RH, 1.41; 95% CI, 1.04-1.89). Further adjustment for traditional CVD risk factors, dialysis modality, comorbidity, and inflammatory markers attenuated the inverse association but strengthened the positive association. CONCLUSIONS: The inverse association of total cholesterol level with mortality in dialysis patients is likely due to the cholesterol-lowering effect of systemic inflammation and malnutrition, not to a protective effect of high cholesterol concentrations. These findings support treatment of hypercholesterolemia in this population.

Adult↗

PubMed2004

Accuracy of identification of patients with immune thrombocytopenic purpura through administrative records: a data validation study.

Administrative data are commonly used to estimate the prevalence of a disease, but the validity of the coding system needs to be evaluated before its use. We assessed the validity of the International Classification of Disease, 9(th) version, Clinical Modification (ICD-9-CM) code of 287.3 for identifying patients with immune thrombocytopenic purpura (ITP). Administrative data from inpatients and outpatients seen were retrieved if the patient or insurer was billed with one of three ICD-9-CM codes for thrombocytopenic disorders, 287.3, 287.4, and 287.5, as a primary or secondary diagnosis; or was physician-identified as having ITP. The electronic medical records for these patients were systematically reviewed to identify patients with ITP and with non-ITP diagnoses. Sensitivity, specificity, positive and negative predictive values, and kappa scores were calculated separately for inpatients and outpatients. Four-hundred eighteen records were reviewed. Among inpatients, the sensitivity of code 287.3 for indicating a diagnosis of ITP was 100% [95% confidence interval 94-100%]. The specificity was 89% [95% confidence interval 84-94%]. The percent agreement was 92%, and the kappa statistic was 0.80. For outpatients, the sensitivity of the billing code 287.3 was 84% [95% confidence interval 76-91%], a conservative estimate because of how the patients with other diagnoses were selected. The specificity for outpatients was 66% [95% confidence interval 56-76%]. ICD-9-CM code 287.3 in administrative billing data is likely to be sufficiently sensitive and specific, particularly when inpatient data are used, for the estimation of the prevalence of ITP.

Accounts Payable and Receivable↗

PubMed2004

Whole body donation for medical science: a population-based study.

Although cadaveric whole-body donation for the purposes of medical science is extremely important for medical education, the number of persons who choose to donate remains low. We assessed persons' willingness to consider whole body donation in a standardized telephone survey of Maryland households, identified using random digit dialing. In multivariable analyses, we assessed the independent relation of sociodemographics and attitudinal factors to willingness to consider donation, and we determined the amount of variation in willingness to consider donation among the study population that could be explained by these factors. Of 385 participants (84% of randomized homes), 49% reported they would consider whole body donation. In bivariate analysis, younger age, African-American race/ethnicity, less education and income, greater number of dependents, marital status, and attitudes about religion/spirituality, trust in hospitals, and income, gender, and racial/ethnic discrimination in hospitals were statistically significantly associated with 40-70% less odds of willingness to consider donation. After adjustment, persons of African-American race/ethnicity, less education, and those agreeing with the statements, "Rich patients receive better care at hospitals than poor patients," and "White patients receive better care at hospitals than other racial or ethnic groups," had 40-60% less odds of willingness to consider donation when compared to their counterparts. Respondents' race/ethnicity and education contributed most to willingness to consider donation. We conclude that demographic and attitudinal factors are strongly related to willingness to consider whole body donation. Efforts to enhance donation should seek to identify ways in which potential barriers to donation can be addressed by health professionals.

Adolescent↗

PubMed2004

A randomized controlled trial of the effects of nurse case manager and community health worker team interventions in urban African-Americans with type 2 diabetes.

The objective of the study was to determine the effectiveness and cost-effectiveness of primary care and community-oriented interventions in managing HbA1c, blood pressure, and lipids, and reducing hospitalizations and emergency room visits over 2 years. We describe an ongoing, randomized controlled trial of 542 urban African-Americans with type 2 diabetes ages 25 years and older who are members of a university-affiliated managed-care organization in Baltimore, MD. The participants are 74% female, have a mean age of 58 years, and 35% have yearly incomes greater than 7500 US dollars. Participants were randomized to one of two intervention groups for a period of 2 years: (1) usual medical care plus minimal telephone intervention implemented by a trained lay health educator (control group) or (2) usual medical care plus intensive intervention implemented by a nurse case manager (NCM)/community health worker (CHW) team. The intensive NCM/CHW team executes individual plans of care using evidence-based algorithms that focus on traditional diabetes self-management, screening and management of diabetes-related complications, and social issues surrounding diabetes care. Face-to-face NCM visits are conducted in the clinic once per year and CHW visits are conducted in the participant's home one to three times per year, both with additional follow-up contacts as needed. Written and verbal feedback (when necessary) is provided to the participant's primary care physician. All participants are expected to attend a 24-month follow-up visit where data are collected by interviewers blinded to intervention assignment. As of May 1, 2003, recruitment is complete, interventions are being fully implemented, and 24-month follow-up visits are beginning. Baseline sociodemographic characteristics, health-care utilization, health behaviors, and clinical characteristics of the study population are reported. This study is designed to test the hypothesis that a primary-care-based NCM plus CHW team approach is an effective, practical, and economically feasible strategy for translating current knowledge about type 2 diabetes into high-quality health care for urban African-Americans.

Black or African American↗

PubMed2004

Restless legs symptoms among incident dialysis patients: association with lower quality of life and shorter survival.

BACKGROUND: Symptoms of restless legs are common among patients treated with long-term hemodialysis. We investigated the relation between symptoms of restless legs, quality of life, and survival among incident hemodialysis and peritoneal dialysis patients. METHODS: This report includes 894 dialysis patients who responded to an item regarding severity of restless legs symptoms in the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Study. We examined participant responses both as categorized by the 5-point symptoms of restless legs item and classified with severe symptoms of restless legs if they reported they were very or extremely bothered by symptoms. Independent predictors of restless legs symptoms were estimated using logistic regression. The association of restless legs symptoms with quality of life was examined by means of mixed-model regression, and adjusted mortality risk was estimated by means of Cox proportional hazards. RESULTS: Fifteen percent of dialysis patients were classified as having severe restless legs. Those characterized by severe restless legs were significantly more likely to be administered benzodiazepines, antidepressants, and antiepileptics. Age and diabetes mellitus were independently associated with severe symptoms of restless legs. Symptoms of restless legs were associated with lower Physical and Mental Component Scores, vitality, bodily pain, and sleep quality (all P < 0.001). After adjustment, severe symptoms of restless legs were significantly associated with an increased mortality hazard ratio of 1.39 (95% confidence interval, 1.08 to 1.79). CONCLUSION: Symptoms of restless legs were associated with lower quality of life and increased risk for death. The effect of treatment for symptoms of restless legs on quality of life and survival awaits additional study.

Adult↗

PubMed2004

Loss of imprinting of insulin growth factor II gene: a potential heritable biomarker for colon neoplasia predisposition.

BACKGROUND & AIMS: Loss of genomic imprinting (LOI) of insulin-like growth factor II gene (IGF2) involves abnormal activation of the normally silent maternally inherited allele. LOI of IGF2 has been associated with personal and family history of colorectal neoplasia (CRN), supporting a role for LOI in colorectal carcinogenesis. Whether LOI of IGF2 is associated with known environmental risk factors for CRN is unknown. METHODS: We performed quantitative hot-stop PCR for imprinting analysis of IGF2 on normal peripheral blood lymphocytes (PBL) of individuals. Environmental exposures including tobacco, alcohol, NSAIDs, and nutrient consumption (calcium, folate, selenium, fiber, and fat) were correlated with LOI expression in PBL. Odds ratios (OR) and 95% CI were calculated. RESULTS: The prevalence of LOI of IGF2 was examined in 172 individuals. Persons with CRN (adenomas/cancer) had 5.1-fold (95% CI: 1.92-13.6) increased risk of having LOI of IGF2 in PBL compared with those without CRN. In contrast, tobacco smoking (OR = 0.96, 95% CI: 0.36-2.55), alcohol consumption (OR = 1.22, 95% CI: 0.45-3.3), and NSAIDs use (OR = 1.21, 95% CI: 0.38-3.94) were not significantly associated with LOI of IGF2. Nutrient ingestion including calcium (P = 0.61), folate (P = 0.23), selenium (P = 0.19), fiber (P = 0.63), and fat (P = 0.14) was not statistically correlated with LOI of IGF2. CONCLUSIONS: Abnormal imprinting of IGF2 gene was strongly associated with CRN but not with any of the environmental exposures examined. LOI of IGF2 does not appear to be an environmentally acquired phenomenon but rather a hereditary risk factor for CRN.

Adenoma↗

PubMed2004

Predicting 1 year mortality in an outpatient haemodialysis population: a comparison of comorbidity instruments.

BACKGROUND: A valid and practical measure of comorbid illness burden in dialysis populations is greatly needed to enable unbiased comparisons of clinical outcomes. We compare the discriminatory accuracy of 1 year mortality predictions derived from four comorbidity instruments in a large representative US dialysis population. METHODS: Comorbidity information was collected using the Index of Coexistent Diseases (ICED) in 1779 haemodialysis patients of a national dialysis provider between 1997 and 2000. Comorbidity was also scored according to the Charlson Comorbidity Index (CCI), Wright-Khan and Davies indices. Relationships of instrument scores with 1 year mortality were assessed in separate logistic regression analyses. Discriminatory ability was compared using the area under the receiver-operating characteristics curve (AUC), based on predictions of each regression model. RESULTS: When mortality was predicted using comorbidity and age, the ICED better discriminated between survivors and those who died (AUC 0.72) as compared with the CCI (0.67), Wright-Khan (0.68) and Davies (0.68) indices. Upon addition of race and serum albumin, predictive accuracy of each model improved further (AUCs of the ICED, 0.77; CCI, 0.75; Wright-Khan Index, 0.75; Davies Index, 0.74). CONCLUSIONS: The ICED had greater discriminatory ability than the CCI, Davies and Wright-Khan indices, when age and a comorbidity index were used alone to predict 1 year mortality; however, the differences among instruments diminished once serum albumin, race and the cause of ESRD were accounted for. None of the currently available comorbidity instruments tested in this study discriminated mortality outcomes particularly well. Assessing comorbidity using the ICED takes significantly more time. Identifying the key prognostic comorbid conditions and weighting these according to outcomes in a dialysis population should increase accuracy and, with restriction to a finite number of items, provide a practical means for widespread comorbidity assessment.

Cause of Death↗

PubMed2004

Frequency of patient-physician contact and patient outcomes in hemodialysis care.

There is little evidence supporting the widespread belief that regular patient-physician contact in chronic disease management leads to better patient outcomes. The objective of this study was to examine the relationship of the frequency of patient-physician contact with several patient outcomes in a prospective cohort study begun in 1995 of incident hemodialysis patients treated at 75 US dialysis clinics. Average frequency of patient-physician contact at each clinic was determined by clinic survey (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly). The authors used logistic, Poisson, and Cox proportional hazards regression analyses to assess the relationship between contact and satisfaction, quality of life, patient adherence, hospitalizations, and mortality. Of 735 hemodialysis patients, 14.3% were treated at clinics with high frequency of contact, 65.2% intermediate, and 20.5% low. Patients treated at clinics reporting less frequent physician contact had lower odds of rating the frequency at which they saw a nephrologist excellent (low: adjusted OR = 0.39, 95% CI, 0.23-0.67; intermediate: adjusted OR = 0.57, 95% CI, 0.37-0.87; reference, high) and greater odds of nonadherence (low: adjusted OR = 2.89, 95% CI, 1.01-8.29; intermediate: adjusted OR = 1.58, 95% CI, 0.78-3.19). However, patient survival did not vary by frequency of physician contact (low: adjusted RH = 0.87, 95% CI, 0.53-1.44; intermediate: adjusted RH = 1.33, 95% CI, 0.82-2.13), nor did patients' overall ratings of care, hospitalization rates, or quality of life measures. Although less frequent patient-physician contact was associated with lower patient satisfaction with that contact and patient nonadherence, it was not associated with several other outcomes of care. Future studies are needed to assess the individual frequency and nature of physician contact over time, including total time spent with the patient and quality of the interaction, to guide the provision of patient-centered and cost-effective care.

Cohort Studies↗

PubMed2004

Changes in quality of life during hemodialysis and peritoneal dialysis treatment: generic and disease specific measures.

Despite more than 20 yr of use, relative differences in health-related quality of life (HRQOL) between hemodialysis (HD) and peritoneal dialysis (PD) are not clearly known. The objective of this study was to compare self-reported HRQOL and overall health status for HD and PD patients at the initiation of dialysis therapy and 1 yr later. A prospective cohort of incident ESRD patients was enrolled between October 1995 and June 1998 at 81 outpatient dialysis units in 19 states and included 698 HD and 230 PD patients who completed a baseline CHOICE Health Experience Questionnaire. The main outcome measured was change in qualify-of-life scores from start of dialysis to 1 yr on dialysis and overall health status. Of 928 patients who completed the baseline questionnaire, 585 also completed the 12-mo questionnaire; 101 had died, 55 had received a kidney transplant, and 88 had moved to a new dialysis clinic. PD patients were slightly younger, were more likely to be white, were well-educated, were employed, were married, had less comorbidity, and had higher hematocrit. Unadjusted baseline scores showed better HRQOL for PD patients in both generic and ESRD domains (bodily pain, travel, diet restrictions, and dialysis access [P < 0.05]). At 1 yr, SF-36 scores improved, whereas some ESRD domains improved and others deteriorated. HD patients had greater improvements in two SF-36 domains (physical functioning and general health perception) than PD patients, but results were mixed for ESRD domains (PD is better for finances, HD is better for sleep and overall quality of life). HD and PD patients did not differ in change in overall health status. HD and PD are associated with similar HRQOL outcomes at 1 yr. Generic HRQOL in two domains improved more for HD patients. However, for ESRD-specific HRQOL, results were not consistent; some domains were better for PD patients whereas others were better for HD patients. In advising patients about modality choices, trade-offs should be discussed and individual preferences for specific aspects of HRQOL should be elicited.

Adult↗

PubMed2004

Frequency of sit-down patient care rounds, attainment of clinical performance targets, hospitalization, and mortality in hemodialysis patients.

Sit-down patient rounding in hemodialysis units allows providers to focus collectively on each patient's needs and may affect patient outcomes positively. The objective was to examine whether sit-down rounding practices improve patient outcomes in a cohort of 644 adult hemodialysis patients from 75 outpatient dialysis clinics in 17 states throughout the United States who survived at least 6 mo after enrollment (average follow-up, 3.2 yr). Achievement of well-accepted 6-mo clinical performance targets of albumin (> or =3.5 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<60 mg(2)/dl(2)), dose (Kt/V > or =1.2), and vascular access type (fistula); hospitalization rates; and all-cause mortality served as outcomes. Monthly or more frequent sit-down rounds were conducted in 36 (48%) of 75 clinics, representing 287 (45%) of 644 patients. More frequent sit-down rounds were positively associated with an increased chance of achieving the 6-mo clinical performance target for albumin compared with less frequent rounds (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.12 to 3.15); patients who were treated at clinics with more frequent rounds also had nearly twice the odds of achieving more of the five performance targets (OR, 1.95; 95% CI, 1.11 to 3.42). After adjustment for potential confounders, patients who were treated at clinics with more frequent sit-down rounds were 32% less likely to be hospitalized (incidence rate ratio, 0.68; 95% CI, 0.51 to 0.91), had fewer hospital days per year (rate ratio, 0.50; 95% CI, 0.26 to 0.98), and were 29% less likely to die (relative hazard, 0.71; 95% CI, 0.53 to 0.95). Adjustment for some clinical performance targets attenuated the statistical significance of the association with hospitalization. More frequent sit-down rounds in hemodialysis units are associated with better patient outcomes, including an increased chance of meeting the albumin clinical performance target, decreased hospitalization, and decreased risk of mortality. This association may be due to the positive effect of collaborative discussion by the patient care team of short- and long-term care goals for individual patients.

Adult↗

PubMed2004

The impact of international medical graduate status on primary care physicians' choice of specialist.

BACKGROUND: Approximately one fourth of practicing physicians in the United States graduated from medical schools in other countries. It is unknown how the role of international medical graduate status affects physician decision-making. OBJECTIVE: The objective of this study was to determine whether a primary care physicians' knowledge of a specialist's international medical graduate status affects his or her decision to refer patients to that specialist. RESEARCH DESIGN AND SUBJECTS: We studied a national, cross-sectional study of primary care physicians who see adult patients. The sample was drawn from the American Medical Association Physician's Professional Data. Each physician received 2 clinical case vignettes describing a patient for whom referral to a specialist was considered necessary. Each vignette was followed by 5 vignette specialist descriptions with medical school graduate status varied randomly alongside other physician characteristics. MEASURE: We measured the decision to refer to an international versus U.S. medical graduate specialist. RESULTS: Of 1054 eligible physicians, 623 (59.1%) responded. Respondents were significantly more likely to refer to a U.S. medical graduate (USMG) compared with an international medical graduate (IMG) (63% vs. 54%, P <0.05). After adjustment for age, race, sex, and referral characteristics of the vignette specialists, a positive referral decision was noted in a higher proportion of vignettes in which the vignette specialist was described as a USMG versus an IMG (63% vs. 51%, P <0.05). CONCLUSION: With other factors being equal, vignette specialists described as IMGs versus USMGs were significantly less likely to be associated with a positive referral decision. Although specialist IMG status, relative to other factors, might not have a major effect on referral decisions, it is possible that negative views of international medical graduates could lead to suboptimal choices in referral decisions. Potentially, a patient could be referred to an USMG who happens to have inferior clinical skills than an IMG with superior clinical skills.

Adult↗

PubMed2004

Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients.

BACKGROUND: Peripheral vascular disease (PVD) has become increasingly common in end-stage renal disease (ESRD) patients, leading to an increase in the rate of revascularization and amputation. We studied the prognosis of ESRD patients undergoing their first revascularization procedure. METHODS: We conducted a longitudinal cohort study of hemodialysis patients enrolled in special studies of the United States Renal Data System. Cox proportional hazards analysis was used to assess the independent effect of type of initial revascularization procedure on lower extremity amputation and all-cause, cardiac, and infectious mortality over 3 years, after adjustment for sociodemographic, clinical, and biologic baseline characteristics. RESULTS: Eight hundred patients underwent an initial revascularization procedure by surgical bypass or angioplasty. The overall incidence of subsequent amputation was 16.3/100 person-years, 22.6 for bypass, and 5.7 for angioplasty. After adjustment for patient characteristics, the risk of amputation was higher for bypass versus angioplasty [relative hazard (RH) 4.00; 95% CI 2.46 to 6.57], for black versus white patients (RH 1.49; 95% CI 1.04 to 2.15), for uninsured or patients on Medicaid versus patients with private insurance or on Medicare (RH 1.65; 95% CI 1.12 to 2.72), and for patients with diabetes versus no diabetes (RH 2.51; 95% CI 1.67 to 3.76). Compared with patients who underwent angioplasty, the risk of all-cause (RH 1.37; 95% CI 1.10 to 1.70), cardiac (RH 1.50; 95% CI 1.08 to 2.09), and infectious (RH 2.17; 95% CI 1.10 to 4.29) mortality was greater among patients who underwent bypass. CONCLUSION: Risk of amputation following revascularization procedures was positively associated with type of procedure, black race, uninsured/Medicaid, and diabetes status. Risk of death was also higher following bypass. While this might reflect underlying severity of disease, patient education, screening, and optimal care of lower extremities should be emphasized to detect PVD at an early stage of the disease process.

Adult↗

PubMed2004

Prevalence and determinants of physician participation in conducting pharmaceutical-sponsored clinical trials and lectures.

BACKGROUND: The relationship between physicians and the pharmaceutical industry is controversial because of the potential for conflicts of interest. However, little empirical evidence exists on the extent of physician participation in activities sponsored by pharmaceutical companies. OBJECTIVES: To determine the prevalence of participation of internal medicine physicians in clinical trials and lectures sponsored by pharmaceutical companies and to describe factors that are associated with such participation. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional regional survey of 1,000 Maryland internal medicine physicians between February 2000 and January 2001 in order to measure the prevalence of physician participation in pharmaceutical-sponsored clinical trials and lectures. We also collected economic and demographic information to examine potential associations between physician characteristics and engagement in such activities. RESULTS: Of 835 eligible physicians 444 (53%) responded, of whom 37% reported engaging in pharmaceutical-sponsored clinical trials and/or lectures to supplement their incomes. In our multivariable analysis, subspecialists versus generalist physicians (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.14 to 2.99), physicians in private group-single specialty and academic practice versus physicians in solo practice (OR, 2.30; 95% CI, 1.19 to 4.44 and OR, 2.56; 95% CI, 1.17 to 5.61, respectively), and physicians with higher versus lower annual incomes (OR, 1.22; 95% CI, 1.04 to 1.44) had a greater odds of participation in these activities. Additionally, physicians dissatisfied with their income had a 140% greater odds of participation (OR, 2.36; 95% CI, 1.45 to 3.83) than those who were satisfied with their income. CONCLUSIONS: A substantial number of internists engage in pharmaceutical industry-sponsored clinical trials and/or lectures in an effort to supplement their incomes. Physician dissatisfaction with income appears to partially explain such participation.

Clinical Trials as Topic↗

PubMed2004

Smoke exposure is associated with a lower prevalence of serum thyroid autoantibodies and thyrotropin concentration elevation and a higher prevalence of mild thyrotropin concentration suppression in the third National Health and Nutrition Examination Survey (NHANES III).

Few modifiable exposures influencing autoimmune thyroid disease have been identified. Studies evaluating cigarette smoke and thyroid disorders have yielded conflicting results. The relationship between smoking and thyroid abnormalities was evaluated in the 1988-1994 Third National Health and Nutrition Examination Survey (NHANES III), a cross-sectional study that used a complex, multistage, stratified, clustered sampling approach to reflect the entire noninstitutionalized United States population. Among 18,148 persons who underwent thyroid testing, data regarding age, gender, iodine status, smoke exposure, and thyroid tests were complete for 16,046 persons. After excluding those taking thyroid-altering medications, 15,592 remaining subjects were analyzed. Subjects with serum cotinine levels greater than 15 ng/ml were classified as smokers. Outcome measures included the presence of 1) antithyroperoxidase antibody levels of 0.5 IU/ml or more or antithyroglobulin antibody levels of 1.0 IU/ml or more, 2) TSH concentration greater than 4.5 mU/liter, 3) TSH concentration less than 0.1 mU/liter, and 4) TSH concentration of 0.1-0.4 mU/liter. Fewer smokers (11%, 95% confidence interval (CI) = [10-13%]) had thyroid autoantibodies compared with nonsmokers (18%, 95% CI = [17-19%]). Prevalence in smokers after adjustment for age, gender, race-ethnicity, and iodine status was 13%, 95% CI = [12-15%]. Fewer smokers (2.6%, 95% CI = [2.0-3.2%]) had elevated TSH compared with nonsmokers (5.5%, 95% CI = [4.7-6.3%]). The adjusted rate in smokers was 3.4%, 95% CI = [2.6-4.3%]). Among persons with thyroid autoantibodies, smokers had 40% lower odds of TSH elevation compared with nonsmokers (adjusted odds ratio [95% CI] = 0.6 [0.4-0.97]). Among persons without TSH elevation, smoke exposure was associated with 200% greater odds of low normal TSH 0.1-0.4 mU/liter (adjusted odds ratio [95% CI] = 2.0 [1.3-2.9]). Smoking appears to be negatively associated with serological evidence of thyroid autoimmunity and hypothyroidism and positively associated with mild TSH decreases. Eliminating smoke exposure may help prevent the low normal TSH measurements that are characteristic of mild hyperthyroidism. Understanding the underlying mechanism could help identify potential pathways for the prevention of autoimmune thyroid disease.

Adolescent↗

PubMed2004

Barriers to health care access among the elderly and who perceives them.

OBJECTIVES: We evaluated self-perceived access to health care in a cohort of Medicare beneficiaries. METHODS: We identified patterns of use and barriers to health care from self-administered questionnaires collected during the 1993-1994 annual examination of the Cardiovascular Health Study. RESULTS: The questionnaires were completed by 4889 (91.1%) participants, with a mean age of 76.0 years. The most common barriers to seeing a physician were the doctor's lack of responsiveness to patient concerns, medical bills, transportation, and street safety. Low income, no supplemental insurance, older age, and female gender were independently related to perceptions of barriers. Race was not significant after adjustment for other factors. CONCLUSIONS: Psychological and physical barriers affect access to care among the elderly; these may be influenced by poverty more than by race.

Aged↗

PubMed2004

Patient race/ethnicity and quality of patient-physician communication during medical visits.

OBJECTIVES: We examined the association between patient race/ethnicity and patient-physician communication during medical visits. METHODS: We used audiotape and questionnaire data collected in 1998 and 2002 to determine whether the quality of medical-visit communication differs among African American versus White patients. We analyzed data from 458 African American and White patients who visited 61 physicians in the Baltimore, Md-Washington, DC-Northern Virginia metropolitan area. Outcome measures that assessed the communication process, patient-centeredness, and emotional tone (affect) of the medical visit were derived from audiotapes coded by independent raters. RESULTS: Physicians were 23% more verbally dominant and engaged in 33% less patient-centered communication with African American patients than with White patients. Furthermore, both African American patients and their physicians exhibited lower levels of positive affect than White patients and their physicians did. CONCLUSIONS: Patient-physician communication during medical visits differs among African American versus White patients. Interventions that increase physicians' patient-centeredness and awareness of affective cues with African Americans patients and that activate African American patients to participate in their health care are important strategies for addressing racial/ethnic disparities in health care.

Affect↗

PubMed2004

Prenatal patients' views of prenatal care services: a medical center-based assessment of knowledge and intent to use support services.

BACKGROUND: Our objective was to ascertain the priority of prenatal support services from the perspective of high-risk patients. The relationship between patients' needs, and both knowledge of and intent to use services, was examined, while documenting factors associated with the intent to use available support services. METHODS: The authors of this study conducted a cross-sectional survey of 102 African-American women at a university-affiliated, urban-health center. Patients' priority support needs were compared to their knowledge of and intent to use support services using chi-square statistics. Logistic regression was used to determine factors independently associated with patients' intent to use 5 support services (substance abuse counseling, community referrals, health education, nutrition services, and social work services), while adjusting for potential socioeconomic confounding variables, knowledge, and need for services. RESULTS: Knowledge of existing services was independently associated with patient intent to use one or more support services (odds ratio 3.6; confidence interval 1.4-9.4). With each one-unit increase in parity, a 30% less odds (odds ratio 0.7; confidence interval 0.4-0.9) of using one or more support services occurred. CONCLUSIONS: Physicians should ensure prenatal patients' knowledge of support services at healthcare centers. Multiparity is inversely related to women's intent to use support services, independent of their knowledge of service availability.

Academic Medical Centers↗