Surrogate consent for living related organ donation.
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Adult↗
Biomedical subjects
Neil Wenger
Publications and source records attributed to Neil Wenger.
New technology and the orthopaedic surgeon: are you protecting your patients?
The treatment of patients with musculoskeletal disease will be revolutionized during the next two decades by advances in technology. Orthopaedic surgeons are eager to incorporate new technology into their practices to improve patient outcomes and practice efficiency. However, as the orthopaedic community embraces new technology and innovative surgical procedures, there is an increased need to consider issues of patient safety and to determine the best way to incorporate technology into our practices.
Conflict of Interest↗
The effects of payment method on clinical decision-making: physician responses to clinical scenarios.
BACKGROUND: The influence of payment mechanisms on physician decisions is not well understood. OBJECTIVES: The objective of this study was to test 2 null hypotheses: 1) physicians' clinical decisions would not be influenced by payment incentives; and 2) physicians would have equal concern about medical decisions made under capitation or fee-for-service (FFS) arrangements. RESEARCH DESIGN: We conducted a physician survey in which patient insurance status (capitated or FFS) was randomly incorporated into 4 clinical scenarios using a Latin square design. SUBJECTS: We used a nationally representative random sample of family physicians in direct patient care. MEASURES: We used treatment decisions and physician "bother" scores (a measure of discomfort about decisions) in response to the clinical scenarios and adjusted for physician gender, age, board certification, income, practice location, practice mix, practice setting, geographic region, local area managed care penetration, and capitation or risk pool contracts in practice. RESULTS: Seventy-two percent of sampled physicians responded. Comparing decisions made under capitation to FFS, physicians were less likely to indicate they would perform discretionary care (relative risks [RR] range, .64-.82; P<0.001), but payment had no effect on selection of life-saving care (RR, 1.02, not significant). Physicians felt significantly more "bothered" when they made clinical decisions under capitated payment (P<0.001 in all scenarios), regardless of whether a treatment was discretionary or life-saving, and whether the decision was made for or against the treatment (P<0.001). CONCLUSIONS: Payment mechanism has significant effects on clinical decision-making. Reduction of resources spent for discretionary care might be achieved under capitated arrangements; however, physicians respond with greater levels of discomfort under capitation than FFS.
Attitude of Health Personnel↗
The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine.
The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep-ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.
Career Choice↗
Physician recognition of cognitive impairment: evaluating the need for improvement.
OBJECTIVES: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition. DESIGN: Survey of physicians and review of medical records. SETTING: Health maintenance organization in southern California. PARTICIPANTS: Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study). MEASUREMENTS: Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia. RESULTS: Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04-1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03-1.45) or stroke (RR=1.37, 95% CI=1.04-1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23-0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09-0.88) or cancer (RR=0.49, 95% CI=0.18-0.90). CONCLUSION: Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia.
Aged↗
The diverse older HIV-positive population: a national profile of economic circumstances, social support, and quality of life.
The objectives of this study were to provide a national profile of socioeconomic circumstances of the middle-aged and older population living with HIV and to evaluate variations in social support and quality of life (QOL) across age and socioeconomic subgroups, controlling for indicators of disease progression. The design used was a cross-sectional analysis of nationally representative interview data on HIV-infected individuals collected in the HIV Cost and Services Utilization Study. Multiple measures of social support and QOL were used. Bivariate comparisons of outcomes across categories of age and exposure category were performed; multivariate analyses to isolate the effect of older age on outcomes within exposure categories were performed, controlling for socioeconomic and clinical co-variates. Study results indicate that older gay men with HIV/AIDS are a predominantly white population and more likely to have health insurance than their younger counterparts; 38% were employed and 48% reported incomes of more than $25,000. Older injection drug users (IDUs) with HIV/AIDS are a predominantly black population with a particularly high concentration of disadvantages; only 11% were employed and 74% reported incomes of less than $10,000. Older IDUs reported especially low levels of physical functioning and emotional support in comparison with their younger counterparts, whereas older gay men did not significantly differ from younger gay men in these respects. The authors conclude that characteristics and care needs of the older HIV-positive population are very diverse and vary sharply by exposure route. Interventions need to be tailored to the needs of these distinct subpopulations, with an emphasis on development of supportive care interventions for older IDUs.
Acquired Immunodeficiency Syndrome↗
Use of complementary/alternative therapies by women with advanced-stage breast cancer.
BACKGROUND: This study sought to describe the pattern of complementary/alternative medicine (CAM) use among a group of patients with advanced breast cancer, to examine the main reasons for their CAM use, to identify patient's information sources and their communication pattern with their physicians. METHODS: Face-to-face structured interviews of patients with advanced-stage breast cancer at a comprehensive oncology center. RESULTS: Seventy three percent of patients used CAM; relaxation/meditative techniques and herbal medicine were the most common. The most commonly cited primary reason for CAM use was to boost the immune system, the second, to treat cancer; however these reasons varied depending on specific CAM therapy. Friends or family members and mass media were common primary information source's about CAM. CONCLUSIONS: A high proportion of advanced-stage breast cancer patients used CAM. Discussion with doctors was high for ingested products. Mass media was a prominent source of patient information. Credible sources of CAM information for patients and physicians are needed.
Adult↗
Acculturation of attitudes toward end-of-life care: a cross-cultural survey of Japanese Americans and Japanese.
OBJECTIVE: Cross-cultural ethical conflicts are common. However, little is known about how and to what extent acculturation changes attitudes toward end-of-life care and advance care planning. We compared attitudes toward end-of-life care among Japanese Americans and Japanese in Japan. DESIGN: Self-administered questionnaire in English and Japanese. SETTING AND PARTICIPANTS: Community-based samples of Japanese Americans in Los Angeles and Japanese in Nagoya, Japan: 539 English-speaking Japanese Americans (EJA), 340 Japanese-speaking Japanese Americans (JJA), and 304 Japanese living in Japan (JJ). MEASUREMENTS AND MAIN RESULTS: Few subjects (6% to 11%) had discussed end-of-life issues with physicians, while many (EJA, 40%; JJA, 55%; JJ, 54%) desired to do so. Most preferred group surrogate decision making (EJA, 75%; JJA, 57%; JJ, 69%). After adjustment for demographics and health status, desire for informing the patient of a terminal prognosis using words increased significantly with acculturation (EJA, odds ratio [OR] 8.85; 95% confidence interval, [95% CI] 5.4 to 14.3; JJA, OR 2.8; 95% CI 1.8 to 4.4; JJ, OR 1.0). EJA had more-positive attitudes toward forgoing care, advance care planning, and autonomous decision making. CONCLUSION: Preference for disclosure, willingness to forgo care, and views of advance care planning shift toward western values as Japanese Americans acculturate. However, the desire for group decision making is preserved. Recognition of the variability and acculturation gradient of end-of-life attitudes among Japanese Americans may facilitate decision making and minimize conflicts. Group decision making should be an option for Japanese Americans.
Acculturation↗
The invalid advance directive.
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Advance Care Planning↗
Institutional ethics: hospital practices and policies for denying life-sustaining treatment.
Explore the source record for details and available documents.
Brain Death↗
Quality indicators for the management of medical conditions in nursing home residents.
PURPOSE: The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vulnerable elders. METHODS: A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an "if" statement, describing persons to whom the quality indicator applied followed by a "then" statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators. RESULTS: One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care addressing assessment, management, and follow up. Fifty-five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis. CONCLUSIONS: Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.
Aged↗
Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents.
PURPOSE: The assessment and management of dementia, falls and mobility disorders, malnutrition, end-of-life issues, pressure ulcers, and urinary incontinence have been identified as important quality improvement targets for vulnerable elders residing in nursing homes. This study aimed to identify valid and feasible measures of specific care processes associated with improved outcomes for these conditions. METHODS: Nine experts in nursing home (NH) care participated in a modified Delphi process to evaluate potential quality indicators (QIs) for care in NHs. Panelists met and discussed potential indicators before completing confidential ballots rating validity (process associated with improved outcomes), feasibility of measurement (with charts or interviews), feasibility of implementation (given staffing resources in average community NHs), and importance (expected benefit and prevalence in NHs). The NH panel's median votes were used to identify a final set of QIs that were subsequently reviewed by a clinical oversight committee. RESULTS: Sixty-eight geriatric syndrome QIs were identified as valid and important in NH populations. Panelists assessed 12 (18%) of these QIs as having questionable feasibility to implement in average community nursing homes trying to provide quality care. Nine (13%) would not be included in systems assessing quality of care for persons with advanced dementia or poor prognosis. CONCLUSIONS: Steps of care critical to the assessment and management of geriatric syndromes in NHs were identified. Feasibility is an important issue for a significant number of these, indicating that much remains to be done to design systems that efficiently and reliably implement these care processes.
Accidental Falls↗
Preferences for cardiopulmonary resuscitation among patients 80 years or older: the views of patients and their physicians.
OBJECTIVE: To describe the cardiopulmonary resuscitation (CPR) preferences of hospitalized patients aged 80 and older. To examine physicians' perceptions of their patients' preferences and agreement between patients' and physicians' preferences, estimation of prognosis, and assessment of quality of life. DESIGN: Prospective cohort study. SETTING: Four academic hospitals. PARTICIPANTS: Patients 80 years or older hospitalized between January 1993 and November 1994. MEASUREMENTS: Detailed clinical data were collected by chart review and interview. Patients and physicians were interviewed to determine their preferences for cardiopulmonary resuscitation (CPR). Agreement between patients and physicians was assessed using the kappa statistic, which measures agreement beyond chance. RESULTS: Of the 1266 patients studied, their median age was 85 years, and 61% were female. The majority (55%) of the 1010 patients with CPR preference information available desired CPR. Compared with patients, fewer physicians wanted CPR (36%) if they were in their patients' condition. Agreement between patients' preferences and physicians' perceptions of these preferences was low (absolute agreement 63%, kappa = 0.21). Agreement was better between physicians' perceptions of patients' preferences and physicians' desire for themselves if they were in their patients' condition (66%, kappa = 0.36). Agreement between patients' and physicians' estimates of survival was only slight (46%, kappa = 0.10). The majority of the disagreement occurred when the physician's prognostic estimate was worse than the patient's. CONCLUSIONS: The majority of hospitalized patients 80 years older wanted CPR. When asked to imagine themselves in the same clinical situation as their patients, physicians were much less likely to want CPR and viewed CPR as undesirable for most patients. Physicians' estimates of patients' prognoses were less optimistic than patients' estimates, raising the possibility that physicians' knowledge of older patients' poor outcomes from CPR explains their lack of enthusiasm about CPR for most patients 80 years and older.
Academic Medical Centers↗
Quality indicators for the management of medical conditions in nursing home residents.
PURPOSE: The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vulnerable elders. METHODS: A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an "if" statement, describing persons to whom the quality indicator applied followed by a "then" statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators. RESULTS: One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care addressing assessment, management, and follow up. Fifty-five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis. CONCLUSIONS: Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.
Aged↗
Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents.
PURPOSE: The assessment and management of dementia, falls and mobility disorders, malnutrition, end-of-life issues, pressure ulcers, and urinary incontinence have been identified as important quality improvement targets for vulnerable elders residing in nursing homes. This study aimed to identify valid and feasible measures of specific care processes associated with improved outcomes for these conditions. METHODS: Nine experts in nursing home (NH) care participated in a modified Delphi process to evaluate potential quality indicators (QIs) for care in NHs. Panelists met and discussed potential indicators before completing confidential ballots rating validity (process associated with improved outcomes), feasibility of measurement (with charts or interviews), feasibility of implementation (given staffing resources in average community NHs), and importance (expected benefit and prevalence in NHs). The NH panel's median votes were used to identify a final set of QIs that were subsequently reviewed by a clinical oversight committee. RESULTS: Sixty-eight geriatric syndrome QIs were identified as valid and important in NH populations. Panelists assessed 12 (18%) of these QIs as having questionable feasibility to implement in average community nursing homes trying to provide quality care. Nine (13%) would not be included in systems assessing quality of care for persons with advanced dementia or poor prognosis. CONCLUSIONS: Steps of care critical to the assessment and management of geriatric syndromes in NHs were identified. Feasibility is an important issue for a significant number of these, indicating that much remains to be done to design systems that efficiently and reliably implement these care processes.
Aged↗