Biomedical subjects

Rahman Azari

Publications and source records attributed to Rahman Azari.

At least 19 recordsLinked to original sources

PubMed2006

Body mass index is not a good predictor of bone density: results from WHI, CHS, and EPIDOS.

Body mass index (BMI) is often used to predict bone mineral density (BMD). This may be flawed. Large epidemiologic studies with BMI and BMD data were analyzed. Weight alone is a better predictor of BMD than BMI. Thus, when selecting individuals for dual-energy X-ray absorptiometry, weight should be used instead of BMI. Low body mass index (BMI) is frequently suggested as one of the factors that indicates the need for bone mineral density (BMD) screening for osteoporosis. The inclusion of the height-squared term in the denominator of this predictive factor is taken on faith or from other data, but it may not be reasonable in this case. We used data from three large epidemiologic studies to test the BMI, height, and weight as predictors of BMD: (1) the Women's Health Initiative (WHI) with 11,390 women; (2) the Cardiovascular Health Study (CHS) with 1,578 men and women; (3) and EPIDOS with 7,598 women. Dual-energy X-ray absorptiometry data on one or more BMD sites, the total hip, the femoral neck, and the lumbar spine from the three studies, as well as height and weight were examined. Correlation coefficients for BMI and weight with BMD were compared. Log transformed models were evaluated to compare the strengths of the models. The result of weight alone was a much better predictor of BMD for all sites in the three studies than BMI. Taller participants had larger BMDs than would have been predicted by BMI. In conclusion, BMIs should not be used to select individuals for BMD screening. A regression model using weight alone or weight and height is a better predictor of BMD in all three populations.

Absorptiometry, Photon↗

PubMed2006

Assessing resident's knowledge and communication skills using four different evaluation tools.

PURPOSE: This study assesses the relationship between 4 Accreditation Council for Graduate Medical Education (ACGME) outcome project measures for interpersonal and communication skills and medical knowledge; specifically, monthly performance evaluations, objective structured clinical examinations (OSCEs), the American Board of Family Practice in-training examination (ABFP-ITE) and the Davis observation code (DOC) practice style profiles. METHODS: Based on previous work, we have DOC scoring for 29 residents from the University of California, Davis Department of Family and Community Medicine. For all these residents we also had the results of monthly performance evaluations, 2 required OSCE exercises, and the results of 3 American Board of Family Medicine (ABFM) ITEs. Data for each of these measures were abstracted for each resident. The Pearson correlation coefficient was used to assess the presence or lack of correlation between each of these evaluation methods. RESULTS: There is little correlation between various evaluation methods used to assess medical knowledge, and there is also little correlation between various evaluation methods used to assess communication skills. CONCLUSION: The outcome project remains a 'work in progress', with the need for larger studies to assess the value of different assessment measures of resident competence. It is unlikely that DOC will become a useful evaluation tool.

Clinical Competence↗

PubMed2006

The influence of obesity, alcohol abuse, and smoking on utilization of health care services.

BACKGROUND AND OBJECTIVES: There is extensive evidence relating individual behavioral risk factors to adverse health outcomes and associated costs; however, more-comprehensive assessments have been limited. Our objective was to examine the relative effects of obesity, alcohol abuse, and smoking on health care use and associated charges. METHODS: New adult patients (n=509) were randomly assigned to primary care physicians, and their utilization of medical services was monitored for 1 year. Variables measured included sociodemographics, self-reported health status, Beck Depression Index, measured body mass index, Michigan Alcohol Screening Test results, and smoking history. RESULTS: Controlling for health status, depression, age, education, income, and gender, obesity was associated with the mean number of primary care visits, diagnostic services, and primary care clinic charges. Alcohol abuse was related to the mean number of emergency department visits and diagnostic services. Smoking was associated with the mean number of specialty clinic visits and hospitalizations. Smoking also predicted charges for emergency department visits, hospitalizations, and total health care charges. CONCLUSIONS: The economic burden of smoking is significant, even after only 1 year. Health care providers should focus attention on smoking prevention and cessation programs as an approach for managing medical costs.

Adult↗

PubMed2005

Preferences of Women Evaluating Risks of Tamoxifen (POWER) study of preferences for tamoxifen for breast cancer risk reduction.

BACKGROUND: The objective of this study was to understand the attitudes and preferences of risk-eligible women regarding use of tamoxifen for breast cancer risk reduction. METHODS: A cross-sectional, mixed-methods interview study was conducted at a university medical center and at community sites. Participants were women who had an estimated 5-year breast cancer risk > or = 1.7% and no prior breast cancer. Interviews were conducted in English or Spanish. The interview included a 15-minute, standardized educational session on the potential benefits and harms of tamoxifen followed by close-ended and open-ended questions about participants' inclinations to take tamoxifen and factors important to their decision. A demographic questionnaire, a test on knowledge of potential benefits and harms of tamoxifen, and an interview evaluation were included. RESULTS: Two hundred fifty-five women completed interviews. Their estimated mean 5-year breast cancer risk was 2.8%; and their mean self-perceived 5-year risk was 32.7%. After the educational intervention, 45 women (17.6%) were inclined to take tamoxifen. Very high risk women (> 3.5%) were no more inclined to take it than women with lower risk (1.7-3.5%). In a multivariable analysis, lower income, confidence in the effectiveness of tamoxifen, and concern about fractures were associated with being inclined to take it; concern about pulmonary embolism, dyspareunia, cataracts, and low self-perceived breast cancer risk were associated negatively with taking tamoxifen. Participants expressed concerns about adverse effects. CONCLUSIONS: Less than 20% of women were interested in tamoxifen after education about potential benefits and harms, despite a very high self-perceived breast cancer risk. Candidate chemoprevention agents must have few potential adverse effects to achieve widespread acceptance.

Adult↗

PubMed2005

Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.

CONTEXT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. OBJECTIVE: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. DESIGN: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). SETTING: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. INTERVENTIONS: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. MAIN OUTCOME MEASURES: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. RESULTS: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). CONCLUSIONS: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Adjustment Disorders↗

PubMed2005

The impact of obesity on primary care visits.

OBJECTIVE: To investigate the influence of patient obesity on primary care physician practice style. RESEARCH METHODS AND PROCEDURES: This was a randomized, prospective study of 509 patients assigned for care by 105 primary care resident physicians. Patient data collected included sociodemographic information, self-reported health status (Medical Outcomes Study Short Form-36), evaluation for depression (Beck Depression Index), and satisfaction. Height and weight were measured to calculate the BMI. Videotapes of the visits were analyzed using the Davis Observation Code (DOC). RESULTS: Regression equations were estimated relating obesity to visit length, each of the 20 individual DOC codes, and the six DOC Physician Practice Behavior Clusters, controlling for patient health status and sociodemographics. Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health (p = 0.0062) and more time discussing exercise (p = 0.0075). Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese (p = 0.0528). Mean pre-visit general satisfaction for obese patients was significantly lower than for non-obese patients (p = 0.0069); however, there was no difference in post-visit patient satisfaction. DISCUSSION: Patient obesity impacts the medical visit. Further research can promote a greater understanding of the relationships between obese patients and their physicians.

Adolescent↗

PubMed2005

Obesity and the use of health care services.

OBJECTIVE: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. RESEARCH METHODS AND PROCEDURES: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self-reported health status using the Medical Outcomes Study Short Form-36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. RESULTS: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. DISCUSSION: Obesity is a chronic condition requiring long-term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity-related diseases will continue to grow, resulting in escalating use of health care services.

Adult↗

PubMed2005

Recruitment strategies for minority participation: challenges and cost lessons from the POWER interview.

BACKGROUND: The importance of recruiting and retaining women from diverse populations is well recognized; however, the recruitment process often presents greater challenges at higher costs than initially anticipated. OBJECTIVES: To describe recruitment strategies and costs from a study evaluating women's preferences regarding tamoxifen use for primary prevention of breast cancer. DESIGN: Description and analysis of recruitment strategies, outcomes, and costs for a cross-sectional interview study. SETTING: University hospital and community sites. PARTICIPANTS: 932 racially and ethnically diverse women respondents, of whom 771 completed the screening process (aged 27-87). INTERVENTION: Women were recruited and screened by using the Breast Cancer Risk Assessment Program (BCRA version 1, National Cancer Institute). Eligibility required an estimated five-year breast cancer risk of at least 1.7%. Recruitment goals targeted a high percentage of ethnic minorities. METHODS: Recruitment strategies included direct mail, flyers, newspapers, media advertising, and community outreach. RESULTS: Of the 771 screened women, 341 (44%) met eligibility criteria and 255 (33%) completed interviews (76.9% White, 10.6% Latina, 7.0% Asian, 3.9% African American, 1.6% Native American). Recruitment costs averaged US $113/screened participant. Direct mail and community contact yielded the largest number of participants (312 screened, 205 eligible). Radio advertising provided few participants (one screened, one eligible) at high cost. CONCLUSIONS: Recruiting an ethnically diverse sample presented multiple challenges. We recommend that future studies budget adequately for recruitment time and costs, develop ongoing relationships with key community leaders, evaluate recruitment strategies closely, and report detailed recruitment findings to the research community.

Adult↗

PubMed2004

Validity of scores generated by a web-based multimedia simulated patient case software: a pilot study.

PURPOSE: The value of multimedia simulated patient cases (MSPCs) in medical education remains unclear. The authors conducted a pilot study to assess the validity of automated scores of diagnostic reasoning ability provided by DxR Clinician, a widely available Web-based MSPC software. METHOD: In 2002-03, all 89 students enrolled in a required third-year primary care clerkship at the University of California, Davis, School of Medicine were assigned to complete four MSPCs. The authors determined the degree of correlation between the Clinical Reasoning Score (CRS) and Level of Diagnostic Performance (LDP) generated by the MSPC software and subscale scores from a validated measure of diagnostic reasoning sophistication, the Diagnostic Thinking Inventory (DTI). RESULTS: Of 356 completed case events, instructor override of automated scoring was required in 206 (58%) to obtain an accurate LDP and CRS. Mean DTI subscale scores improved significantly from the beginning to the end of the year (p <.0001, Wilcoxon signed rank test). However, there were no significant correlations between CRS or LDP scores on any of the four cases and either of the two DTI subscale scores. CONCLUSION: Automated diagnostic reasoning scores generated by one widely available MSPC software appear to lack criterion validity. The validity of automated diagnostic reasoning scores generated by MSPCs should be established before such cases can be confidently employed as educational tools.

Clinical Clerkship↗

PubMed2003

Nonparametric regression to the mean.

Available data may reflect a true but unknown random variable of interest plus an additive error, which is a nuisance. The problem in predicting the unknown random variable arises in many applied situations where measurements are contaminated with errors; it is known as the regression-to-the-mean problem. There exists a well known solution when both the distributions of the true underlying random variable and the contaminating errors are normal. This solution is given by the classical regression-to-the-mean formula, which has a data-shrinkage interpretation. We discuss the extension of this solution to cases where one or both of these distributions are unknown and demonstrate that the fully nonparametric case can be solved for the case of small contaminating errors. The resulting nonparametric regression-to-the-mean paradigm can be implemented by a straightforward data-sharpening algorithm that is based on local sample means. Asymptotic justifications and practical illustrations are provided.

Algorithms↗

PubMed2003

Direct observation of requests for clinical services in office practice: what do patients want and do they get it?

BACKGROUND: Requests can influence the conduct and content of the medical visit. However, little is known about the nature, frequency, and impact of such requests. We performed this study to ascertain the prevalence, antecedents, and consequences of patients' requests for clinical services in ambulatory practice. METHODS: This observational study combined patient and physician surveys with audiotaping of 559 visits to 45 physicians in 2 health care systems between January and November 1999. All patients had a new problem or significant health concern. Main outcome measures included prevalence of 8 categories of requests for physician action; odds of patients' requesting tests, referrals, or new prescriptions; odds of physicians' ordering diagnostic tests, making specialty referrals, or writing new prescriptions; patient satisfaction; and physicians' perceptions of the visit. RESULTS: The 559 patients made 545 audiocoded requests for physician action; 23% requested at least 1 diagnostic test, specialty referral, or new prescription medication. Requests for diagnostic tests were more common among new patients (P<.001). Requests for any clinical service were more common among patients experiencing greater health-related distress (P<.05) and less common among patients of cardiologists (P<.001). After adjusting for predisposing, need, and contextual factors, referral requests were associated with higher odds of receiving specialty referrals (adjusted odds ratio [AOR], 4.1; 95% confidence interval [CI], 1.6-10.7) and prescription requests were associated with higher odds of receiving new prescription medications (AOR, 2.8; 95% CI, 1.2-6.3). Physicians reported that visits during which patients requested diagnostic tests were more demanding than visits in which no such requests were made (P =.02). CONCLUSIONS: Though more common in primary care than in cardiology, patients' requests for clinical services are both pervasive and influential. The results support placing greater emphasis on understanding and addressing the patient's role in determining health care utilization.

Adult↗

PubMed2003

Impact of environmental tobacco smoke on children with sickle cell disease.

BACKGROUND: Parallels between the biological effects of exposure to environmental tobacco smoke (ETS) on nonsmokers and the pathophysiology of sickle cell disease (SCD) suggest that complications of SCD could be exacerbated by ETS exposure. OBJECTIVE: To determine whether children with SCD who are exposed to ETS at home have more sickle cell crises than do those who live in nonsmoking households. DESIGN: A retrospective cohort study in which ETS exposure was measured by using a survey of caretakers and patients. SETTING: A university-based pediatric sickle cell center. PARTICIPANTS: Fifty-two of 66 eligible children aged 2 to 18 years with SCD. OUTCOME MEASURES: The number of sickle cell vaso-occlusive crises requiring hospitalization per patient during the 2-year study (inpatient sickle cell crises). Total hospital days and hospital costs were secondary outcome measures. RESULTS: Patients exposed to ETS had more inpatient sickle cell crises than did unexposed patients (mean +/- SD, 3.7 +/- 5.7 vs 1.7 +/- 3.5; P =.02), and this association retained significance after adjustment for important covariates (risk ratio, 1.9; 95% confidence interval, 1.3-2.7). Hospital costs were greater in the exposed group than in the unexposed group (mean +/- SD, 21,671 US dollars +/- 41,809 US dollars vs 9705 US dollars +/- 19 146 US dollars; effect estimate, 11.4; 95% confidence interval, 1.0-129.5). CONCLUSIONS: Children with SCD who are exposed to ETS have a higher risk of sickle cell crises requiring hospitalization than do those not exposed, independent of other factors known to increase the frequency of sickle cell crises. Decreasing the exposure of these children to ETS could reduce morbidity and may provide cost savings.

Adolescent↗

PubMed2003

A randomized trial of telenursing to reduce hospitalization for heart failure: patient-centered outcomes and nursing indicators.

This trial compared 3 post-hospitalization nursing care models for reducing congestive heart failure (CHF) readmission charges during 180-days of follow-up. Subjects received in-person visits at baseline and 60 days plus 1 of 3 care modalities in the interim: (a) video-based home telecare; (b) telephone calls; and (c) usual care. CHF-related readmission charges were > 80% lower in the telenursing groups compared to usual care, and these groups also had significantly fewer CHF-related emergency visits. In-person visits were more than 3 times longer than telenursing visits (p < 0.0001), only partially due to added travel time. Patient self-care adherence, medications, health status, and satisfaction did not significantly differ between groups. Telenursing can reduce CHF hospitalizations and allow increased frequency of communication with patients.

Aged↗

PubMed2003

Patient pain: its influence on primary care physician-patient interaction.

BACKGROUND AND OBJECTIVES: Heightened awareness of the importance of appropriate pain management in health care delivery has stimulated researchers to examine the impact of patient pain on medical encounters. In this study, we explored how patient pain might influence the physician-patient interaction during medical visits. METHODS: New adult patients (n = 509) were randomized to see primary care physicians in videotaped visits at a university medical center Self-reported patient pain was measured before the visit using the Visual Analog Scale and the Medical Outcomes Study Short Form-36 (MOS SF-36) pain scale; patient sociodemographics were also measured. Physician practice style during the visit was analyzed with the Davis Observation Code (DOC). RESULTS: Regression analyses revealed that patient pain during the medical visit was associated with the physician spending a greater portion of the visit on technical tasks and a smaller portion on preventive services and other activities designed to encourage the patients' active participation in their own health care. CONCLUSIONS: Patient pain may influence the physician-patient interaction and its outcomes. Primary care physicians should be aware that there may be less focus on patients' active involvement in their own care and less emphasis on providing disease prevention when treating patients who are experiencing pain.

Adult↗

PubMed2003

Effects of physician gender on patient satisfaction.

OBJECTIVES: To measure the impact of physician gender on patient satisfaction, controlling for confounding patient variables, and to examine the extent to which differences in satisfaction with male and female physicians can be explained by physician practice styles. METHOD: New adult patients (n=509) were randomized to see male and female primary care physicians at a university medical center outpatient facility. Patient sociodemographics and self-reported health status (using the Medical Outcomes Study Short Form-36) were measured before the initial visit, and satisfaction with the physician was measured immediately following the visit. The entire medical encounter was videotaped and physician practice style was later analyzed using the Davis Observation Code. RESULTS: Female physicians spent a significantly greater proportion of the visit on preventive services and counseling than male physicians did, and male physicians devoted more time to technical practice behaviors and discussions of substance abuse. Visit length was not significantly different for male and female physicians. Patients of female physicians were more satisfied than were those of male physicians, even after adjusting for patient characteristics, visit length, and physician practice style behaviors. CONCLUSION: Patient satisfaction with primary care physicians appears to be influenced not only by patient characteristics and physician behaviors, but also by the gender of the provider. Possible explanations for this may be that psychosocial aspects of the physician-patient interaction are different for male and female physicians. Patients may also bring expectations about female physicians to the encounter, presuming them to be more empathetic, nurturing, and responsive.

Adult↗

PubMed2003

Does time use in outpatient residency training reflect community practice?

BACKGROUND: The degree to which the ideals practiced during residency training persist amidst the pressures of community practice is unknown. Therefore, this paper compares time use during outpatient visits to family practice residents and experienced family physicians. METHODS: Visits of 244 new adult outpatients to 33 second- and third-year residents in a university clinic in Northern California were compared to 277 new adult outpatient visits to 92 community family physicians in Northeast Ohio, using the Davis Observation Code (DOC). The DOC uses observation to classify visit time into 20 different behavioral categories, reflecting different physician styles of interaction with patients. RESULTS: Controlling for patient mix, residents had longer visits, a less technical focus, and spent a greater percent of the visit on efforts to promote health behavior change, patient activation, preventive services, discussion of substance abuse, and counseling. CONCLUSIONS: Experienced family physicians provide more technical and less preventive and psychosocially oriented care than residents. This may reflect differences in patient mix, practice setting, physician experience, and the time and financial pressures of community practice. These findings may be used to modify residency training to better reflect actual community practice and to guide future studies of the effects of experience and different practice environments on physician style with patients.

Ambulatory Care↗

PubMed2002

Unmet expectations for care and the patient-physician relationship.

OBJECTIVE: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations. DESIGN: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit. SETTING: The offices of 45 family practice, internal medicine, and cardiology physicians. PATIENTS: Nine hundred nine adults reporting a health problem or concern. MEASUREMENTS AND MAIN RESULTS: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled. CONCLUSIONS: Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.

Cardiology↗

PubMed2002

Patient trust in the physician: relationship to patient requests.

BACKGROUND: Patient trust is a key component of the patient-physician relationship. A previous qualitative study has suggested that a low level of trust is associated with unfulfilled requests. OBJECTIVE: Our aim was to test the hypothesis that patients with a low level of trust will be more likely to report that requested or needed services were not provided during an office visit. METHODS: An observational study was carried out of office visits by 732 patients of 45 physicians (16 family physicians, 18 general internists and 11 cardiologists), within two managed care settings. Participants were consecutive, English-speaking patients, age 18 and older who had a significant health concern. Visit questionnaires were completed by 68% of patients known to be eligible. Post-visit measures included services requested (information, examination, prescription, test or referral); services provided; and requested or needed services not provided during the visit. Measures at 2-week follow-up included patient satisfaction, intended adherence to advice, interval contacts with the health system and symptom improvement. RESULTS: After adjustment for patient and physician characteristics, patient trust in the physician was not associated with the likelihood that a service was requested or provided during the visit, with the exception that prescription of a new medication was more frequent among patients with higher trust. In contrast, patients with low trust prior to the visit consistently were more likely to report that a needed or requested service was not provided (P < 0.001 for all services). Patients with a low level of trust were less satisfied with their care (P < 0.001), were less likely to intend to follow the doctor's advice (P < 0.001) and were less likely to report symptom improvement at 2 weeks (P = 0.03). CONCLUSIONS: Patients with a lower level of trust in their physician are more likely to report that requested or needed services are not provided. Understanding this relationship may lead to better ways of responding to patient requests that preserve or enhance patient trust, leading to better outcomes.

Adult↗