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PubMed2000

Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission.

BACKGROUND AND PURPOSE: The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment. METHODS: Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use. RESULTS: The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively). CONCLUSIONS: Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.

Age Factors↗

PubMedDate not supplied

Effect of training on physician attitudes and practices in home and community care of the elderly.

OBJECTIVES: To evaluate the effectiveness of continuing medical education seminars in changing physician attitudes and practice approaches to the provision of home health care and use of community resources, to increase physician awareness of the needs of homebound older adults, and to teach physicians appropriate medical management in the home. DESIGN: A quasi-experimental pretest and multiple posttest design. SETTING: Twenty-six seminars were conducted at medical and specialty society annual meetings in 10 states selected for their high proportion of elderly and minority populations. PARTICIPANTS: Experimental subjects were a convenience sample of 355 primary care physicians who attended the seminars for which continuing medical education credits were granted. The control subjects were a proportional sample of 249 primary care physicians randomly selected from the American Medical Association Physician Masterfile matched for age, sex, locus of training (United States or abroad), and specialty. INTERVENTION: A half-day interactive seminar. Participants were given a packet of printed materials that reinforced subject matter presented during the seminar. Core faculty for each state consisted of 2 physicians, a home health nurse, and a case manager who was familiar with community resources; physician faculty were identified by peers as local opinion leaders. All participated in a "train-the-trainer" workshop held at the American Medical Association, Chicago, Ill. Questionnaires were administered to the experimental group before the start of the seminar, immediately following the seminar, and 3 months later. The control group completed baseline and follow-up questionnaires but did not attend the seminars. MAIN OUTCOME MEASURES: Change in physician attitudes toward providing geriatric home care, the degree to which physicians made accommodations in office practices to better manage care of patients at home, and physician willingness to use community resources. RESULTS: Compared with preseminar attitudes, participants reported a change in feelings of adequacy to provide home care, as well as changes in office practice, number of home visits, and referrals to community agencies (P=.001). Before and after the seminars, US-educated male physicians were more likely to make home visits than female physicians or international medical graduates. At the 3-month follow-up, male international medical graduates were similar to US-trained male physicians. Regardless of sex or locus of training, having a high proportion (>50%) of Medicaid or minority patients or both is inversely associated with willingness to make home visits. CONCLUSIONS: The seminars achieved the intended outcomes of bridging the gap in the awareness and provision of geriatric home health care and of producing physician attitude and behavior change.

Aged↗

PubMed1998

Physician resource use and willingness to participate in assisted suicide.

OBJECTIVE: To explore the relationship between general internists' tendency to conserve medical resources and their willingness to participate in physician-assisted suicide (PAS). DESIGN AND PARTICIPANTS: Survey of a random sample of general internists in 6 urban areas of the United States. MEASUREMENTS: We assessed the physicians' use of medical resources by constructing a scale based on 6 hypothetical clinical scenarios in which respondents were given a choice between resource-intensive and resource-conserving options. We then presented a scenario of a competent terminally ill patient with breast cancer making stable and persistent requests for PAS. RESULTS: Sixty-seven (33%) of the 206 respondents indicated that they would participate in the suicide of the depicted patient. In a multivariate model, physicians who were more conservative with resources were 6.4 times more likely than their resource-intensive counterparts to prescribe the requested drugs (P = .02); minority physicians were less willing than whites to participate in PAS (odds ratio, 0.34; P = .03). Physicians' number of years in practice, location, sex, reported percentage of fee-for-service patients, and self-reported strength and direction of financial incentives in the respondents' practices were not associated with willingness to prescribe drugs for PAS. CONCLUSIONS: Most general internists, especially minority physicians, are personally reluctant to participate in PAS. While the characteristics of their practices do not affect PAS, physicians who tend to practice resource-conserving medicine are significantly more likely than their resource-intensive counterparts to provide a lethal prescription at the request of a terminally ill patient.

Health Resources↗

PubMed2000

Attitudes and practices concerning the end of life: a comparison between physicians from the United States and from The Netherlands.

BACKGROUND: This study compares attitudes and practices concerning the end-of-life decisions between physicians in the United States and in the Netherlands, using the same set of questions. METHODS: A total of 152 physicians from Oregon and 67 from the Netherlands were interviewed using the same questions about (1) their attitudes toward increasing morphine with premature death as a likely consequence, physician-assisted suicide (PAS), and euthanasia; and (2) their involvement in cases of euthanasia, PAS, or the ending of life without an explicit request from the patient. Odds ratios, with 95% confidence intervals, were calculated to investigate relation between attitudes and various characteristics of the respondents. RESULTS: American physicians found euthanasia less often acceptable than the Dutch, but there was similarity in attitudes concerning increasing morphine and PAS. American physicians found increasing morphine and PAS more often acceptable in cases where patients were concerned about becoming a burden to their family. There was a discrepancy between the attitudes and practices of Dutch physicians concerning PAS. The proportions of physicians having practiced euthanasia, PAS, or ending of life without an explicit request from the patient differ more between the countries than do their attitudes, with American physicians having been involved in these practices less often than the Dutch. CONCLUSIONS: In this study of American and Dutch physicians, 2 important differences emerge: different attitudes toward the patient who is concerned over being a burden, and different frequency of euthanasia and PAS in the two countries.

Adult↗

PubMedDate not supplied

Regional and institutional variation in the initiation of early do-not-resuscitate orders.

BACKGROUND: Do-not-resuscitate (DNR) orders are an important step in decision making about aggressiveness of care for patients in hospitals. The use of DNR orders is known to vary with patient characteristics, but few studies have investigated the role of hospital factors or of regional variation. We examined these influences on the use of early DNR orders (written <24 hours after admission). METHODS: We conducted a retrospective cross-sectional study of patients 50 years and older admitted to acute-care hospitals in California in 2000 from the most prevalent medical and surgical diagnosis related groups. We performed multivariate logistic regression predicting use of DNR by hospital characteristics while accounting for patient characteristics, and estimated indirectly standardized rates of DNR use by county. RESULTS: In the selected diagnosis related groups, 819 686 persons were admitted to 386 hospitals. Early DNR orders varied from 2% (patients aged 50-59 years) to 17% (patients aged > or =80 years). In multivariate analyses, the odds of having early DNR orders written were significantly lower in for-profit (vs private nonprofit) hospitals, higher in the smallest (vs the largest) hospitals, and lower in academic (vs nonacademic) hospitals. Standardized rates of DNR order use varied 10-fold across counties. The highest rates were among patients from rural areas. However, variation in use did not correspond well to county population, hospital bed availability, or population density. CONCLUSIONS: Hospital characteristics appear to be associated with the use of DNR orders, even after accounting for differences in patient characteristics. This association reflects institutional culture, technological bent, and physician practice patterns. If these factors do not match patient preferences, then improvements in care are needed.

Aged↗

PubMed1999

National survey of pediatricians' violence prevention counseling.

BACKGROUND: Recommendations for child health care providers to counsel patients and their families on violence prevention have been issued by a number of major health care organizations. OBJECTIVE: To assess the knowledge, attitudes, training, and practices of pediatricians concerning violence prevention counseling in the areas of family violence, discipline, television viewing, peer violence, and guns in the home. DESIGN: Survey. PARTICIPANTS: A national random sample of 1350 pediatricians, divided equally among residents in their final year of training, practitioners who had completed their residency training within the last 5 years, and those who had completed their training more than 5 years ago. MAIN OUTCOME MEASURES: Knowledge, attitudes, training, and current practices regarding violence prevention counseling. RESULTS: The overall response rate was 41%. When providing health supervision to patients, most pediatricians never or rarely screen for family and community violence, peer violence, and weapons. For example, 68% of residents and 73% of practitioners never or rarely screen for domestic violence, 56% of residents and 67% of practitioners never or rarely ask adolescents about their involvement in physical fighting, and 54% of residents and 56% of practitioners never or rarely identify families who have guns in the home. Regarding preparation for providing violence prevention counseling, 76% of residents and 83% of practitioners rated their training as inadequate. Receiving training in the prevention of child/adolescent violence in medical school (P<.001), residency (P<.001), or fellowship/continuing medical education (P=.002) were major determinants of more frequent violence prevention counseling. Pediatricians who believed that parents rarely or never follow through on a physician's advice about safe gun storage, switching to nonviolent disciplining techniques, or limiting their child's television viewing were less likely to ask or advise patients in these areas. CONCLUSIONS: Pediatricians are not adequately prepared to provide violence prevention counseling, and few currently screen for exposure to family and community violence, peer violence, and access to weapons. Comprehensive information about violence prevention should be integrated into medical education, and the efficacy of violence prevention counseling strategies should be evaluated.

Adult↗

PubMed2000

Minority and nonminority pediatricians' care of minority and poor children.

BACKGROUND: Although it has been established that minority physicians tend to see more minority and more poor or uninsured patients, pediatrics as a specialty has not been studied in this regard. OBJECTIVE: To determine if minority pediatricians disproportionately provide care to minority children and to poor and uninsured children, relative to nonminority pediatricians, while controlling for possible confounding variables (socioeconomic background, sex, use of non-English languages in practice, and subspecialty training). METHODS: In 1996, a stratified random sample of 1044 pediatricians, half of whom were underrepresented minorities (URMs) (African, Native, and Mexican Americans, mainland Puerto Ricans, and other Hispanics) and half of whom were Asian or Pacific Islanders, commonwealth Puerto Ricans, and whites (non-URMs), were surveyed about personal, practice, and patient characteristics. RESULTS: Multivariate analyses reveal that, independent of other variables, being a URM pediatrician is significantly (P = .001) and positively associated with caring for a greater proportion of minority and Medicaid-insured or uninsured patients. Underrepresented minority pediatricians saw 24 percentage points more minority patients and 13 percentage points more Medicaid-insured or uninsured patients than did non-URM pediatricians. CONCLUSIONS: Compared with what non-URM pediatricians report, URM pediatricians report caring for significantly (P =.001) more minority and poor and uninsured patients. Given the few pediatricians who are URM, non-URM pediatricians should be adequately prepared to provide care for minority patients, as the proportion of minority children is high and will be increasing significantly in the next several years. Most important, efforts to ensure a racially and ethnically diverse health care workforce should be greatly enhanced, as its diversity, and hence representativeness, will improve the health care system for all Americans.

Adult↗

PubMed2003

Physician variation in test ordering in the management of gastroenteritis in children.

OBJECTIVES: To describe the variation among physicians in test ordering when caring for children with gastroenteritis and to explore the effect of hospital charge information on such variation. DESIGN: Prospective, nonmasked, observational study and controlled trial of price information. SETTING: Urban, university-affiliated pediatric emergency department. PARTICIPANTS: Pediatric emergency medicine faculty (n = 10) and fellows (n = 5). METHODS: Test-ordering practices were reviewed during 3 periods: control, intervention, and washout. During the intervention period, test charge information was placed on patients' emergency department records. Telephone contact with families was initiated 7 days after care. RESULTS: We included 3198 visits. Individual physician mean test charges varied more than 2-fold during the control period (mean, 127 US dollars; range, 82 US dollars-185 US dollars). Based on their test charges (control period), physicians were assigned to the "high" (n = 8) or "low" (n = 7) test user group. Differences in mean charges in high vs low test users during the control period (144 US dollars vs 112 US dollars) persisted in the intervention period (80 US dollars vs 52 US dollars; Mann-Whitney P =.01), as did rates of intravenous fluid use (20% vs 14% in both periods). Among the lowest-acuity patients, low test users exhibited greater price sensitivity (vs high users). Patients treated by low test users did not differ in improved condition (82% vs 86%) or family satisfaction (93% vs 92%); they had more unscheduled follow-up (25% vs 17%; P<.01), but were no more often admitted (5% vs 3%; P =.11). CONCLUSIONS: Physicians varied in resource use when treating children with gastroenteritis. High and low test users were sensitive to price information. This intervention did not seem to compromise patient outcome.

Child↗

PubMed1986

Total cholecystectomy utilization by diagnosis related group.

Utilization rates for total cholecystectomy by diagnosis related group in Sacramento, Calif, and Syracuse, NY, between 1981 and 1984 were studied. The two areas had similar hospital discharge rates and bed supplies. The data included 8989 discharges. Discharge rates for the combined cholecystectomy diagnosis related groups differed by only 1% to 3%. Syracuse mean stays for these categories exceeded those of Sacramento by 34% to 38% and were the principal cause of differences in hospital utilization for the procedure. These differences were related to more conservative community-wide physician practice patterns in Syracuse rather than to differences in the composition of the samples by age and payor status, or to the impact of length of stay variability. In the future, shorter stays for cholecystectomy, such as those of Sacramento, may become the norm for the entire nation.

Adult↗

PubMed1998

Physicians' experiences and beliefs regarding informal consultation.

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.

Humans↗

PubMed2001

Oregon physicians' attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act.

CONTEXT: The Oregon Death with Dignity Act, passed by ballot measure in 1994 and enacted in October 1997, legalized physician-assisted suicide for competent, terminally ill Oregonians, but little is known about the effects of the act on clinical practice or physician perspective. OBJECTIVE: To examine Oregon physicians' attitudes toward and practices regarding care of dying patients since the passage of the Death with Dignity Act. DESIGN, SETTING, AND PARTICIPANTS: A self-administered questionnaire was mailed in February 1999 to Oregon physicians eligible to prescribe under the act. Of 3981 eligible physicians, 2641 (66%) returned the questionnaire by August 1999. MAIN OUTCOME MEASURES: Physicians' reports of their efforts to improve care for dying patients since 1994, their attitudes, concerns, and sources of information about participating in the Death with Dignity Act, and their conversations with patients regarding assisted suicide. RESULTS: A total of 791 respondents (30%) reported that they had increased referrals to hospice. Of the 2094 respondents who cared for terminally ill patients, 76% reported that they made efforts to improve their knowledge of the use of pain medications in the terminally ill. Nine hundred forty-nine responding physicians (36%) had been asked by a patient if they were potentially willing to prescribe a lethal medication. Seven percent of all survey participants reported that 1 or more patients became upset after learning the physician's position on assisted suicide, and 2% reported that 1 or more patients left their care after learning the physician's position on assisted suicide. Of the 73 physicians who were willing to write a lethal prescription and who had received a request from a patient, 20 (27%) were not confident they could determine when a patient had less than 6 months to live. CONCLUSION: Most Oregon physicians who care for terminally ill patients report that since 1994 they have made efforts to improve their ability to care for these patients and many have had conversations with patients about assisted suicide.

Adult↗

PubMed2000

Primary care physicians' perceptions of barriers to genetic testing and their willingness to participate in research.

Our objective was to explore the barriers and motivations to: 1) appropriate diffusion of genetic services into primary care practice; and 2) primary care physicians' (PCPs) willingness to participate in clinical studies to assess the safety and effectiveness of emerging genetic technologies. A random sample (n = 994) of PCPs was invited to be interviewed. Of the 80 who agreed, 60 were interviewed, 52 by telephone. A semi-structured guide was used. A questionnaire mailed to 752 of the PCPs was used to elicit information from physicians who did not want to be interviewed. Among interviewees, uncertainty as to the clinical utility and clinical validity of predictive genetic testing were the leading barriers to incorporation of this technology into practice, being mentioned by 60 and 43% of subjects, respectively. Of the 100 (13. 3%) physicians returning the questionnaire who declined to be interviewed, 30% said they would be willing to participate in research on the safety and effectiveness of predictive genetic tests. Of those who were interviewed, 92% were willing to participate in such research. Most physicians do not see genetics as important in their practice today; many anticipate greater importance in the future. The proportion of physicians interested in participating in research to assess the safety and effectiveness of genetic tests is sufficient to make large scale, collaborative, practice-based evaluation feasible. Additionally, participation in research may serve as an effective medium for physician education in genetics.

Adult↗

PubMed2003

US physicians' attitudes toward genetic testing for cancer susceptibility.

Genetic testing for an inherited susceptibility to cancer is an emerging technology in medical practice. Little information is currently available about physicians' attitudes toward these tests. To assess US physicians' opinions on unresolved issues surrounding genetic testing, a 15-min survey was administered to a stratified random sample of 1,251 physicians from 8 specialties, selected from a file of all licensed physicians in the US (response rate = 71.0%). Dependent measures included physicians' attitudes toward genetic counseling and testing qualifications, availability of guidelines, patient confidentiality and insurance discrimination issues, and clinical utility of genetic tests. More than 89% of physicians reported a need for physician guidelines, 81% thought that patients with positive genetic test results are at risk for insurance discrimination, and more than 53% thought that it was difficult to ensure the confidentiality of test results. Almost 25% indicated that genetic tests for cancer susceptibility have too many inaccurate or ambiguous results; nearly 75% thought that clear guidelines are not available for managing patients with positive test results. Only 29% of physicians reported feeling qualified to provide genetic counseling to their patients. More than 84% of oncologists considered themselves qualified to recommend genetic testing to their patients compared with 40% of primary care physicians (PCPs), and 57% of tertiary care physicians (TCPs). US physicians expressed great uncertainty about issues surrounding genetic testing for cancer susceptibility. Results of this national survey underscore the need to provide physicians with clear guidelines on the use of genetic cancer susceptibility tests and effective medical training on their appropriate implementation.

Attitude of Health Personnel↗

PubMed2005

Physician exposure to and attitudes toward advertisements for genetic tests for inherited cancer susceptibility.

Commercial marketing materials may serve as a source of information for physicians about genetic testing for inherited cancer susceptibility (GTICS) in addition to medical guidelines, continuing education, and journal articles. The primary purposes of this study were to: (1) determine the percentage of physicians who received advertisements for GTICS early in the diffusion of commercial GTICS (1999-2000); (2) assess associated characteristics; and (3) measure the perceived importance of commercial advertisements and promotions in physicians' decisions to recommend testing to patients. A nationally representative, stratified random sample of 1,251 physicians from the American Medical Association (AMA) Physician Masterfile completed a 15-20 min mixed mode questionnaire that assessed specialty, previous use of genetic tests, practice characteristics, age, and receipt of advertising materials (response rate = 71%). Overall, 27.4% (n = 426) had received advertisements. In multivariate analysis, factors associated with receipt of advertisements included: specialties in obstetrics/gynecology, oncology, or gastroenterology; past GTICS use, and age 50+. One of four felt that advertisements would be important in their decision to recommend GTICS. Study results indicate that physicians, particularly in oncology, obstetrics/gynecology, and gastroenterology, began receiving GTICS advertisements commensurate with the early diffusion of commercially available tests into clinical practice. At that time, one-quarter of the physicians considered advertisements to play an important role in their clinical decision making, suggesting attention to other sources of information and additional factors.

Advertising↗

PubMed2005

Physicians' attitudes toward preventive therapy for coronary artery disease: is there a gender bias?

BACKGROUND: While much of the gender difference in the treatment of coronary artery disease (CAD) results from the fact that the women being treated are older and have more comorbidities, it remains to be established whether a true gender bias exists. We compared physicians' attitudes and practice toward preventive therapy in men and women with CAD. HYPOTHESIS: Physicians perceive the prevention of CAD in men as more important than in women. METHODS: In the "attitude study," we obtained data on the attitudes of 172 physicians toward treatment, using hypothetical case histories of 58-year-old male and postmenopausal female patients with identical clinical and laboratory data and mild coronary atherosclerosis on angiography. In the "actual practice study," we evaluated the lipoprotein levels and prescription of lipid-lowering medications from medical records of 344 male and female patients with angiographic evidence of CAD. RESULTS: In the hypothetical case histories, physicians in general considered the male patient to be at higher risk and prescribed aspirin (91 vs. 77%, p < 0.01) and lipid-lowering medications (67 vs. 54%, p < 0.07) more often for the male patient. Evaluation of medical charts of patients with CAD revealed that in patients with baseline low-density lipoprotein cholesterol > 110 mg/dl, 77% of the males received a lipid-lowering medication, compared with only 47% of the female patients (p < 0.001). CONCLUSIONS: We found evidence for a gender bias in the attitude as well as in actual practice of secondary prevention toward patients with CAD. While the proportion of male patients receiving lipid-lowering medications appears appropriate, the proportion of women receiving such treatment remains undesirable.

Adult↗

PubMed2004

Using stated preference and revealed preference modeling to evaluate prescribing decisions.

The use of stated preference analyses to evaluate choice of health care products has been growing in recent years. This paper shows how revealed preference data can be enriched with stated preference data and highlights the relative advantages of revealed and stated preference data. The techniques were applied to a study of determinants of physicians' prescriptions of alcoholism medications. Analyses were conducted on the relationship between physicians' perceptions of existing alcoholism medication attributes and their prescribing rates of those medications. Analyses were also conducted on physicians' decisions to prescribe hypothetical alcoholism medications with varying attributes such as efficacy, side effects, compliance, mode of action, and price. Finally, analyses were conducted on the combined stated and revealed preference data. Joint estimation suggests that parameters from the revealed and stated preference data are equal, up to scale. Joint analyses highlight how stated preference data can be used to estimate parameters for attributes that are not observed in the marketplace, that do not vary in the marketplace, or that are highly collinear with other attributes in actual markets.

Alcoholism↗

PubMed2006

Clinical trials in head and neck oncology: an evaluation of clinicians' willingness to participate.

BACKGROUND: This study investigated the individual and collective ("community") equipoise of surgeons and oncologists and their willingness to take part in each of six hypothetical randomized controlled trials in head and neck oncology. METHODS: A survey was mailed to Australasian head and neck specialists. RESULTS: Among 109 respondents (74% response), the scenario with the highest level of individual equipoise pertained to the use of adjuvant interferon for patients with high-risk malignant melanoma, with 45% indicating complete uncertainty between treatment approaches. Significant differences in levels of community equipoise were demonstrated between surgeons and oncologists for three of the scenarios. Willingness to participate in randomized controlled trials ranged from 39% to 72%. Increasing strength of treatment preference was associated with unwillingness to participate in randomized controlled trials for two of six scenarios. CONCLUSION: High levels of equipoise and willingness to participate in clinical research augur well for future randomized controlled trials in head and neck oncology.

Adult↗

PubMedDate not supplied

Analysis of pain management in critically ill patients.

We analyzed the adequacy of pain control for 17 trauma patients during the initial part of their stay in the intensive care unit, and assessed reasons for inadequate analgesia, if it occurred. Patients, and physicians, and nurses were interviewed. A verbal pain intensity scale was used to determine whether patients received adequate analgesia. Patients were asked if the pain hindered their activities, and whether they requested pain medication from their caregivers. Caregivers were questioned whether patients received adequate analgesia. Prescribed morphine regimens and the amount of narcotic administered were analyzed. Twenty-seven percent of patients rated pain intensity as moderate and 47% as severe. Ninety-five percent of housestaff and 81% of nurses reported the patients received adequate pain control. Forty-seven percent of the patients who had moderate or severe pain asked their physician for more pain medication, and 65% asked the nurse. Thirteen residents did not order a larger dose of morphine due to concern about respiratory depression or hypotension. Morphine dosages ranged from 1-8 mg intravenously every 1-2 hours as necessary. Nurses administered less than the maximum amount ordered 58% of the time. The mean dosing interval was 2.3 hours. Barriers to adequate pain management were disparity in the perception of pain between patients and caregivers; patients not requesting more analgesia despite despite the presence of moderate to severe pain; and physician and nurse concerns about patients' adverse physiologic response to increased dosages.

Adult↗