Health care costs associated with escalation of drug treatment in type 2 diabetes mellitus

The cost of different intensities of therapy in HMO patients with type 2 diabetes mellitus was studied. Health care utilization data from 1995 were obtained for 12,200 registrants from the Kaiser Permanente Northwest Diabetes Registry who had type 2 diabetes mellitus. The data were used to determine costs associated with the escalation of antidiabetic therapies in persons with type 2 diabetes mellitus. The total annual costs (in 1993 dollars) associated with no drug therapy, a sulfonylurea only, metformin, a sulfonylurea plus insulin, and insulin alone were $4400, $4187, $4838, $8856, and $7365, respectively. Per patient total costs were higher for patients who had received antidiabetic therapy in 1995 or previously than for those who had not ($5303 versus $4365) and for patients who had received insulin therapy than for those who had not ($7379 versus $4117). Macrovascular complications accounted for 62-89% of the cost associated with inpatient treatment of diabetes-related complications. The total cost of treating patients with type 2 diabetes mellitus at an HMO increased as antidiabetic therapies escalated.

Patients' attitudes to comforting touch in family practice

OBJECTIVE

To examine patients' attitudes to comforting touch in family practice.

DESIGN

A survey was designed with statements and responses to proposed scenarios.

SETTING

Twenty family practices throughout Ontario.

PARTICIPANTS

Family practice patients; of 400 surveys distributed, 376 were completed (94% response rate).

MAIN OUTCOME MEASURES

Patients responded to scenarios on a five-point Likert scale, ranging from strongly disagree to strongly agree. Results were analyzed using SPSS for DOS.

RESULTS

Most patients in this population believed that touch can be comforting (66.3%) and healing (57.9%). Women were more accepting of comforting touch than men in all scenarios. Acceptance of comforting touch declined for both sexes as touch became proximal and more intimate. Men and women were more accepting of comforting touch from female doctors. Acceptance of all comforting touch declined markedly if a physician was unfamiliar to a patient, regardless of the physician's sex.

CONCLUSION

Most patients surveyed believed touch is comforting and healing and viewed distal touches (on the hand and shoulder) as comforting.

The global diabetes model: user friendly version 3.0

The attributes of Release 3.0 of the user friendly version (UFV) of the global diabetes model (GDM) are described and documented in detail. The GDM is a continuous, stochastic microsimulation model of type 2 diabetes. Suitable for predicting the medical futures of both individuals with diabetes and representative diabetic populations, the GDM predicts medical events (complications of diabetes), survival, utilities, and medical care costs. Incidence rate functions for microvascular and macrovascular complications are based on a combination of published studies and analyses of data describing diabetic members of Kaiser Permanente Northwest Region, a non-profit group-model health maintenance organization. Active risk factors include average blood glucose (HbAlc), systolic blood pressure (SBP), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), triglycerides, smoking status, and use of prophylactic aspirin. Events predicted include diabetic eye disease, diabetic nephropathy, peripheral neuropathy amputation, myocardial infarction, stroke, peripheral artery disease, congestive heart failure, coronary artery surgery, coronary angioplasty, and death.

The Mt. Hood challenge: cross-testing two diabetes simulation models

Starting from identical patients with type 2 diabetes, we compared the 20-year predictions of two computer simulation models, a 1998 version of the IMIB model and version 2.17 of the Global Diabetes Model (GDM). Primary measures of outcome were 20-year cumulative rates of: survival, first (incident) acute myocardial infarction (AMI), first stroke, proliferative diabetic retinopathy (PDR), macro-albuminuria (gross proteinuria, or GPR), and amputation. Standardized test patients were newly diagnosed males aged 45 or 75, with high and low levels of glycated hemoglobin (HbA(1c)), systolic blood pressure (SBP), and serum lipids. Both models generated realistic results and appropriate responses to changes in risk factors. Compared with the GDM, the IMIB model predicted much higher rates of mortality and AMI, and fewer strokes. These differences can be explained by differences in model architecture (Markov vs. microsimulation), different evidence bases for cardiovascular prediction (Framingham Heart Study cohort vs. Kaiser Permanente patients), and isolated versus interdependent prediction of cardiovascular events. Compared with IMIB, GDM predicted much higher lifetime costs, because of lower mortality and the use of a different costing method. It is feasible to cross-validate and explicate dissimilar diabetes simulation models using standardized patients. The wide differences in the model results that we observed demonstrate the need for cross-validation. We propose to hold a second 'Mt Hood Challenge' in 2001 and invite all diabetes modelers to attend.

Type 2 diabetes: incremental medical care costs during the 8 years preceding diagnosis

OBJECTIVE

To describe and analyze medical care costs for the 8 years preceding a diagnosis of type 2 diabetes.

RESEARCH DESIGN AND METHODS

From electronic records of a large group-model health maintenance organization (HMO), we ascertained the medical care costs preceding diagnosis for all members with type 2 diabetes who were newly diagnosed between 1988 and 1995. To isolate incremental costs (costs caused by the future diagnosis of diabetes), we subtracted the costs of individually age- and sex-matched HMO members without impending diabetes from the costs of members who were destined to receive this diagnosis. We also compared these prediagnosis costs with the first 3 years of postdiagnosis costs.

RESULTS

An economic burden from impending diabetes is apparent for at least 8 years before diagnosis, beginning with costs for outpatient and pharmacy services. Diabetes-associated incremental costs (costs of type 2 diabetic patients minus matched costs of nondiabetic patients) averaged $1,205 per type 2 diabetic patient per year during the first eight prediagnostic years, including $1,913 each year for the 3 years preceding diagnosis. In the year immediately preceding diagnosis, incremental costs were equivalent to those observed in the second and third years after diagnosis.

CONCLUSIONS

Incremental costs of diabetes begin at least 8 years before diagnosis and grow at an accelerating rate as diagnosis approaches and immediately after diagnosis. These incremental costs span the full range of medical services. Furthermore, the majority of these costs are for conditions not normally associated with diabetes or its complications.

Application of the Woman Abuse Screening Tool (WAST) and WAST-short in the family practice setting

BACKGROUND

Our study objectives were to assess the validity and reliability of the Woman Abuse Screening Tool (WAST) in the general population within the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in practice; and to determine the self-reported comfort of patients being asked the WAST questions by their family physicians.

METHODS

We included a stratified random sample of 20 physicians practicing in both urban and rural settings drawn from 400 family physicians in London, Ontario, Canada, and the surrounding area. These physicians administered the WAST to 10 to 15 eligible and consenting patients during the course of regular care. Following the physician-patient encounter, patients were asked to complete both a measure about their comfort in being asked each of the WAST questions and the Abuse Risk Inventory (ARI).

RESULTS

Scores on the WAST correlated well with those on the ARI. The reliability of the WAST among this sample was demonstrated by a coefficient alpha of 0.75. With the WAST-Short (the first 2 questions of the WAST), 26 of the 307 patients screened (8.5%) were identified as experiencing abuse. The physicians were comfortable administering the WAST to their women patients, and 91% of the patients reported being comfortable or very comfortable when asked the WAST questions by their family physician.

CONCLUSIONS

The WAST was found to be a reliable and valid measure of abuse in the family practice setting, with both patients and family physicians reporting comfort with it being part of the clinical encounter.

Is respite care available for chronically ill seniors?

OBJECTIVE

To determine family physicians' perceptions of how available respite care is and how easy it is to refer chronically ill older people to it, and to examine their opinions of respite care.

DESIGN

Mailed survey to family physicians on the Thames Valley Family Practice Research Unit's mailing list.

SETTING

London, Ont, and surrounding area.

PARTICIPANTS

Of the 448 surveys mailed to eligible physicians, 288 were completed and returned for a response rate of 64.3%.

MAIN OUTCOME MEASURES

Respondents' perceptions of how available respite care is and how easy it is to refer chronically ill older people to it and their opinions on the effectiveness of respite care.

RESULTS

More than half the respondents reported that outpatient respite care is always available, but how available depended on practice location. Inpatient respite care was reported as less available. More than half the respondents found referral to respite care difficult. Respondents were very positive about the role of respite services in long-term care and in lowering caregiver stress. Respondents' perceptions varied according to where they had attended medical school. Their perceptions of respite care's role in long-term care and in helping patients remain at home were influenced by whether they thought respite care was available.

CONCLUSION

Family physicians need education in the value of respite services for their chronically ill older patients and their families. Physicians also need information on the respite services available and strategies for accessing them. Our findings suggest a need for greater attention to regional discrepancies in availability of services.

The impact of patient-centered care on outcomes

BACKGROUND

We designed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization.

METHODS

We selected 39 family physicians at random, and 315 of their patients participated. Office visits were audiotaped and scored for patient-centered communication. In addition, patients were asked for their perceptions of the patient-centeredness of the visit. The outcomes were: (1) patients' health, assessed by a visual analogue scale on symptom discomfort and concern; (2) self-report of health, using the Medical Outcomes Study Short Form-36; and (3) medical care utilization variables of diagnostic tests, referrals, and visits to the family physician, assessed by chart review. The 2 measures of patient-centeredness were correlated with the outcomes of visits, adjusting for the clustering of patients by physician and controlling for confounding variables.

RESULTS

Patient-centered communication was correlated with the patients' perceptions of finding common ground. In addition, positive perceptions (both the total score and the subscore on finding common ground) were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals.

CONCLUSIONS

Patient-centered communication influences patients' health through perceptions that their visit was patient centered, and especially through perceptions that common ground was achieved with the physician. Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.

Achieving further glycemic control in type 2 diabetes mellitus

OBJECTIVES

To identify patients with type 2 diabetes mellitus who were in poor glycemic control and therapeutic adjustments that might improve control.

DESIGN

Using electronic pharmacy data, we assigned subjects to 1 of 4 therapeutic categories. We then identified patients within each category who did not meet the recommended standard of glycemic control (glycosylated hemoglobin [Hb A(1c)] <0. 08 [<8.0%]) and studied their therapetic regimens for possible improvements.

SUBJECTS

The subjects were 5,061 members of a large group-model health maintenance organization who had type 2 diabetes and 12 months of 1997 health plan eligibility. Main outcome measures The dosage of antihyperglycemic agents (sulfonylureas, metformin, and insulin) in relation to glycemic control as measured by the Hb A(1c).

RESULTS

A significant number (n = 1,570 [31.0%]) of persons with type 2 diabetes might improve their glycemic control with simple adjustments to their pharmacologic therapy.

CONCLUSION

Busy clinicians with heavy workloads can improve their management of diabetes by identifying patients whose glycemic control could be improved through a change in medication or simple adjustment in dosage.

Adapting a national guideline for local use: a comparative case study in a US and an Israeli health maintenance organization

OBJECTIVES

We compared the way a US and an Israeli health maintenance organization (HMO) used the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (the JNC-V) in developing a hypertension guideline.

METHODS

Comparative case study. We describe and contrast the two HMOs, the social contexts in which they function, their motivations for creating a local guideline and their guideline development processes. We then compare the two HMO guidelines with each other and with the JNC-V. Based on this analysis, we offer provisional answers to some key concerns raised by local adaptations of national or international guidelines. These include whether adaptations will reflect local cost-containment concerns in ways that could threaten quality of care, whether guidelines constitute a threat to physician autonomy and the relationship between local adaptations and the evolution of national or international guidelines.

RESULTS

The HMO guidelines differed substantially, and in similar ways, from the JNC-V in format, coverage and emphasis of topics. They differed from it minimally, but also in similar ways, in the content of their recommendations. Each HMO guideline 'improvised' on the JNC-V in ways that differed to reflect local needs and objectives but did not significantly distort the original. Quality of care considerations appeared to predominate over cost considerations, and we found no evidence that guidelines threatened physician autonomy.

CONCLUSIONS

Local adaptations may function as part of the iterative process through which national or international guidelines evolve in ways more suitable for potential local use.

Use of complementary/alternative medicine by breast cancer survivors in Ontario: prevalence and perceptions

PURPOSE

To determine the prevalence of use of complementary/alternative medicine (CAM) by breast cancer survivors in Ontario, Canada, and to compare the characteristics of CAM users and CAM nonusers.

PATIENTS AND METHODS

A questionnaire was mailed to a random sample of Ontario women diagnosed with breast cancer in 1994 or 1995.

RESULTS

The response rate was 76.3%. Overall, 66.7% of the respondents reported using CAM, most often in an attempt to boost the immune system. CAM practitioners (most commonly chiropractors, herbalists, acupuncturists, traditional Chinese medicine practitioners, and/or naturopathic practitioners) were visited by 39.4% of the respondents. In addition, 62.0% reported use of CAM products (most frequently vitamins/minerals, herbal medicines, green tea, special foods, and essiac). Almost one half of the respondents informed their physicians of their use of CAM. Multiple logistic regression analysis determined that support group attendance was the only factor significantly associated with CAM use.

CONCLUSION

CAM use is common among Canadian breast cancer survivors, many of whom are discussing CAM therapy options with their physicians. Knowledge of CAM therapies is necessary for physicians and other health care practitioners to help patients make informed choices. CAM use may play a role in the positive benefits associated with support group attendance.

Following depression in primary care: do family practice physicians ask about depression at different rates than internal medicine physicians?

OBJECTIVE

To determine whether the chronically or recurrently depressed patients of family practice and internal medicine physicians differed in the proportion reporting that their primary care physician asked them about depression symptoms.

DESIGN

A cross-sectional observational study of chronically or recurrently depressed survey respondents who identified a family practice or internal medicine physician as their primary care provider.

SETTING

A large not-for-profit group-model health maintenance organization in the northwestern United States, with a population representative of its service area.

PATIENTS

Health maintenance organization members (n= 1161) with ongoing or recurring depression or dysthymia who responded to a 1993 survey and who identified either a family practice or internal medicine physician as their primary care provider.

MAIN OUTCOME MEASURE

Patients' self-report of their primary care physician asking them: (1) whether they had been feeling sad, blue, or depressed; (2) to fill out a questionnaire about their mood or feelings; and (3) whether they had been thinking about death or suicide.

RESULTS

Chronically or recurrently depressed patients of family practice physicians were more likely to report that their physician asked them about depressive symptoms than were patients of internal medicine physicians (34.0% vs 27.3%) (P=.02). This finding persisted in a multivariate analysis.

CONCLUSION

Family practice physicians may be more attentive to depressive disorders than internal medicine physicians.

Experience of fibromyalgia. Qualitative study

OBJECTIVE

To explore illness experiences of patients diagnosed with fibromyalgia.

DESIGN

Qualitative method of in-depth interviews.

SETTING

Midsize city in Ontario.

PARTICIPANTS

Seven patients diagnosed with fibromyalgia.

METHOD

Seven in-depth interviews were conducted to explore the illness experience of patients diagnosed with fibromyalgia. All interviews were audiotaped and transcribed verbatim. All interview transcriptions were read independently by the researchers, who then compared and combined their analysis. Final analysis involved examining all interviews collectively, thus permitting relationships between and among central themes to emerge. The analysis strategy used a phenomenologic approach and occurred concurrently rather than sequentially.

MAIN FINDINGS

Themes that emerged from the interpretive analysis depict patients' journeys along a continuum from experiencing symptoms, through seeking a diagnosis, to coping with the illness. Experiencing symptoms was composed of four subcategories: pain, a precipitating event, associated symptoms, and modulating factors. Seeking a diagnosis entailed frustration and social isolation. Confirmation of diagnosis brought relief as well as anxiety about the future. After diagnosis, several steps led to creation of adaptive coping strategies, which were influenced by several factors.

CONCLUSION

Findings suggest that the conventional medical model fails to address the complex experience of fibromyalgia. Adopting a patient-centred approach is important for helping patients cope with this disease.

Women's experience of maternal serum screening

OBJECTIVE

To explore the ideas, opinions, feelings, and experiences of women regarding prenatal genetic screening, specifically maternal serum screening (MSS).

DESIGN

Qualitative technique of focus groups.

SETTING

Northern, rural, inner-city, urban, and suburban communities in Ontario.

PARTICIPANTS

Women who had given birth to babies from January 1994 to May 1996, but who were not currently pregnant (n = 60).

METHOD

Six focus groups composed of women living in various communities who had recently given birth to babies explored the experience of MSS.

MAIN FINDINGS

Women want informed choice about prenatal genetic screening. Three factors influenced women's decisions to undergo or decline prenatal genetic screening: their personal values, including their philosophy of life, moral, and religious values, and attitudes regarding Down syndrome and disability; social support including their partners, families, and friends; and quality of information from health care providers. Women want their providers to give them information personally; they want to receive the information as early as possible in prenatal care to allow time for reflection; and they want unbiased, accurate information in order to make a decision that is in keeping with their personal values and beliefs.

CONCLUSIONS

Knowledge of women's ideas, opinions, feelings, and experiences regarding MSS suggests specific ways health care providers can facilitate informed decision making in prenatal screening. Providing information about genetic testing needs to be individualized, with women actively participating in the decision-making process. Information needs described by these women could apply to other prenatal genetic tests that might be available in the future.

Predictors of glycemic control in insulin-using adults with type 2 diabetes

OBJECTIVE

To determine the characteristics that influence glycemic control among insulin-using adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We studied all 1,333 eligible members of a large not-for-profit health maintenance organization who responded to a 1997 survey. We tested associations among demographic, treatment, and psychometric variables with mean 1997 HbA1c values. The Problem Areas in Diabetes (PAID) instrument was used to assess the emotional effect of living with diabetes, and the Short Form 12 Physical Function Scale was used to assess the effect of physical limitations on daily activities. Based on differences between and within treatment groups, we built models to predict glycemic control for subgroups of subjects who were using insulin alone and those who were using insulin in combination with an oral hypoglycemic agent.

RESULTS

Younger age, lower BMI, and increased emotional distress about diabetes (according to the PAID scale) were all significant predictors (P < 0.05) of worse glycemic control. However, except among individuals with an HbA1c level of >8.0 who were receiving combination therapy, only approximately 10% of the variance in glycemic control could be predicted by demographic, treatment, or psychometric characteristics.

CONCLUSIONS

Personal characteristics explain little of the variation in glycemic control in insulin-using adults with type 2 diabetes. Possible explanations are that the reduced complexity of control in type 2 diabetes makes the disease less sensitive to personal factors than control in type 1 diabetes, that health-related behavior is less driven by personal and environmental characteristics among older individuals, or that, in populations exposed to aggressive glycemic control with oral hypoglycemic agents and nurse care managers, personal differences become largely irrelevant.

Breast cancer patients' experiences of patient-doctor communication: a working relationship

The traumas of diagnosis and treatment for breast cancer are well researched and generally addressed in care. While women with breast cancer continue to identify the need for better communication with physicians, studies to date have not investigated how the process of communication between physicians and women with breast cancer actually unfolds. This phenomenological study therefore explored how women with breast cancer experience patient-physician communication to gain a greater understanding of effective approaches. Interviews of a purposeful sample of 11 women within 6 months of initial diagnosis or recurrence of breast cancer were audiotaped, transcribed verbatim and analyzed using inductive interpretation. Themes and patterns of positive and negative experiences emerged. All experiences began with the woman's feeling of vulnerability. In positive experiences, information sharing and relationship building were inextricably linked components of a working relationship which was at the same time affective, behavioural and instrumental. This experience, in turn, influenced the woman's experience of control and mastery of the illness experience, and their experience of learning to live with breast cancer. Findings illuminate the importance of comprehensively patient-centred, working relationships. Several specific techniques to enhance effective communication are identified.

The influence of older patient-physician communication on health and health-related outcomes

Effective patient-physician communication significantly influences health outcomes of older patients. For example, concordance between patient and physician expectations and patient participation in the decision-making process affects older patients. Communication is also linked to patient recall, adherence, and satisfaction. Furthermore, communication impacts emotional and physical outcomes of older patients, although evidence of improved physical outcomes remains under-investigated in this population. Dimensions of communication, such as continuity of relationship, seem to be important in decreasing hospitalization of older patients. This article explores the link between communication and health care outcomes in the older population.

Case-control study of 10 years of comprehensive diabetes care

OBJECTIVE

To describe the long-term clinical impact of a comprehensive management program instituted throughout a health system for members with diabetes mellitus.

DESIGN

10 year case-control evaluation.

SETTING

Kaiser Permanente Northwest, Portland, OR.

PARTICIPANTS

Members of the health maintenance organization between 1987 and 1996; members with diabetes were compared with equal numbers of members without diabetes. The number of participants with diabetes ranged from 5331 in 1987 to 13,099 in 1996.

MAIN OUTCOME MEASURES

Number in diabetes register, mortality, change in comorbidity, rates of uptake of preventive health measures, use of pharmaceuticals, levels of risk factors, hospital days per thousand per year, emergency room visits per thousand per year.

RESULTS

The prevalence of diabetes identified in this population rose from 2.54% (7,895/310,819) in 1987 to 3.66% (14,741/402,754) in 1996, and the mean (SEM) age of members at the time of diagnosis fell slightly from 62.9 (+/- 0.21) years to 62.0 (+/- 0.13) years (P < 0.05). By 1996, 10,885 of the 13,099 (83% +/- 0.3%) of members with diabetes had an annual laboratory test to assess glycemic control, the annual screening rate for retinopathy was 67.6% (+/- 0.4%), the rate of uptake of influenza immunizations was 60.2% (7,886/13,099) and the screening rate for nephropathy was 43% (5,698/13,099) (+/- 0.49%). The use of home glucose testing increased from 32.4% (1721/5331) of members with diabetes to 53.0% (6,942/12,099); the use of lipid lowering drugs increased from 3.5% (187/55,331) to 19.8% (2,594/13,099). The use of angiotensin converting enzyme inhibitors increased from 8.5% to 34.8% of members with diabetes. Mean blood pressure decreased from 144/82 mm Hg (+/- 0.8/0.4) to 138/79 mm Hg (+/- 0.3/0.15), and mean total cholesterol concentrations dropped from 243 mg/dL (+/- 4.2) to 215 mg/dL (+/- 0.6). By 1996, 56.4% (7,388/1,3099) (+/- 0.5%) of members on the diabetes register had good to excellent glycemic control (HbA1c < 8%). Mortality decreased from 4.8% (256/5331) (+/- 0.3%) to 3.6% (472/13,099) (+/- 0.2%) among members with diabetes, this was a more rapid decrease than was observed among those without diabetes (P < 0.01). The annual ratio of visits to the emergency room by members with diabetes to members without fell from 2.5 to 1.8, and the ratio for the number of days spent in acute care in the hospital dropped from 3.6 to 2.5.

CONCLUSIONS

This centrally organized program based in a primary care setting and utilizing a register of patients with diabetes was associated with substantial improvements in the process and outcomes of care in a large population of health maintenance organization members with diabetes.

Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression

BACKGROUND

The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms.

METHODS

Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the setting's two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis.

RESULTS

Most of the CQI team's recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status.

CONCLUSIONS

New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.

Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial

BACKGROUND

Although substantial resources have been invested in communication skills training for clinicians, little research has been done to test the actual effect of such training on patient satisfaction.

OBJECTIVE

To determine whether clinicians' exposure to a widely used communication skills training program increased patient satisfaction with ambulatory medical care visits.

DESIGN

Randomized, controlled trial.

SETTING

A not-for-profit group-model health maintenance organization in Portland, Oregon.

PARTICIPANTS

69 primary care physicians, surgeons, medical subspecialists, physician assistants, and nurse practitioners from the Permanente Medical Group of the Northwest.

INTERVENTION

"Thriving in a Busy Practice: Physician-Patient Communication," a communication skills training program consisting of two 4-hour interactive workshops. Between workshops, participants audiotaped office visits and studied the audiotapes.

MEASUREMENTS

Change in mean overall score on the Art of Medicine survey (HealthCare Research, Inc., Denver, Colorado), which measures patients' satisfaction with clinicians' communication behaviors, and global visit satisfaction.

RESULTS

Although participating clinicians' self-reported ratings of their communication skills moderately improved, communication skills training did not improve patient satisfaction scores. The mean score on the Art of Medicine survey improved more in the control group (0.072 [95% CI, -0.010 to 0.154]) than in the intervention group (0.030 [CI, -0.060 to 0.1201).

CONCLUSIONS

"Thriving in a Busy Practice: Physician-Patient Communication," a typical continuing medical education program geared toward developing clinicians' communication skills, is not effective in improving general patient satisfaction. To improve global visit satisfaction, communication skills training programs may need to be longer and more intensive, teach a broader range of skills, and provide ongoing performance feedback.

Metformin as secondary therapy in a defined population with type 2 diabetes

This study was undertaken to assess the effect of metformin as a second-line oral antihyperglycemic agent in a defined population with type 2 diabetes mellitus. We measured the extent and circumstances of metformin use in the 15,000-person diabetes registry of a large, group-model health maintenance organization (HMO). Among subsets of patients in whom adequate glycemic control could not be maintained with sulfonylurea (SU) therapy, we compared glycemic control before and after metformin use to glycemic control during a similar interval before metformin was introduced. Metformin users were significantly more likely than nonusers to have had poor glycemic control at baseline. Nearly two thirds (63.8%) of patients with a glycosylated hemoglobin (Hb A1c) level >10% switched to metformin, as did 46.3% of those with an Hb A1c level of 8% to 10%. In all patients (metformin users and nonusers) in whom SU therapy failed to maintain glycemic control, Hb A1c levels decreased 0.9% after metformin was introduced, compared with a decrease of 0.4% during the control period. In a group-model HMO that promoted the use of metformin as second-line therapy in patients unable to maintain glycemic control with SU therapy, metformin reduced hyperglycemic levels.

Using the patient-centered method to achieve excellence in care for women with breast cancer

The diagnosis of breast cancer remains one of the most threatening and emotionally debilitating diagnoses given to patients. Breast cancer elicits fears of loss of ability, control, hope, and at worst--loss of life. Patients and their families, devastated by the diagnosis of cancer, often feel unsupported or dismissed by their health care providers. Using the example of breast cancer, this paper describes how the application of the patient-centred clinical method can assist physicians in caring for patients diagnosed with breast cancer. Composite cases and quotes drawn from qualitative research studies with breast cancer patients are used to illustrate the application of the patient-centred clinical method.

Architectural characteristics of muscle in black and white college football players

PURPOSE

The purpose of this study was to determine whether architectural characteristics of skeletal muscle differ by race.

METHODS

Skeletal muscle architectural characteristics and body composition were studied in 13 black and 31 white male college football players. Fat-free mass (FFM) and percentage body fat (% fat) were determined by hydrostatic weighing technique. Muscle thickness (MTH) was measured by B-mode ultrasound at 13 anatomical sites. Isolated MTH and muscle pennation angle (PANG) of the triceps long head, vastus lateralis, and gastrocnemius medialis muscles were measured by ultrasound, and fascicle length was estimated.

RESULTS

There were no significant differences between blacks and whites in isolated MTH, PANG, and fascicle length in the triceps long head, vastus lateralis, and gastrocnemius medialis muscles. On average, % fat and FFM of black and white football players were 18.8 +/- 4.6% and 17.2 +/- 5.6% for % fat, and 89.9 +/- 15.6 kg and 89.1 +/- 10.4 kg for FFM, respectively. Blacks had a significantly greater, 30%-quadriceps (P < 0.05), 50%-hamstrings (P < 0.05), biceps (P < 0.01), and abdomen (P < 0.01) MTH than those of whites. Standing height and body weight were similar between blacks and whites, but the ratio of leg length to standing height was significantly greater in blacks compared with whites.

CONCLUSIONS

It appears that although there may be race differences in anatomical stature, muscle architecture is likely independent of race.