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1.  National Performance on Door-In to Door-Out Time Among Patients Transferred for Primary Percutaneous Coronary Intervention 
Archives of internal medicine  2011;171(21):1879-1886.
Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for per-cutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time(ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services.
We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model.
Among 13 776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except >75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P<.001).
Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.
PMCID: PMC4312661  PMID: 22123793
2.  The Advantages of Second Best 
Archives of internal medicine  2012;172(9):712-714.
PMCID: PMC4285709  PMID: 22782200
5.  Mood Food 
Archives of internal medicine  2010;170(8):699-703.
Much lore but few studies describe a relation of chocolate to mood. We examined the cross-sectional relationship of chocolate consumption with depressed mood in adult men and women.
A sample of 1018 adults (694 men and 324 women) from San Diego, California, without diabetes or known coronary artery disease was studied in a cross-sectional analysis. The 931 subjects who were not using antidepressant medications and provided chocolate consumption information were the focus of the analysis. Mood was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). Cut points signaling a positive depression screen result (CES-D score, ≥16) and probable major depression (CES-D score, ≥22) were used. Chocolate servings per week were provided by 1009 subjects. Chocolate consumption frequency and rate data from the Fred Hutchinson Food Frequency Questionnaire were also available for 839 subjects. Chocolate consumption was compared for those with lower vs higher CES-D scores. In addition, a test of trend was performed.
Those screening positive for possible depression (CES-D score ≥16) had higher chocolate consumption (8.4 servings per month) than those not screening positive (5.4 servings per month) (P = .004); those with still higher CES-D scores (≥22) had still higher chocolate consumption (11.8 servings per month) (P value for trend, <.01). These associations extended to both men and women. These findings did not appear to be explained by a general increase in fat, carbohydrate, or energy intake.
Higher CES-D depression scores were associated with greater chocolate consumption. Whether there is a causal connection, and if so in which direction, is a matter for future prospective study.
PMCID: PMC4285457  PMID: 20421555
6.  Reduction in Blood Pressure With Statins 
Archives of internal medicine  2008;168(7):721-727.
Some studies have suggested reductions in blood pressure (BP) with statin treatment, particularly in persons with hypertension. Randomized trial evidence is limited.
We performed a randomized, double-blind, placebo-controlled trial with equal allocation to simvastatin, 20 mg; pravastatin sodium, 40 mg; or placebo for 6 months. Nine hundred seventy-three men and women without known cardiovascular disease or diabetes mellitus, with low-density lipoprotein cholesterol screening levels of 115 to 190 mg/dL, had assessment of systolic and diastolic BP (SBP and DBP, respectively). Blood pressure values were compared for placebo vs statins by intention-to-treat (ITT) analysis. Additional analyses were performed that (1) were confined to subjects with neither high baseline BP (SBP >140 mm Hg or DBP >90 mm Hg) nor receiving BP medications, to exclude groups in whom BP medications or medication changes may have influenced results, and (2) separately evaluated simvastatin and pravastatin (vs placebo). The time course of BP changes after statin initiation and the effect of stopping statins on BP were examined.
Statins modestly but significantly reduced BP relative to placebo, by 2.2 mm Hg for SBP (P = .02) and 2.4 mm Hg for DBP (P<.001) in ITT analysis. Blood pressure reductions ranged from 2.4 to 2.8 mm Hg for both SBP and DBP with both simvastatin and pravastatin, in those subjects with full follow-up, and without potential for influence by BP medications (ie, neither receiving nor meriting BP medications).
Reductions in SBP and DBP occurred with hydrophilic and lipophilic statins and extended to normotensive subjects. These modest effects may contribute to the reduced risk of stroke and cardiovascular events reported on statins.
Trial Registration Identifier: NCT00330980
PMCID: PMC4285458  PMID: 18413554
7.  Cancer and the Media: How Does the News Report on Treatment and Outcomes? 
Archives of internal medicine  2010;170(6):515-518.
Cancer receives a great deal of news media attention. Although approximately half of all US patients with cancer die of their illness or of related complications, it is unknown whether reports in the news media reflect this reality.
To determine how cancer news coverage reports about cancer care and outcomes, we conducted a content analysis of US cancer news reporting in 8 large-readership newspapers and 5 national magazines. Trained coders determined the proportion of articles reporting about cancer survival, cancer death and dying, aggressive cancer treatment, cancer treatment failure, adverse events of cancer treatment, and end-of-life palliative or hospice care.
Of 436 articles about cancer, 140 (32.1%; 95% confidence interval [CI], 28%-37%) focused on survival and only 33 (7.6 %; 5%-10%) focused on death and dying (P < .001, χ2 test). Only 57 articles (13.1%; 10%-17%) reported that aggressive cancer treatments can fail, and 131 (30.0%; 26%-35%) reported that aggressive treatments can result in adverse events. Although most articles (249 of 436 [57.1%]; 95% CI, 52%-62%) discussed aggressive treatments exclusively, almost none (2 of 436; [0.5%]; 0%-2%) discussed end-of-life palliative or hospice care exclusively (P < .001, χ2 test), and only a few (11 of 436 [2.5%]; 1%-6%) discussed aggressive treatment and end-of-life care.
News reports about cancer frequently discuss aggressive treatment and survival but rarely discuss treatment failure, adverse events, end-of-life care, or death. These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis.
PMCID: PMC4255973  PMID: 20233800
8.  Physician Visits prior to Treatment for Clinically Localized Prostate Cancer 
Archives of internal medicine  2010;170(5):440-450.
The two primary therapeutic interventions for localized prostate cancer are delivered by different types of physicians, urologists and radiation oncologists. We evaluate how visits to specialists and primary care physicians (PCPs) by men with localized prostate cancer relate to treatment choice.
Using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database, we identified 85,088 men with clinically localized prostate cancer diagnosed at age ≥65 years between 1994 and 2002. Men were categorized by primary treatment received within 9 months of diagnosis: radical prostatectomy (n=18,201, 21%), radiotherapy (n=35,925, 42%), androgen deprivation (n=14,021, 17%), or expectant management (n=16,941, 20%). Office visits to urologists, radiation oncologists, medical oncologists, and PCPs were analyzed by patient characteristics and primary therapy received, and were identified using Medicare claims and the AMA Physician Masterfile.
Overall, 42,309 men (50%) were seen exclusively by urologists, 37,540 (44%) by urologists and radiation oncologists, 2,329 (3%) by urologists and medical oncologists, and 2,910 (3%) by all 3 specialists. There was a strong association between the type of specialist seen and primary therapy received. PCP visits were infrequent between diagnosis and receipt of therapy (22% of patients visited any PCP and 17% visited an established PCP provider) and were not associated with a greater likelihood of specialist visits. Irrespective of age, comorbidity status, or specialist visits, men seen by PCPs were more likely to be managed expectantly.
Specialist visits relate strongly to prostate cancer treatment choices. In light of these findings, prior evidence that specialists prefer the modality they themselves deliver, the lack of conclusive comparative studies demonstrating superiority of one modality over another, and the differing potential morbidities associated with each treatment, it is essential to ensure that men have access to balanced information before choosing a particular therapy for prostate cancer.
PMCID: PMC4251764  PMID: 20212180
9.  Hospitalization Rates and In-Hospital Mortality Among Centenarians 
Archives of internal medicine  2012;172(15):1179-1180.
PMCID: PMC4241633  PMID: 22710863
10.  Proton Pump Inhibitor Use, Hip Fracture and Change in Bone Density In Postmenopausal Women Results from the Women’s Health Initiative 
Archives of internal medicine  2010;170(9):765-771.
Proton pump inhibitor (PPI) medications have been inconsistently shown to be associated with osteoporotic fractures. The objective was to examine the association of PPI use with bone outcomes (fracture, bone mineral density [BMD])
This prospective analysis included 161,806 postmenopausal women ages 50 to 79 years without history of hip fracture enrolled in the Women’s Health Initiative (WHI) Observational Study and Clinical Trials with a mean (SD) follow-up of 7.8 (1.6) years. Analyses were conducted on 130,487 women with complete information. Medication information was taken directly from drug containers during in-person interviews (baseline, year 3). Main outcome measures were self-reported fractures (hip [adjudicated], clinical spine, lower arm or wrist, and total fractures) and for a subsample (3 densitometry sites), 3-year change in BMD.
During 1,005,126 person-years of follow-up, 1500 hip fractures, 4881 lower arm or wrist fractures, 2315 clinical spine fractures and 21247 total fractures occurred. The multivariate-adjusted hazard ratios for current PPI use were 1.00 (95% CI, 0.71 to 1.40) for hip fracture, 1.47 (CI 1.18–1.82) for clinical spine fracture, 1.26 (CI, 1.05 to 1.51) for lower arm or wrist fracture, and 1.25 (CI, 1.15 to 1.36) for total fractures. BMD measurements did not vary between PPI users and nonusers at baseline. PPI use was associated with only a marginal effect on 3-year BMD change at the hip (p=0.05) but not at other sites.
PPI use was not associated with hip fractures, but was modestly associated with clinical spine, lower arm or wrist and total fractures.
PMCID: PMC4240017  PMID: 20458083
14.  The effect of multidisciplinary care teams on intensive care unit mortality 
Archives of internal medicine  2010;170(4):369-376.
Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care.
We conducted a population-based retrospective cohort study of medical patients admitted to Pennsylvania acute hospitals (N=169) from July 1, 2004 to June 30, 2006, linking a statewide hospital organizational survey to hospital discharge data. Multivariate logistic regression was used to determine the independent relationship between daily multidisciplinary rounds and 30-day mortality.
112 hospitals and 107,324 patients were included in the final analysis. Overall 30-day mortality was 18.3%. After adjusting for patient and hospital characteristics, multidisciplinary care was associated with significant reductions in the odds of death (OR=0.84, 95% CI: 0.76–0.93, p=0.001). When stratifying by intensivist physician staffing, the lowest odds of death were in ICUs with high-intensity physician staffing and multidisciplinary care teams (OR=0.78, 95% CI: 0.68–0.89, p<0.0001), followed by ICUs with low intensity physician staffing and multidisciplinary care teams (OR=0.88, 95%CI: 0.79–0.97, p=0.014), compared to hospitals with low intensity physician staffing but without multidisciplinary care teams. The effects of multidisciplinary care were consistent across key subgroups including patients with sepsis, patients requiring invasive mechanical ventilation, and patients in the highest quartile of severity of illness
Daily rounds by a multidisciplinary team are associated with lower mortality among medical ICU patients. The survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary teams in high-intensity staffed ICUs.
PMCID: PMC4151479  PMID: 20177041
15.  Systematic Review: The Association and Impact of Financial Conflicts of Interest in Basic Science Research 
Archives of internal medicine  2010;170(16):1490-1498.
No prior study has evaluated financial relationships of investigators with pharmaceutical manufacturers for basic science. An example of the importance and impact of such relationships is in the evaluation of erythropoietin receptors’(EpoRs) effects on cancer cell lines, since studies have reported increased mortality when cancer patients receive erythropoiesis stimulating agents (ESAs).
To assess the disclosed association that exist between pharmaceutical industry support and EpoRs effects on solid cancer cell lines.
Data Sources
MEDLINE and EMBASE (1988- July 2008) and two EpoR conferences sponsored by the National Institutes of Health.
Study Selection
All publications investigating EpoRs that met inclusion criteria were identified and included.
Data Extraction
Data were extracted on detection of EpoRs, presence of erythropoietin-induced signaling events, presence of erythropoietin-induced changes in cellular function, nature of qualitative conclusions, and sources of funding for all 74 studies.
Data Synthesis
In comparison to studies of academic investigators with no disclosed funding support from ESA manufacturers (n=64), the studies from academic investigators with funding support from ESA manufacturers (n= 7) and the laboratories directed by investigators employed by ESA manufacturers (n=3) were both less likely to identify: EpoR presence on solid tumor cells; erythropoietin-induced signaling events; erythropoietin-induced changes in cellular function; and less likely to conclude that their research had identified potentially harmful effects of erythropoietin on cancer cells. Additionally, presentations from industry-based investigator teams at NIH conferences were less likely to report EpoRs on cancer cell lines, downstream effects of erythropoietin, and cell proliferation and migration effects following EpoR administration.
Financial conflicts of interest impact the outcomes and presentation of basic science research data as well as publications.
PMCID: PMC4138541  PMID: 20837837
16.  Less Is More 
Archives of internal medicine  2011;171(15):1371-1378.
Little is known about trends in the timing of first nephrology consultation and associated outcomes among older patients initiating dialysis.
Data from patients aged 67 years or older who initiated dialysis in the United States between January 1, 1996, and December 31, 2006, were stratified by timing of the earliest identifiable nephrology visit. Trends of earlier nephrology consultation were formally examined in light of concurrently changing case mix and juxtaposed with trends in 1-year mortality rates after initiation of dialysis.
Among 323 977 older patients initiating dialysis, the proportion of patients receiving nephrology care less than 3 months before initiation of dialysis decreased from 49.6% (in 1996) to 34.7% (in 2006). Patients initiated dialysis with increasingly preserved kidney function, from a mean estimated glomerular filtration rate of 8 mL/min/1.73 m2 in 1996 to 12 mL/min/1.73 m2 in 2006. Patients were less anemic in later years, which was partly attributable to increased use of erythropoiesis-stimulating agents, and fewer used peritoneal dialysis as the initial modality. During the same period, crude 1-year mortality rates remained unchanged (annual change in mortality rate, +0.2%; 95% confidence interval, 0% to +0.4%). Adjustment for changes in demographic and comorbidity patterns yielded estimated annual reductions in 1-year mortality rates of 0.9% (95% confidence interval, 0.7% to 1.1%), which were explained only partly by concurrent trends toward earlier nephrology consultation (annual mortality reduction after accounting for timing of nephrology care was attenuated to 0.4% [0.2% to 0.6%]).
Despite significant trends toward earlier use of nephrology consultation among older patients approaching maintenance dialysis, we observed no material improvement in 1-year survival rates after dialysis initiation during the same time period.
PMCID: PMC4123329  PMID: 21824952
17.  Frequent hypoglycemia among elderly with poor glycemic control 
Archives of internal medicine  2011;171(4):362-364.
Hypoglycemia in elderly patients with diabetes increases the risk of cardiovascular and cerebrovascular events(1), progression of dementia(2), injurious falls(3), emergency department visits, and hospitalization(4). Hypoglycemic episodes are difficult to diagnose in this population and are easily missed by intermittent finger-stick measurements. Recent large studies(5) have shown lack of benefit and sometimes higher risk of morbidity and mortality with tight glycemic control, especially in older adults. Therefore, the American Geriatric Society and the American Diabetes Association recommend relaxing glycemic control for vulnerable patients(6) (A1C<8% instead of the usual <7%). However, whether relaxing the goal to A1C>8% improves the frequency of hypoglycemia in older patients remains unknown. Thus, we evaluated hypoglycemia in older diabetic patients with A1C>8% with continuous glucose monitoring (CGM)
PMCID: PMC4123960  PMID: 21357814
18.  Subclinical Thyroid Dysfunction and Incident Hip Fracture in Older Adults 
Archives of internal medicine  2010;170(21):1876-1883.
Subclinical thyroid dysfunction is common in older adults and affects bone metabolism, but its effects on fracture risk have not been reported. We sought to determine prospectively whether older men and women with subclinical hyperthyroidism or hypothyroidism have an increased risk of hip fracture.
Prospective cohort of 3567 US community-dwelling adults, 65 years or older, with biochemically defined subclinical thyroid dysfunction or euthyroidism was enrolled from June 10, 1989, through May 30, 1990, and followed up through 2004. Main outcome measures included incidence and hazard ratios (HRs), with 95% confidence intervals (CIs), of confirmed incident hip fractures for groups with subclinical hypothyroidism, subclinical hyperthyroidism, and euthyroidism as defined at baseline.
During 39 952 person-years (median follow-up, 13 years), hip fracture incidence (per 1000 men-years) was 13.65 in men with subclinical hyperthyroidism (n = 29) and 10.27 in men with subclinical hypothyroidism (n = 184), both greater than 5.0 in men with euthyroidism (n = 1159). Men with subclinical hypothyroidism had a multivariable-adjusted HR of 2.31 (95% CI, 1.25–4.27); those with subclinical hyperthyroidism, 3.27 (0.99–11.30). After excluding those with baseline use of thyroid-altering medications, men with endogenous subclinical hyperthyroidism had a higher HR of 4.91 (95% CI, 1.13–21.27), as did men with endogenous subclinical hypothyroidism (2.45, 1.27–4.73). Hip fracture incidence (per 1000 women-years) was 8.93 in women with subclinical hypothyroidism (n = 359) and 10.90 in women with subclinical hyperthyroidism (n = 142) compared with 10.18 in women with euthyroidism (n = 1694). No clear association between subclinical dysfunction and fracture was observed in women.
Older men with subclinical hyperthyroidism or hypothyroidism are at increased risk for hip fracture. Whether treatment of the subclinical syndrome reduces this risk is unknown.
PMCID: PMC4122328  PMID: 21098345
19.  Comparative Effectiveness of Two Beta Blockers in Hypertensive Patients 
Archives of internal medicine  2012;172(18):1406-1412.
Randomized controlled trials have demonstrated the efficacy of selected beta blockers for preventing cardiovascular (CV) events in patients following myocardial infarction (MI) or with heart failure (HF). However, the effectiveness of beta blockers for preventing CV events in patients with hypertension has been questioned recently, but it is unclear whether this is a class effect.
Using electronic medical record and health plan data from the Cardiovascular Research Network Hypertension Registry, we compared incident MI, HF, and stroke in patients who were new beta blocker users between 2000–2009. Patients had no history of CV disease and had not previously filled a prescription for a beta blocker. Cox proportional hazards regression was used to examine the associations of atenolol and metoprolol tartrate with incident CV events using both standard covariate adjustment (N=120,978) and propensity matching methods (N=22,352).
During follow-up (median 5.2 years), there were 3,517 incident MI, 3,272 incident HF, and 3,664 incident stroke events. Hazard rate ratios for MI, HF and stroke in metoprolol users were 0.99 (95% confidence interval 0.97–1.02), 0.99 (95% CI 0.96–1.01), and 0.99 (95% CI 0.97–1.02), respectively. An alternative approach using propensity score matching yielded similar results in 11,176 new metoprolol tartrate users who were similar to 11,176 new atenolol users with regard to demographic and clinical characteristics.
There were no statistically significant differences in incident CV events between atenolol and metoprolol tartrate users with hypertension. Large registries similar to the one used in this analysis may be useful for addressing comparative effectiveness questions that are unlikely to be resolved by randomized trials.
PMCID: PMC4120749  PMID: 22928181
20.  Frailty, Dialysis Initiation, and Mortality in End-Stage Renal Disease 
Archives of internal medicine  2012;172(14):1071-1077.
In light of the recent trend toward earlier dialysis initiation and its association with mortality among patients with end-stage renal disease, we hypothesized that frailty is associated with higher estimated glomerular filtration rate (eGFR) at dialysis start and may confound the relation between earlier dialysis initiation and mortality.
We examined frailty among participants of the Comprehensive Dialysis Study (CDS), a special study of the US Renal Data System, which enrolled incident patients from September 1, 2005, through June 1, 2007. Patients were followed for vital status through September 30, 2009, and for time to first hospitalization through December 31, 2008. We used multivariate logistic regression to model the association of frailty with eGFR at dialysis start and proportional hazards regression to assess the outcomes of death or hospitalization.
Among 1576 CDS participants included, the prevalence of frailty was 73%. In multivariate analysis, higher eGFR at dialysis initiation was associated with higher odds of frailty (odds ratio [OR], 1.44 [95% CI, 1.23–1.68] per 5 mL/min/1.73 m2; P<.001). Frailty was independently associated with mortality (hazard ratio [HR], 1.57 [95% CI, 1.25–1.97]; P<.001) and time to first hospitalization (HR, 1.26 [95% CI, 1.09–1.45]; P<.001). While higher eGFR at dialysis initiation was associated with mortality (HR, 1.12 [95% CI, 1.02–1.23] per 5 mL/min/1.73 m2; P=.02), the association was no longer statistically significant after frailty was accounted for (HR, 1.08 [95% CI, 0.98–1.19] per 5 mL/min/1.73 m2; P=.11).
Frailty is extremely common among patients starting dialysis in the United States and is associated with higher eGFR at dialysis initiation. Recognition of signs and symptoms of frailty by clinicians may prompt earlier initiation of dialysis and may explain, at least in part, the well-described association between eGFR at dialysis initiation and mortality.
PMCID: PMC4117243  PMID: 22733312
21.  Fulfilling Our Obligation to the Caregiver: It's Time for Action 
Archives of internal medicine  2011;171(4):359-360.
PMCID: PMC4115074  PMID: 21357812
22.  Dietary supplements and mortality in older women: the Iowa Women's Health Study 
Archives of internal medicine  2011;171(18):1625-1633.
Although dietary supplements are commonly taken to avoid chronic disease, long-term health consequences of many compounds are unknown.
We assessed the use of vitamin and mineral supplements in relation to total mortality in 38 772 older women in the Iowa Women's Health Study, mean age 61.6 years at baseline in 1986. Supplement use was self-reported in 1986, 1997 and 2004. Through December 31, 2008, 15 594 deaths (40.2%) were identified through the State Health Registry of Iowa and the National Death Index.
In multivariable adjusted proportional hazards regression models, the use of multivitamins (Hazard Ratio (HR), 1.06 [95% CI, 1.02-1.10], Absolute Risk Increase (ARI), 2.4%), vitamin B6 (HR, 1.10 [95% CI, 1.01-1.21], ARI, 4.1%), folic acid (HR, 1.15 [95% CI, 1.00-1.32], ARI, 5.9%), iron (HR, 1.10 [95% CI, 1.03-1.17], ARI, 3.9%), magnesium (HR, 1.08 [95% CI, 1.01-1.15], ARI, 3.6%), zinc (HR, 1.08 [95% CI, 1.01-1.15], ARI, 3.0%) and copper (HR, 1.45 [95% CI, 1.20-1.75], ARI, 18.0%) were associated with increased risk of total mortality when compared with corresponding nonusers, while calcium was inversely related (HR, 0.91 [95% CI, 0.88-0.94], Absolute Risk Reduction (ARR), 3.8%). Findings for iron and calcium were replicated in separate shorter-term analyses (10-year, 6-year and 4-year follow-up) each with about 15% dead, starting in 1986, 1997, and 2004.
In older women several commonly used dietary vitamin and mineral supplements may be associated with increased total mortality risk, most strongly supplemental iron, while calcium, in contrast to many studies, was associated with decreased risk.
PMCID: PMC4114071  PMID: 21987192
Cohort; Iowa Women's Health study; minerals; supplement; total mortality; vitamins; women
23.  Chronic Disease Management for Tobacco Dependence 
Archives of internal medicine  2011;171(21):1894-1900.
Tobacco dependence disorder is a chronic relapsing condition, yet treatment is delivered in discrete episodes of care that yield disappointing long-term quit rates.
We conducted a randomized controlled trial from June 1, 2004, through May 31, 2009, to compare telephone-based chronic disease management (1 year; longitudinal care [LC]) with evidence-based treatment (8 weeks; usual care [UC]) for tobacco dependence. A total of 443 smokers each received 5 telephone counseling calls and nicotine replacement therapy by mail for 4 weeks. They were then randomized to UC(2 additional calls) or LC(continued counseling and nicotine replacement therapy for an additional 48 weeks). Longitudinal care targeted repeat quit attempts and interim smoking reduction for relapsers. The primary outcome was 6 months of prolonged abstinence measured at 18 months of follow-up.
At 18 months, 30.2% of LC participants reported 6 months of abstinence from smoking, compared with 23.5% in UC (unadjusted, P=.13). Multivariate analysis showed that LC (adjusted odds ratio, 1.74; 95% CI, 1.08–2.80), quit attempts in past year (1.75; 1.06–2.89), baseline cigarettes per day (0.95; 0.92–0.99), and smoking in the 14- to 21-day interval post-quit (0.23; 0.14–0.38) predicted prolonged abstinence at 18 months. The LC participants who did not quit reduced smoking more than UC participants (significant only at 12 months). The LC participants received more counseling calls than UC participants (mean, 16.5 vs 5.8 calls; P<.001), longer total duration of counseling (283 vs 117 minutes; P<.001), and more nicotine replacement therapy (4.7 vs 2.4 boxes of patches; P<.001).
A chronic disease management approach increases both short- and long-term abstinence from smoking.
Trial Registration Identifier: NCT00309296
PMCID: PMC4110895  PMID: 22123795
24.  Curbing the Use of Ultrasonography in the Diagnosis of Acute Kidney Injury 
Archives of internal medicine  2010;170(21):1907-1908.
PMCID: PMC4095784  PMID: 21098349
25.  Getting to “No” 
Archives of internal medicine  2010;170(4):381-388.
Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness.
Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test.
Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P=.001).
Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.
PMCID: PMC4090224  PMID: 20177043

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