Biomedical subjects

J B Brown

Publications and source records attributed to J B Brown.

At least 37 records · Page 2Linked to original sources

PubMed2000

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.

Evidence-Based Medicine↗

PubMed2000

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.

Attitude↗

PubMed2000

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.

Age Factors↗

PubMed2000

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.

Activities of Daily Living↗

PubMed2000

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.

Adolescent↗

PubMed2000

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.

Adaptation, Psychological↗

PubMed2000

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.

Aged↗

PubMed2000

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.

Adult↗

PubMed2000

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.

Adolescent↗

PubMed2000

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.

Adolescent↗

PubMed1999

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.

Adult↗

PubMed1999

The progressive cost of complications in type 2 diabetes mellitus.

BACKGROUND: A substantial proportion of the costs of diabetes treatment arises from treating long-term complications, particularly cardiovascular and renal disease. However, little is known about the progressive cost of these complications. Firmer knowledge would improve diabetes modeling and might increase the financial and organizational support for the prevention of diabetic complications. METHODS: We analyzed 9 years of clinical data on 11 768 members of a large group-model health maintenance organization who had probable type 2 diabetes mellitus. We ascertained the presence of cardiovascular and renal complications, staged the members progression, and estimated their incremental costs by stage. RESULTS: We found no significant differences between men and women in the prevalence or staging of complications. Per-person costs increased over baseline ($2033) by more than 50% ($1087) after initiation of cardiovascular drug therapy and/or use of a cardiologist, and by 360% ($7352) after a major cardiovascular event. Abnormal renal function increased diabetes treatment costs by 65% ($1337); advanced renal disease, by 195% ($3979); and end-stage renal disease, by 771% ($15 675). Both cardiovascular and renal diseases were more common among older subjects, but age did not affect the additional costs of these complications. Women had substantially higher medical care costs after controlling for age and presence of complications. Incremental cost estimates based solely on "labeled" events significantly underestimate true incremental cost. CONCLUSIONS: In an aggregate population, the greatest cost savings would be achieved by preventing major cardiovascular events. For individuals, the greatest savings would be achieved by preventing progression to stage 3 renal disease.

Adult↗

PubMed1999

Ten-year follow-up of antidiabetic drug use, nonadherence, and mortality in a defined population with type 2 diabetes mellitus.

Studies performed for drug registration provide little insight into the long-term use and effectiveness of drugs in "real world" populations and settings. To obtain such insight, we used 10 years of electronic medical-record data from Kaiser Permanente Northwest Division, a large, group-model health maintenance organization in the United States, to study drug transitions, lapses in drug therapy, and mortality among 693 persons with newly diagnosed type 2 diabetes mellitus in 1988. We also studied an equivalently defined cohort of 1071 persons with new diagnoses in 1994, for whom the availability of laboratory results via electronic data permitted additional analyses. Cumulative mortality in the 1988 cohort increased steadily to 207 of 571 patients (36%) by 1997 (year 10). In 1988, 548 of 693 patients (79%) received initial monotherapy with a sulfonylurea. Insulin use rose as the use of sulfonylureas declined. Over this period, 504 of 693 patients (73%) discontinued or added drug therapy. Eight percent to 10% of both sulfonylurea users and insulin users discontinued drug use during the study period. In the 1994 cohort, two thirds of the subjects who discontinued therapy and were tested for glycosylated hemoglobin (Hb A1c) (n = 86) maintained good-to-excellent glycemic control. However, 78 discontinuers (38%) were not tested for Hb A1c, and, among this subset, 32% failed to visit a primary care clinician. The results of this study suggest that 5% to 10% of persons with type 2 diabetes mellitus avoid contact with the medical care system. Avoidance persists for at least the first 10 years after diagnosis but is more common in the first year after diagnosis. In addition, secondary failure of sulfonylureas begins within 1 year of diagnosis and continues at a steady pace. Almost 80% of patients initially treated with sulfonylureas added or switched to metformin or insulin within 10 years of diagnosis.

Cohort Studies↗

PubMed1999

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.

Adult↗

PubMed1999

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.

Attitude to Health↗

PubMed1999

Practical methods to increase use of advance medical directives.

OBJECTIVE: To compare the effectiveness of two means for increasing the use of advance medical directives: written materials only versus written materials and an educational videotape. DESIGN: Population-based, randomized controlled trial with 3-month follow up. SETTING: Kaiser Permanente Colorado Region, a not-for-profit group-model health maintenance organization. PARTICIPANTS: A population-based sample of all 1,302 members aged 75 years and older who used the Franklin Medical Office, excluding 55 persons who died or disenrolled during the study period or were identified by their physicians as blind or cognitively impaired. INTERVENTIONS: All subjects were mailed a 10-page cartoon-illustrated educational pamphlet on patient choices, a selection of Colorado advance medical directive forms, and a guide to their completion; 619 subjects also were mailed a 20-minute videotape on advance directives. Both groups had access to a study nurse for assistance in completing and placing advance medical directives. MEASUREMENTS AND MAIN RESULTS: The main outcome measure is the proportion of subjects who placed a directive in their medical record for the first time. Placement rates increased almost identically, from 21.2% to 35.0% in the written materials-only group and from 18.9% to 32.6% in the group receiving the videotape (95% confidence interval for difference -0.04, 0.04, p =.952). CONCLUSIONS: In an elderly population with a substantial baseline placement rate, mailing of written materials substantially increased placement of an advance directive in the medical record, but the addition of a videotape did not. Mailing the video did increase the use of treatment trials and made patients more aware of reasons not to use advance directives.

Advance Directives↗

PubMed1999

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.

Adult↗

PubMed1999

Breast cancer survivors' perceptions of complementary/alternative medicine (CAM): making the decision to use or not to use.

The study described in this article explored breast cancer survivors' perceptions and experiences as they decided whether to use a variety of complementary/alternative therapies. Six focus groups were conducted composed of women who had been diagnosed with breast cancer. Each 2-hour session was audiotaped and transcribed verbatim. In this article, the process by which the participants made the decision to use or not to use complementary/alternative therapies, including their discovery and investigation of complementary/alternative medicine (CAM) and their experiences using or not using CAM, are described. Barriers to using CAM included cost, access, and time. Family and friends generally supported the decision to use CAM; however, the participants described health care practitioners' reactions as mixed.

Adult↗