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Biomedical subjects

J R Curtis

Publications and source records attributed to J R Curtis.

At least 19 recordsLinked to original sources
PubMed2006

Prevalence and predictors of osteoporosis treatment in nursing home residents with known osteoporosis or recent fracture.

SUMMARY: We studied nursing home residents with osteoporosis or recent fracture to determine the frequency and predictors of osteoporosis treatment. There was wide variation in performance, and both clinical and systems variables predicted use. This study shows that improvement in osteoporosis care is possible and important for many nursing homes. INTRODUCTION: We determined the prevalence and predictors of osteoporosis evaluation and treatment in high-risk nursing home residents. METHODS: We identified 67 nursing facilities in North Carolina and Arizona with > 10 residents with osteoporosis or recent hip fracture. Medical records (n=895) were abstracted for osteoporosis evaluation [dual-energy X-ray absorptiometry (DXA), vitamin D level, serum calcium), treatment (calcium, vitamin D, osteoporosis medication, hip protectors), clinical, and systems covariates. Data were analyzed at the facility level using mixed models to account for the complex nesting of residents within providers and nursing facilities. RESULTS: Calcium and vitamin D was prescribed for 69% of residents, bisphosphonates for 19%, calcitonin for 14%, other pharmacologic therapies for 6%, and hip protectors for 2%. Overall, 36% received any bone protection (medication or hip protectors), with wide variation among facilities (0-85%). Factors significantly associated with any bone protection included female gender [odds ratio (OR) 2.4, (1.5-3.7)] and nonurban/suburban location [1.5, (1.1-2.2)]. Residents with esophagitis, peptic ulcer disease (PUD), or dysphagia [0.6, (0.4-0.9)] and alcohol abuse [0.2, (0.0-0.9)] were less likely to receive treatment. CONCLUSIONS: There is substantial variation in the quality of osteoporosis treatment across nursing homes. Interventions that improve osteoporosis quality of care are needed.

Aged↗
PubMed2006

Channeling and adherence with alendronate and risedronate among chronic glucocorticoid users.

INTRODUCTION: Despite the efficacy of bisphosphonates to reduce fractures in high risk populations, bisphosphonate adherence among chronic glucocorticoid users has received limited attention. Moreover, perceived differences in GI tolerability may lead physicians to preferentially prescribe particular bisphosphonates. METHODS: Among chronic glucocorticoid users (>60 days of therapy) enrolled in managed care, we identified individuals initiating therapy with alendronate or risedronate during 2001-2004. Multivariable logistic regression and proportional hazards models were used to examine factors associated with channeling patients to risedronate (versus alendronate) and with discontinuation (>3-month gap without refill). The Medication Possession Ratio (MPR) was calculated as the filled days of medication divided by the interval of time between prescriptions. RESULTS: Of 1,158 glucocorticoid users initiating bisphosphonate therapy, demographic characteristics of alendronate users (n=754) and risedronate users (n=404) were similar for age (mean 53 years) and gender (approximately 80% female). Past history of a GI symptom or event was associated with risedronate receipt (OR=2.24, 95% CI 1.15-4.35). After multivariable adjustment, rates of discontinuation (mean time to discontinuation approximately 18 months) and adherence (mean MPR=73%) were similar between users of the two bisphosphonates. Younger age, greater medical comorbidity, and lack of BMD testing were significantly associated with discontinuation. CONCLUSIONS: Overall persistence rates were suboptimal for bisphosphonate use among chronic glucocorticoids users and did not differ significantly by drug. Newer strategies to promote long-term adherence are needed to improve osteoporosis therapeutic effectiveness.

Adult↗
PubMed2006

High prevalence of abnormal acid gastro-oesophageal reflux in idiopathic pulmonary fibrosis.

The aim of this prospective study was to determine the prevalence and characteristics of acid gastro-oesophageal reflux (GER) in patients with idiopathic pulmonary fibrosis (IPF). Sixty-five consecutive patients with well-defined IPF were subjected to 24-h pH monitoring and oesophageal manometry. A total of 133 consecutive patients with intractable asthma and symptoms of GER were used as comparisons. The prevalence of abnormal acid GER in IPF patients was 87%, with 76% and 63% demonstrating abnormal distal and proximal oesophageal acid exposures, respectively. Abnormal acid GER was significantly more common in IPF patients than asthma patients. Only 47% of IPF patients experienced classic GER symptoms. Despite treatment with standard doses of proton pump inhibitors (PPIs), 12 out of 19 patients receiving PPIs during the 24-h pH monitoring had abnormal oesophageal acid exposures by pH probe. There was no correlation between IPF severity and acid GER severity. In conclusion, abnormal acid gastro-oesophageal reflux is highly prevalent, but often clinically occult in patients with idiopathic pulmonary fibrosis. Standard doses of proton pump inhibitors may not suppress the acid gastro-oesophageal reflux in this population. Therefore, further studies are needed to determine if acid abnormal gastro-oesophageal reflux represents an important risk factor for idiopathic pulmonary fibrosis development or progression, and if optimal suppression of acid gastro-oesophageal reflux slows the progression of idiopathic pulmonary fibrosis and/or decreases episodic exacerbations of idiopathic pulmonary fibrosis.

Adult↗
PubMed2004

Patient-physician communication about end-of-life care for patients with severe COPD.

Since patients with chronic obstructive pulmonary disease (COPD) infrequently discuss treatment preferences about end-of-life care with physicians, the goal of the present study was to identify which specific areas of communication about end-of-life care occur between patients with severe COPD and their physicians, and how patients rate the quality of this communication. A total of 115 patients with oxygen-dependent COPD, identified in pulmonary clinics in three hospitals and through an oxygen delivery company, were enrolled in this study. A 17-item quality of communication questionnaire (QOC) was administered to patients, along with other measures, including satisfaction with care. The patients reported that most physicians do not discuss how long the patients have to live, what dying might be like or patients' spirituality. Patients rated physicians highly at listening and answering questions. Areas patients rated relatively low included discussing prognosis, what dying might be like and spirituality/religion. Patients' assessments of physicians' overall communication and communication about treatment correlated well with the QOC. Patients' overall satisfaction with care also correlated significantly with the QOC. In conclusion, this study identifies areas of communication that physicians do not address and areas that patients rate poorly, including talking about prognosis, dying and spirituality. These areas may provide targets for interventions to improve communication about end-of-life care for patients with chronic obstructive pulmonary disease. Future studies should determine the responsiveness of these items to interventions, and the effect such interventions have on patient satisfaction and quality of care.

Advance Care Planning↗
PubMed2003

The assessment of health status among patients with COPD.

Survival and physiological measures alone do not represent the full experiences of patients with chronic obstructive pulmonary disease. Reducing the personal and social burden of disease by improving patients' symptoms, functional status and quality of life are also important goals. There has been a substantial increase in the use of newly developed tools that measure health status and it is important for clinicians and researchers to understand these instruments' strengths and weaknesses in providing insight into a patient's condition and experience. Relying only on mortality and physiological outcomes could blind a clinician to significant benefits patients may receive from a treatment. A growing body of research utilises end-points assessed directly by patients whose self-reported health status includes health-related quality of life and functional status. This article reviews major concepts and methods in health-status assessments for patients with chronic obstructive pulmonary disease, which will have an important role in assessing the efficacy and effectiveness of new treatments.

Aged↗
PubMed2001

Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death.

BACKGROUND: Efforts to improve communication between physicians and dying patients have been unsuccessful, and guidelines for improving patient-physician communication about end-of-life care are based primarily on expert opinion. This study assessed which aspects of communication between patients and physicians are important in end-of-life care. METHODS: Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care professionals from hospice or acute care settings, and physicians with expertise in end-of-life care. Focus group analyses determined domains of physician skill at end-of-life care. Communication with patients was identified as one of the most important domains. Analyses of components important in communicating with dying patients and their families were performed. RESULTS: The following 6 areas were of central importance in communicating with dying patients: talking with patients in an honest and straightforward way, being willing to talk about dying, giving bad news in a sensitive way, listening to patients, encouraging questions from patients, and being sensitive to when patients are ready to talk about death. Within these components, subthemes emerged that provide guidelines for physicians and educators. Dying patients also identified the need to achieve a balance between being honest and straightforward and not discouraging hope. CONCLUSIONS: Several areas emerged for physicians to focus their attention on when communicating with dying patients. These findings provide guidance in how to improve this communication. They also highlight the need to approach communication about end-of-life care as a spectrum that requires attention from the time of a terminal diagnosis through death.

Clinical Competence↗
PubMed2001

Improving end-of-life experience and care in the community: a conceptual framework.

End-of-life research and interventions have mostly focused on patients and family. There are compelling reasons for studying end-of-life experience and care from a community perspective. "Whole community" approaches to end-of-life care have been endorsed by the Institute of Medicine Committee on Care at End of Life. Building on the model developed by Stewart and colleagues, which integrates quality of life and quality of health indicators, a conceptual framework is presented that describes pertinent whole-community characteristics, structures, processes, and outcomes. The framework offers a map for whole-community research, intervention, and evaluation with the goal of changing the community culture related to life's end and thereby improving the quality of life for dying people and their families.

Community Health Services↗
PubMed2001

Evaluating the quality of dying and death.

We propose a model for evaluating the quality of dying and death based on concepts elicited from literature review, qualitative interviews with persons with and without chronic and terminal conditions, and consideration of desirable measurement properties. We define quality of dying and death as the degree to which a person's preferences for dying and the moment of death agree with observations of how the person actually died, as reported by others. Expected level of agreement is modified by circumstances surrounding death that may prevent following patient's prior preferences. Qualitative data analysis yielded six conceptual domains: symptoms and personal care, preparation for death, moment of death, family, treatment preferences, and whole person concerns. These domains encompass 31 aspects that can be rated by patients and others as to their importance prior to death and assessed by significant others or clinicians after death to assess the quality of the dying experience. The proposed model uses personal preferences about the dying experience to inform evaluation of this experience by others after death. This operational definition will guide validation of after-death reports of the quality of dying experience and evaluation of interventions to improve quality of end-of-life care.

Death↗
PubMed2001

Use of hypertonic saline in the treatment of cerebral edema in diabetic ketoacidosis (DKA).

Cerebral edema is the primary cause of morbidity and mortality in children and adolescents with diabetic ketoacidosis (DKA). We report a case of an adolescent female with life-threatening DKA-related cerebral edema who responded to a combination of mannitol and hypertonic saline. This is the first report of the use of hypertonic saline in the treatment of cerebral edema due to DKA.

Journal Article↗
PubMed2001

A randomized, controlled trial of advanced care planning discussions during preoperative evaluations.

BACKGROUND: Although many patients and physicians support the concept of advance care planning, only a small percentage of patients actually have the necessary discussion with health care providers. Hospital-based physicians other than primary care providers often are needed to increase physician, patient, and proxy communication about advanced directives. This study evaluated the effectiveness of a 5-10-min discussion designed to foster dialogue between patients and their proxies in a preoperative evaluation clinic. The discussions were lead by anesthesiologists. METHODS: A randomized controlled trial was conducted from September 1998 through May 1999 in a preoperative evaluation clinic at University of California, San Francisco, a tertiary care center. English-speaking patients aged 65 yr or older who were scheduled for elective surgery were randomized to receive a short information session stressing the importance of communication about end-of-life care between the patients and their proxies. Patients randomized to the control group received the standard preoperative anesthesia screening. An admitting counselor questioned all patients (control and intervention) about whether they have an advanced directive as part of the registration process before their arrival in clinic. RESULTS: The intervention significantly increased discussions about end-of-life care between patients and their proxies. Eighty seven percent of patients reported having discussions with their proxies as compared with only 66% of control patients (P = 0.001). The intervention also increased durable power of attorney completion rate to 27% as compared with 10% completion rate by controls. CONCLUSIONS: The preoperative evaluation period can be an opportunity to encourage patient and proxy communication about end-of-life care.

Aged↗
PubMed2001

Primary care residency graduates' reported training needs.

Primary care residency graduates were surveyed about their satisfaction with their training. The respondents desired more training in outpatient knowledge and procedures, psychosocial skills, and business skills.

Attitude of Health Personnel↗
PubMed2001

The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement.

The intensive care unit (ICU) represents a hospital setting in which death and discussion about end-of-life care are common, yet these conversations are often difficult. Such difficulties arise, in part, because a family may be facing an unexpected poor prognosis associated with an acute illness or exacerbation and, in part, because the ICU orientation is one of saving lives. Understanding and improving communication about end-of-life care between clinicians and families in the ICU is an important focus for improving the quality of care in the ICU. This communication often occurs in the "family conference" attended by several family members and members of the ICU team, including physicians, nurses, and social workers. In this article, we review the importance of communication about end-of-life care during the family conference and make specific recommendations for physicians and nurses interested in improving the quality of their communication about end-of-life care with family members. Because excellent end-of-life care is an important part of high-quality intensive care, ICU clinicians should approach the family conference with the same care and planning that they approach other ICU procedures. This article outlines specific steps that may facilitate good communication about end-of-life care in the ICU before, during, and after the conference. The article also provides direction for the future to improve physician-family and nurse-family communication about end-of-life care in the ICU and a research agenda to improve this communication. Research to examine and improve communication about end-of-life care in the ICU must proceed in conjunction with ongoing empiric efforts to improve the quality of care we provide to patients who die during or shortly after a stay in the ICU.

Advance Directives↗
PubMed2001

End-of-life care in the intensive care unit: a research agenda.

BACKGROUND: The intensive care unit (ICU) represents a unique clinical setting in which mortality is relatively high and the professional culture tends to be one of "rescue therapy" using technological and invasive interventions. For these reasons, the ICU is an important environment for understanding and improving end-of-life care. Although there have been consensus statements and review articles on end-of-life care in the ICU, there is limited evidence on which to base an assessment of best practices for providing high-quality end-of-life care in this setting. OBJECTIVE: To convene a Working Group of experts in critical care, palliative medicine, medical ethics, and medical law to address the question "What research needs to be done to improve end-of-life care to patients in the ICU?" METHODS: Participants were identified for membership in the Working Group by purposive sampling within the fields of critical care medicine and nursing, palliative medicine, and medical ethics; others were chosen to represent social work and hospital chaplains. Through a process of breakout and plenary sessions, the group identified important questions that need to be addressed in the areas of defining the problem, identifying solutions, evaluating solutions, and overcoming barriers. CONCLUSIONS: Outlining unanswered questions on end-of-life care in the ICU is a first step to providing the answers that will allow us to improve care to patients dying in the ICU. These questions also serve to focus clinicians and educators on the important areas for improving quality of care.

Attitude to Death↗
PubMed2001

Underestimation of mortality following lung volume reduction surgery resulting from incomplete follow-up.

STUDY OBJECTIVES: Incomplete follow-up can bias interpretation of data that are collected in longitudinal studies. We noted that many patients failed to return for follow-up in a study of effect of lung volume reduction surgery (LVRS) on quality of life (QOL). Accordingly, we designed this investigation to determine the reasons patients dropped out, and to assess differences between those who continued in the study (attendees) and those who did not (nonattendees). DESIGN: Telephone survey. SUBJECTS: Patients with advanced emphysema who had undergone LVRS and had previously agreed to participate in a longitudinal QOL study. RESULTS: No differences were found with regard to age, gender, preoperative pulmonary function, or oxygen use between attendees and nonattendees. Long-term mortality in nonattendees (27%) was considerably greater than that seen in attendees (3%, p < 0.05). Distance from the hospital, financial burden, and living out of the region were the most common reasons cited by surviving nonattendees for their failure to return for follow-up. CONCLUSIONS: Studies reporting the long-term mortality after LVRS can be biased in the direction of underestimating the true value if they are compromised by incomplete follow-up.

Adult↗
PubMed2001

Risk of myocardial ischaemia and beta-adrenoceptor agonists.

Modern therapy for both cardiovascular disease and obstructive lung disease involves diametrically opposed manipulations of the beta-adrenoceptor. Beta-agonists reduce airflow limitation and improve symptoms among patients with obstructive lung disease while beta-blockers reduce symptoms, recurrent myocardial ischaemia and all-cause mortality among patients with ischaemic heart disease. There is biological plausibility for beta-agonists leading to adverse cardiovascular outcomes, and observational trials have raised concern about the safety of beta-agonists among patients with cardiovascular disease. Although there are many potential causal and noncausal explanations for these observational findings, the implications from these studies are the same. Physicians should be careful when prescribing beta-agonists for patients at risk for ischaemic heart disease. Furthermore, careful consideration should be given to distinguish symptoms caused by cardiovascular versus respiratory aetiologies.

Adrenergic beta-Agonists↗
PubMed2001

Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health care workers.

BACKGROUND: A framework for understanding and evaluating physicians' skills at providing end of life care from the perspectives of patients, families, and health care workers will promote better quality of care at the end of life. OBJECTIVE: To develop a comprehensive understanding of the factors contributing to the quality of physicians' care for dying patients. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Seattle, Washington. PARTICIPANTS: Eleven focus groups of patients with chronic obstructive pulmonary disease, AIDS, or cancer (79 patients); 3 groups of family members who had a loved one die of chronic disease (20 family members); 4 groups of nurses and social workers from hospice or acute care settings (27 health care workers); and 2 groups of physicians with expertise in end-of-life care (11 physicians). RESULTS: We identified 12 domains of physicians' skills at providing end-of-life care: accessibility and continuity; team coordination and communication; communication with patients; patient education; inclusion and recognition of the family; competence; pain and symptom management; emotional support, personalization; attention to patient values; respect and humility; and support of patient decision making. within these domains, we identified 55 specific components of physicians' skills. Domains identified most frequently by patients and families were emotional support and communication with patients. Patients with the 3 disease groups, families, and health care workers identified all 12 domains. Investigators used transcript analyses to construct a conceptual model of physicians' skills at providing end-of-life care that grouped domains into 5 categories. CONCLUSIONS: The 12 domains encompass the major aspects of physicians' skills at providing high-quality end-of-life care from the perspectives of patients, their families, and health care workers, and provide a new framework for understanding, evaluating, and teaching these skills. Our findings should focus physicians, physician-educators, and researchers on communication, emotional support, and accessibility to improve the quality of end-of-life care.

Adult↗