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Biomedical subjects

K Kroenke

Publications and source records attributed to K Kroenke.

At least 37 records · Page 2Linked to original sources
PubMed2000

How common are various causes of dizziness? A critical review.

BACKGROUND: Although dizziness is a common symptom in both primary care and referral practices, the relative frequency of various causes has not been well delineated. METHODS: A MEDLINE search identified 12 articles containing original data on the etiology of dizziness in consecutive patients. Study sites included primary care offices (n = 2), emergency room (n = 4), and referral clinics (n = 6). Each study's strength of design was graded using nine quality criteria. RESULTS: Dizziness was attributed to a peripheral vestibulopathy in 44% of patients, a central vestibulopathy in 11%, psychiatric causes in 16%, other conditions in 26%, and an unknown cause in 13%. Certain serious causes were relatively uncommon, including cerebrovascular disease (6%), cardiac arrhythmia (1.5%), and brain tumor (<1%). CONCLUSIONS: Dizziness is due to vestibular or psychiatric causes in more than 70% of cases. Since serious treatable causes appear uncommon, diagnostic testing can probably be reserved for a small subset of patients.

Adult↗
PubMed1999

Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.

CONTEXT: The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness. OBJECTIVE: To determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD. DESIGN: Criterion standard study undertaken between May 1997 and November 1998. SETTING: Eight primary care clinics in the United States. PARTICIPANTS: Of a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ. MAIN OUTCOME MEASURES: Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions. RESULTS: A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, kappa = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized. CONCLUSION: Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use.

Adult↗
PubMed1999

Use of complementary therapies for arthritis among patients of rheumatologists.

BACKGROUND: Use of complementary and alternative medicine (CAM) is common among persons with chronic conditions. OBJECTIVE: To identify correlates of and describe patients' perspective on use of CAM for rheumatologic conditions. DESIGN: Telephone survey. SETTING: Three university practices and three private rheumatology practices. PATIENTS: 232 of 428 eligible consecutive patients (54%) with scheduled appointments. MEASUREMENTS: Patients answered questions on CAM use, functional status, pain, provider satisfaction, and health services utilization. Chart reviews provided demographic information and rheumatologic diagnoses. Bivariate analyses identified correlates of four CAM outcomes (history, magnitude, and frequency of CAM use and communication about CAM use with a physician), and multiple logistic regression identified independent correlates of regular CAM use. RESULTS: Approximately two thirds of the respondents (n = 146) had used CAM. Of these 146 respondents, 82 (56%) currently used CAM and 132 (90%) regularly used CAM or had done so in the past. Fifty-five respondents (24%) had used three or more types of CAM. In multivariate analyses, persons who used CAM regularly were more likely to have osteoarthritis (odds ratio, 5.6 [95% CI, 1.9 to 16.8]), severe pain (odds ratio, 2.5 [CI, 1.4 to 4.8]), and a college degree (odds ratio, 2.6 [CI, 1.3 to 5.4]) than patients who had never used CAM. Nearly half of the respondents discussed CAM use with their physicians. The most common reasons for not disclosing CAM use were that the physician had not asked about it and that the patient forgot to tell the physician; fear of disapproval was rarely cited. Discussions about CAM use between patient and physician occurred more frequently among patients with fibromyalgia and persons who regularly used CAM or used several types of CAM. CONCLUSIONS: Patients with rheumatologic conditions frequently use CAM. Severe pain and osteoarthritis predict regular use of CAM but do not predict a greater likelihood of discussing CAM use with physicians. Routine inquiry by physicians will probably detect CAM use.

Arthralgia↗
PubMed1999

Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes.

BACKGROUND: One sixth of patient encounters are perceived as difficult by clinicians. Our goal was to assess clinical predictors and outcomes from such encounters. METHODS: Five hundred adults presenting to a primary care walk-in clinic with a physical symptom completed surveys before the visit, immediately after the visit, at 2 weeks, and at 3 months. Patient measurements included mental disorders (PRIME-MD), functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), satisfaction (RAND 9-item survey), symptom resolution, visit costs, previsit and residual expectations of care, and health services utilization. Measurements from the 38 participating clinicians included the Physician's Belief Scale and physician perception of encounter difficulty (Difficult Doctor-Patient Relationship Questionnaire). RESULTS: Seventy-four patient encounters (15%) were rated as difficult. Patients in such encounters were more likely to have a mental disorder (odds ratio, 2.4; 95% confidence interval, 1.3-4.4), more than 5 somatic symptoms (odds ratio, 1.4; 95% confidence interval, 1.1-1.8), and more severe symptoms (odds ratio, 1.6; 95% confidence interval, 1.04-2.3). Difficult-encounter patients had poorer functional status, more unmet expectations (P=.005), less satisfaction with care (P=.03), and higher use of health services (P<.001). Clinicians with poorer psychosocial attitudes as reflected by higher scores on the Physician's Belief Scale experienced more encounters as being difficult (23% vs 8%; P<.001). CONCLUSIONS: Patients presenting with physical symptoms who are perceived as difficult are more likely to have a depressive or anxiety disorder, poorer functional status, unmet expectations, reduced satisfaction, and greater use of health care services. Physicians with poorer psychosocial attitudes are more likely to experience encounters as difficult.

Adult↗
PubMed1999

Case-finding for depression in primary care: a randomized trial.

PURPOSE: Depression is a highly prevalent, morbid, and costly illness that is often unrecognized and inadequately treated. Because depression questionnaires have the potential to improve recognition, we evaluated the accuracy and effects on primary care of two case-finding instruments compared to usual care. SUBJECTS AND METHODS: The study was conducted at three university-affiliated and one community-based medical clinics. Consecutive patients were randomly assigned to be asked a single question about mood, to fill out the 20-item Center for Epidemiologic Studies Depression Screen, or to usual care. Within 72 hours, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders Third Revised Edition (DSM-III-R) disorders by an assessor blinded to the screening results. Process of care was assessed using chart audit and administrative databases; patient and physician satisfaction was assessed using Likert scales. At 3 months, depressed patients and a random sample of nondepressed patients were re-assessed for DSM-III-R disorders and symptom counts. RESULTS: We approached 1,083 patients, of whom 969 consented to screening and were assigned to the single question (n = 330), 20-item questionnaire (n = 323), or usual care (n = 316). The interview for DSM-III-R diagnosis was completed in 863 (89%) patients; major depression, dysthymia, or minor depression was present in 13%. Both instruments were sensitive, but the 20-item questionnaire was more specific than the single question (75% vs 66%, P = 0.03). The 20-item questionnaire was less likely to be self-administered (54% vs 90%) and took significantly more time to complete (15 vs 248 seconds). Case-finding with the 20-item questionnaire or single question modestly increased depression recognition, 30/77 (39%) compared with 11/38 (29%) in usual care (P = 0.31) but did not affect treatment (45% vs 43%, P = 0.88). Effects on DSM-III-R symptoms were mixed. Recovery from depression was more likely in the case-finding than usual care groups, 32/67 (48%) versus 8/30 (27%, P = 0.03), but the mean improvement in depression symptoms did not differ significantly (1.6 vs 1.5 symptoms, P = 0.21). CONCLUSIONS: A simple question about depression has similar performance characteristics as a longer 20-item questionnaire and is more feasible because of its brevity. Case-finding leads to a modest increase in recognition rates, but does not have consistently positive effects on patient outcomes.

Aged↗
PubMed1999

Evaluating dizziness.

PURPOSE: To conduct a structured literature synthesis on the etiology, prognosis, and diagnostic evaluation of dizziness, and to suggest a primary-care approach to evaluating this symptom. METHODS: Studies were identified from MEDLINE searches (1966 through 1996) and a manual search of bibliographies from retrieved articles. Two investigators independently abstracted study data. RESULTS: The most common etiologies for dizziness were peripheral vestibulopathies (35% to 55% of patients) and psychiatric disorders (10% to 25% of patients). Cerebrovascular disease (5%) and brain tumors (<1%) were infrequent. The history and physical examination led to a diagnosis in about 75% of patients. At least 10% of patients eluded diagnosis. Symptoms were usually self-limited and not associated with an increased risk of mortality. The diagnostic testing literature, which was often methodologically flawed, suggested that routine laboratory tests as well as cardiovascular and neurologic testing had a low yield in unselected patients. We could not derive evidence-based guidelines for using specialized vestibular function tests such as electronystagmography. CONCLUSIONS: Dizziness is usually a benign, self-limited complaint. When a diagnosis can be made, a careful history and physical examination will usually identify the probable cause. Cardiovascular, neurologic, and laboratory testing should be guided by the clinical evaluation. Rigorous studies are needed to determine the accuracy and utility of specialized vestibular testing.

Audiometry↗
PubMed1999

Symptoms in hospitalized patients: outcome and satisfaction with care.

PURPOSE: Physical symptoms are responsible for substantial morbidity in outpatients. We assessed symptoms in patients admitted to a hospital to determine their frequency, persistence at discharge, and the relation between symptom outcome and satisfaction with care. METHODS: During a 12-month period, 2,126 hospitalized medical patients completed a study interview within 2 hours of admission. More than half (n = 1,168) of the patients were re-interviewed within 24 hours of discharge. We ascertained the presence and severity of 11 physical symptoms, as well as activities of daily living, mobility, mood, self-rated health, physiologic severity of illness, satisfaction with care, and length of stay. RESULTS: Symptoms were common at the time of hospital admission, particularly fatigue (80% of patients), dyspnea (60%), cough (51%), dizziness (51%), headache (47%), chest pain (46%), and nausea or vomiting (43%). Individual symptoms failed to resolve by hospital discharge approximately 25% to 50% of the time. The three most prominent predictors of persistence of symptoms were shorter length of stay, severity of the symptom on admission, and total symptom count. Patient satisfaction with care was associated with total symptom severity score at discharge and the degree of symptomatic improvement that had occurred during hospitalization. CONCLUSION: Because symptoms are common at discharge and associated with decreased satisfaction with care, asking about them would be a reasonable way to enhance patient-oriented care.

Hospital Bed Capacity, 300 to 499↗
PubMed1999

Validity and utility of patient-reported health measures on hospital admission.

Patient perceptions of their health are often inadequately captured and explored on hospital admission where physiologic and other objective measures are the focus of attention. Therefore, we conducted a prospective study to develop and validate measures of several domains of patient-reported health status at the time of admission to a general medicine inpatient service, and to determine the value of these new measures in predicting length of stay (LOS). Within 2 hours of the time that a decision to admit a patient was made, research assistants delivered a structured interview that captured patients' current symptoms, functional status, mood, and perceived health. Interviews were conducted between 8 a.m. and 11 p.m., 5 days per week from July 1996 through June 1997. During this time, there were 3621 unique patients admitted to the medicine service; 2672 (74%) of these patients were eligible for an interview. Eighty-eight percent of the 2672 eligible patients were interviewed. In addition to the patient-reported measures captured through the structured interview, the acute physiology score (APS) of the APACHE II was calculated for all subjects. The internal consistency (i.e., Cronbach's alpha) of the scales was 0.76 or greater and concurrent validity (i.e., correlation) of the patient-reported measures with the APS was 0.01 to 0.13. Overall perceived health was correlated 0.20 to 0.45 with symptoms and functional status, and was correlated 0.07 with the APS. The patient-reported measures performed comparably to the APS in predicting LOS (R-square = 0.08). When the patient-reported measures and the APS were included in the same model, the R-square was 0.14. These analyses suggest that patient-reported measures of health and function on admission hold validity, and that responses to as few as 15 questions can provide data that may help to explain differences in length of a hospital stay.

APACHE↗
PubMed1999

What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study.

PURPOSE: To determine what learners and teachers value most in ambulatory learning encounters and whether the choices of the two groups are in concordance. METHOD: In 1996, the authors surveyed learners and teachers at a walk-in clinic immediately after each of 103 consecutive learning encounters. The participants answered two open-ended questions: (1) What was the one most valuable aspect of this learning encounter? and (2) List one thing that would make it better. Using qualitative analysis methods, two raters categorized the responses; their agreement was substantial (kappa = .75). RESULTS: Half the responses fit five categories: diagnosis (15%), general management (14%), physical examination skills (9%), patient selection (6%), and time issues (6%). The participants most valued general exposure to diagnosis (29%) and general management issues (29%). Regarding their suggestions for improving the encounters, 33% cited structural issues (often "more time"), while 43% had no suggestions ("nothing" or "fine as is"). Substantial concordance existed between the rankings by category of the teachers' and learners' comments, but (1) learners were more likely to rate the educational value of the encounter excellent or very good (64% vs 47%, p < .01); (2) teachers were more likely than medical students (but not interns) to place the most educational value on the physical examination (30% vs 4%, p = .001); and (3) agreement on what was most valuable in any individual encounter was poor (kappa = .03). CONCLUSIONS: In evaluating ambulatory educational encounters, learners and teachers placed highest value on general exposure to diagnosis and disease management; while the most commonly recommended changes related to structural issues, particularly inadequate time. While learners and teachers agreed in general on the relative ranking of teaching activities, they often found different things to be educationally salient in a particular encounter.

Ambulatory Care↗
PubMed1999

A comparison of outcomes for walk-in clinic patients who see interns and those who see staff physicians.

PURPOSE: To collect pilot data on the effect of interns' involvement on patient care outcomes. METHOD: Between January 1995 and August 1998, 750 patients at a walk-in clinic completed pre-visit questionnaires on symptom-related expectations and functional status. Three follow-up surveys (immediately after the visit, at two weeks, and at three months) assessed symptom outcomes, satisfaction, illness worry, and unmet expectations. Physicians were surveyed about their perceptions of the "difficulty" of each patient encounter. RESULTS: During the study period, 195 patients (26%) were seen by interns and 555 (74%) by staff physicians. The patient groups did not differ in illness worry, unmet expectations, or satisfaction immediately after the visit, at two weeks, or at three months. Patients seen by interns were more satisfied with the time they had spent with their clinicians (p = .007). Interns were more likely to experience their patient encounters as difficult. There was no difference in visit costs, subspecialty referrals, health utilization, or hospitalization rates. CONCLUSION: Patients who are seen by interns in an ambulatory clinic are similar to those who are seen by staff physicians in terms of post-visit satisfaction, residual expectations, symptom resolution, and functional status improvement.

Ambulatory Care Facilities↗
PubMed1999

A psychometric comparison of military and civilian medical practices.

BACKGROUND: Our purpose was to compare the psychometric properties of military and civilian ambulatory internal medicine care. METHODS: Military data came from two cohorts of patients presenting for primary care. Variables collected included mental disorders (the PRIME-MD study), previsit symptom-related concerns and expectations, functional status (Medical Outcomes Study SF-6 and SF-20 scales), postvisit unmet expectations, satisfaction with care (Medical Outcomes Study five-item survey), and physician-perceived "difficulty" (Difficult Doctor-Patient Relationship Questionnaire). This data set was compared with data abstracted from several civilian studies of ambulatory primary care. These studies used the same instruments and took place during the same period. RESULTS: Military and civilian patient populations were equally likely to have mental disorders, with no differences in the prevalence of disorders within the broad categories of mood, anxiety, somatoform, eating, or alcohol disorders. Civilian populations had a slightly higher rate of some specific diagnoses, including major depression, panic disorder, and generalized anxiety disorder. There was a similar distribution of previsit expectations of care and in the types of postvisit unmet patient expectations, with military patients having slightly lower rates of unmet expectations. Patients in both practice settings had similar self-reported ratings in the six domains of functioning (role, social, pain, emotion, physical, general health), with civilian patients reporting slightly worse overall self-rated health. Both settings had high rates of fully satisfied patients (40% "excellent" for both), with patients with unmet expectations in both groups much less likely to be fully satisfied. There was also a similar proportion of encounters rated as difficult by the clinician (military, 11%; civilian, 15%; p = 0.99). The correlates of difficulty in both groups were similar, with mental disorders and multiple symptoms increasing the likelihood of a difficult encounter. CONCLUSIONS: The psychometric properties of patient care in military and civilian internal medicine ambulatory settings are remarkably similar. These data support mutual generalizability of primary care research findings with respect to psychometric properties between military and civilian populations.

Activities of Daily Living↗
PubMed1999

Antidepressant therapy for unexplained symptoms and symptom syndromes.

OBJECTIVE: To determine the efficacy of antidepressant therapy for unexplained symptoms or symptom syndromes. SEARCH STRATEGIES: We identified original studies through searching MEDLINE, EMBASE, PsycLIT, the Federal Research in Progress database, and The Cochrane Library. We also searched the bibliographies of primary and review articles for additional studies. SELECTION CRITERIA: We excluded trials of patients with neuropathic, oncologic, or degenerative joint pain. Independent duplicate review of 392 articles identified 94 relevant reports of randomized trials involving 6595 patients across 6 symptom syndromes. Independent duplicate assessment was made for inclusion and data abstraction. Meta-analysis was performed on extractable placebo-controlled data. MAIN RESULTS: Of 94 included trials, most studied either tricyclic antidepressants, antiserotonin antidepressants, selective serotonin reuptake inhibitors (SSRIs), or multiple agents for the treatment of the following syndromes: headache (50), fibromyalgia (18), functional gastrointestinal syndromes (13), idiopathic pain (11), tinnitus (2), and chronic fatigue (2). The quality of the studies was fair (mean score = 4.8 on a scale of 0 to 8). A majority of the studies (69%) demonstrated benefit for at least one outcome measure. Symptom improvement typically did not correlate with depression response in the few studies where it was assessed. Meta-analysis of all extractable data showed a substantial benefit from antidepressants: For the dichotomous outcome of improvement, the odds ratio was 3.4 (95% confidence interval [CI], 2.6 - 4.5), and for continuous outcomes, the standardized mean difference was 0.87 (95% CI, 0.59-1.14). The absolute percentage difference in improvement between the antidepressant and placebo arms was 32%, yielding a number needed to treat of 3 to improve one person's symptoms. Meta-regression indicated no differential effect across the classes of antidepressants; however, onbivariate tally tricyclic studies were associated with a greater likelihood of efficacy than SSRI studies (P = .02). CONCLUSIONS: Antidepressants can be effective for various physical symptoms and symptom syndromes. The relation of outcome to depression and the efficacy of SSRIs needs further study.

Adult↗
PubMed1998

The value of screening for psychiatric disorders in rheumatology referrals.

BACKGROUND: Musculoskeletal complaints are common and often unexplained and often lead to rheumatology referrals. The prevalence of psychiatric disease in patients with musculoskeletal complaints is unknown. OBJECTIVES: To determine the prevalence of common psychiatric disorders among patients referred to a rheumatology clinic and the likelihood of establishing a rheumatic diagnosis if a psychiatric disorder is present. DESIGN: Prospective diagnostic survey. SETTING: Two hospital-based rheumatology clinics and a general medicine clinic. PARTICIPANTS: A consecutive sample of newly referred patients (n = 185) and their rheumatologists (n = 9). INTERVENTION: Before their visit, all patients filled out a self-administered version of PRIME-MD (Primary Care Evaluation of Mental Disorders), a questionnaire that makes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, diagnoses of depressive, anxiety, and somatoform disorders. After the visit, the study rheumatologists, who were unaware of the PRIME-MD results, completed a questionnaire regarding their diagnostic assessment. These patients were compared with 210 patients with musculoskeletal complaints who were cared for in a general medicine clinic. MAIN OUTCOME MEASURES: Psychiatric and rheumatic disorders. RESULTS: Compared with patients with musculoskeletal complaints in a general medicine clinic, patients referred to a rheumatology clinic had a higher prevalence of psychiatric disease (40% vs 29%; P = .008), had an almost 2-fold higher prevalence of anxiety disorders, and were more likely to have multiple psychiatric disorders (odds ratio = 2.70, 95% confidence interval = 1.50-5.00). The likelihood of a psychiatric disorder differed among patients with connective tissue disease, nonsystemic articular or periarticular disorders, and nonarticular disorders (27%, 38%, 55%, respectively; P = .006). In a best-fitting logistic regression model, psychiatric disorders markedly decreased the likelihood of a connective tissue disease (odds ratio = 0.24, 95% confidence interval = 0.09-0.62). CONCLUSIONS: Forty percent of patients referred to a rheumatology clinic in this study had a psychiatric disorder, and its presence predicted a lower likelihood of a connective tissue disease. Prospective studies are needed to determine if screening for psychiatric disease before referring patients with unexplained musculoskeletal complaints would reduce costs or improve recognition of potentially treatable psychiatric disorders.

Adolescent↗
PubMed1998

Clinician-educators in academic medical centers: a two-part challenge.

As academic medical centers increasingly deliver care in primary care settings, a new category of faculty-clinician-educators-has emerged. Although the shift of education and patient care to outpatient settings makes the expanded role of clinician-educators necessary, it also presents challenges to clinician-educators themselves and to the institutions for which they work. This article examines these contemporary challenges (including financial constraints, undefined processes of promotion, and limited opportunities for professional development) and suggests strategies for meeting them. The number of clinician-educators joining the ranks of medical school faculties will probably continue to increase. As clinician-educators seek to provide the highest-quality education and patient care in the new medical marketplace, their success will be critical to the viability of the academic centers of the future.

Academic Medical Centers↗
PubMed1998

The value of screening for psychiatric disorders prior to upper endoscopy.

Gastrointestinal (GI) complaints are among the most common symptoms in primary care yet are frequently unexplained and often lead to costly diagnostic testing. We sought to determine the prevalence of psychiatric disorders in patients with unexplained GI complaints undergoing upper endoscopy, and the likelihood of endoscopic abnormalities in patients with and without psychiatric diagnoses. We prospectively evaluated 116 adult patients who were undergoing upper endoscopy to evaluate GI complaints. All subjects received a structured psychiatric interview prior to endoscopy using PRIME-MD, and endoscopists were blinded to the PRIME-MD results. Psychiatric disorders were detected in 70 (60%) patients. Overall, there were 113 diagnoses (some patients had multiple disorders) with the most common being somatoform (44%), depressive (29%), and anxiety (19%) disorders. Only 29 patients had major endoscopic abnormalities, including esophageal disease (14), peptic ulcer (9), severe gastritis (4), gastric cancer (1), and esophageal cancer (1). There was a much higher prevalence of psychiatric disorders in patients without major endoscopic abnormalities (74% vs. 21%, p < 0.0001). Psychiatric disease was strongly predictive of endoscopic findings (OR for major abnormality = 0.11 in women, and 0.40 in men), especially if somatoform disorder was present (OR = 0.15). We conclude that, with a simple questionnaire, psychiatric disorders can be diagnosed in a large proportion of patients with unexplained GI complaints who are referred for upper endoscopy. The presence of a psychiatric disorder, particularly if somatoform, makes it unlikely that endoscopy will reveal significant GI disease.

Adult↗
PubMed1998

A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts.

OBJECTIVE: To compare physicians' and their patients' attitudes toward pharmaceutical gifts. DESIGN: Survey of physicians and their patients. SETTING: Two tertiary-care medical centers, one military and one civilian. PARTICIPANTS: Two hundred sixty-eight of 392 consecutively surveyed physicians, 100 of 103 randomly selected patients at the military center, and 96 patients in a convenience sample at the civilian center completed the survey. MEASUREMENTS: Participants rated 10 pharmaceutical gifts on whether they were appropriate for physicians to accept and whether they were likely to influence prescribing. Patients found gifts less appropriate and more influential than did their physicians. About half of the patients were aware of such gifts; of those unaware, 24% responded that this knowledge altered their perception of the medical profession. Asked whether they thought their own physician accepted gifts, 27% said yes, 20% no, and 53% were unsure. For patients, feeling that gifts were inappropriate was best predicted by a belief that gifts might influence prescribing, while for physicians, the best predictor was knowledge of guidelines. CONCLUSIONS: Patients feel pharmaceutical gifts are more influential and less appropriate than do their physicians. Physicians may want to consider this in deciding whether to accept particular gifts. Broader dissemination of guidelines may be one means of changing physician behavior. At the same time, future guidelines should further consider the potentially different viewpoints of patients and physicians.

Attitude of Health Personnel↗