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Biomedical subjects

K Kroenke

Publications and source records attributed to K Kroenke.

At least 55 records · Page 3Linked to original sources
PubMed1998

Outcome in general medical patients presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up.

BACKGROUND: Although physical complaints account for over half of all ambulatory visits, surprisingly little is known about their natural history and factors affecting prognosis. OBJECTIVES: Our aims were to determine the outcome in general medical patients presenting with physical complaints and to delineate which factors impact upon recovery rates. METHODS: In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed in order to determine symptom characteristics, the presence of depressive or anxiety disorders, and expectations regarding the visit. Outcomes were assessed immediately post-visit and at 2 weeks and 3 months. The primary outcome was symptomatic improvement, and secondary outcomes included functional status, unmet expectations, satisfaction with care and visit costs. RESULTS: The majority (70%) of patients improved by 2 weeks follow-up and, of those who had not, 60% got better within 3 months. Moreover, relapse in patients initially better at 2 weeks was uncommon (6%) in the ensuing several months. While symptoms of recent onset had the highest improvement rates, half of those patients whose symptom had been present a year or longer also improved within 2 weeks. Improvement rates varied somewhat by symptom type, but no specific symptom had an improvement rate of less than 50%. Patients who had not improved at 2 weeks were more likely to report continuing serious illness worry, unmet expectations, functional impairment and dissatisfaction, even 3 months after the initial visit. CONCLUSION: Most general medical patients with physical complaints improve within 2 weeks of their initial clinic visit. Further attention may best be focused on the minority of patients who fail to improve and experience continuing concerns and impairment.

District of Columbia↗
PubMed1998

Multiple organ toxicity from addition of erythromycin to long-term lovastatin therapy.

A patient who had taken lovastatin for 7 years received erythromycin before dental procedures. Multiple organ toxicity developed, manifested as rhabdomyolysis, acute renal failure, pancreatitis, ileus, livedo reticularis, and elevated aminotransferase values, without liver injury. No previous reports have identified multiple organ injury of this magnitude. A computer literature search identified only three other reported instances of erythromycin and lovastatin interaction. Manifestations in these previous cases consisted of rhabdomyolysis in all three, as well as elevated aminotransferase values and acute renal failure in two cases. In all the cases, the clinical presentation of organ toxicity occurred after the cessation of erythromycin therapy between day 1 and day 5. Advanced age and chronic renal insufficiency were identified as potential risk factors for drug interaction. Health care professionals should be aware of the potential interaction between these two commonly prescribed drugs, which can mimic sepsis.

Acute Kidney Injury↗
PubMed1998

Chronic medications in the perioperative period.

BACKGROUND: While most chronic medications can be safely continued in the perioperative period, decisions regarding certain medications remain controversial. METHODS: We mailed a questionnaire to all 150 anesthesiology program directors in the United States, with 113 (75%) responding. Opinions regarding preoperative discontinuance or modification of selected medications were assessed. RESULTS: Antiplatelet agents are typically discontinued preoperatively, although the number of days varies widely. Few respondents discontinue tricyclic antidepressants, oral contraceptives, diuretics, or oral hypoglycemic agents. For a patient on insulin, the most popular regimen is half the patient's usual dose of neutral protamine Hagedorn insulin (50%) or no preoperative insulin (37%), whereas an insulin infusion for tight control was rarely advised. Respondents varied widely in their approach to steroid coverage, their cancellation of elective operations in patients with inadvertent aspirin ingestion, and the length of time before surgery they would discontinue warfarin. In patients with chronic atrial fibrillation, 72% of respondents favored use of a heparin window preoperatively. CONCLUSIONS: Practice variations regarding insulin regimens, steroid coverage, aspirin, and anticoagulants reflect a lack of firm evidence favoring one approach.

Adult↗
PubMed1998

Symptoms in 18,495 Persian Gulf War veterans. Latency of onset and lack of association with self-reported exposures.

Toxic or environmental exposures have been suggested as a possible cause of symptoms reported by Gulf War veterans. To further explore this hypothesis, we analyzed findings in 18,495 military personnel evaluated in the Department of Defense Comprehensive Clinical Evaluation Program. The program was established in 1994 to evaluate Persian Gulf veterans eligible for Department of Defense medical care who had health concerns after service in the Persian Gulf during Operation Desert Shield/Desert Storm. The evaluation included a structured clinical assessment, a physician-administered symptom checklist, and a patient questionnaire addressing self-reported exposures, combat experiences, and work loss. Among 18,495 patients examined, the most common symptoms were joint pain, fatigue, headache, memory or concentration difficulties, sleep disturbances, and rash. Symptom onset was often delayed, with two-thirds of symptoms not developing until after individuals returned from the Gulf War and 40% of symptoms having a latency period exceeding one year. There was no association between individual symptoms and patient demographics, specific self-reported exposures, or types of combat experience. Increased symptom counts were associated with work loss, the number of self-reported exposures, the number of types of combat experience, and certain ICD-9 diagnostic categories, particularly psychological disorders. Prolonged latency of symptom onset and the lack of association with any self-reported exposures makes illness related to toxic exposure less likely.

Analysis of Variance↗
PubMed1997

Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome.

BACKGROUND: Specific concerns and expectations may be a key reason that people with common physical complaints seek health care for their symptoms. OBJECTIVES: To determine the frequency of symptom-related patient concerns and expectations, physician perceptions and actions, and the relationship of these factors to patient satisfaction and symptom outcome. METHODS: This was a prospective cohort study of 328 adult outpatients presenting for evaluation of a physical complaint. The setting was a general medicine clinic in a teaching hospital. Measures included previsit patient questionnaire to identify symptom-related concerns and expectations; a postvisit physician questionnaire to determine physician perceptions and actions; and a 2-week follow-up patient questionnaire to assess symptom outcome and satisfaction with care. RESULTS: Pain of some type accounted for 55% of common symptoms, upper respiratory tract illnesses for 22%, and other physical complaints for 23%. Two thirds of patients were worried their symptom might represent a serious illness, 62% reported impairment in their usual activities, and 78%, 46%, and 41% hoped the physician would prescribe a medication, order a test, or provide a referral. Physicians often perceived symptoms as less serious or disabling and frequently did not order anticipated tests or referrals. While symptoms improved 78% of the time at 2-week follow-up, only 56% of patients were fully satisfied. Residual concerns and expectations were the strongest correlates of patient satisfaction. CONCLUSIONS: Improved recognition of symptom-related concerns and expectations might improve satisfaction with care in patients presenting with common physical complaints.

Activities of Daily Living↗
PubMed1997

Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care.

BACKGROUND: For clinical or research use in primary care, the DSM-IV diagnostic criteria for somatization disorder are too restrictive, while the criteria for undifferentiated somatoform disorder are overly inclusive. In this article, we examine the validity of multisomatoform disorder, defined as 3 or more medically unexplained, currently bothersome physical symptoms plus a long (> or = 2 years) history of somatization. METHODS: Data from the Primary Care Evaluation of Mental Disorders Study of 1000 patients from 4 primary care sites were analyzed. The outcomes assessed were 6 domains of health-related quality of life, using the 20-item Short-Form General Health Survey; self-reported disability days and health care use; satisfaction with care; and physician-rated difficulty of the encounter. RESULTS: Multisomatoform disorder was diagnosed in 82 (8.2%) of the 1000 patients who were enrolled in the Primary Care Evaluation of Mental Disorders Study. Compared with mood and anxiety disorders, multisomatoform disorder was associated with comparable impairment in health-related quality of life, more self-reported disability days and clinic visits, and greater clinician-perceived patient difficulty. CONCLUSIONS: Multisomatoform disorder may be a valid diagnosis and potentially more useful than the DSM-IV diagnosis of undifferentiated somatoform disorder. Also, because multisomatoform disorder has a large and independent effect on impairment, its diagnosis should not be precluded simply because of a coexisting mood or anxiety disorder.

Adolescent↗
PubMed1997

Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome.

PURPOSE: To identify the predictors of depressive and anxiety disorders in general medical patients presenting with physical complaints and to determine the effect of these mental disorders on patient outcome. PATIENTS AND METHODS: In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed with PRIME-MD to diagnose DSM-IV depressive and anxiety disorders. Clinical predictors were identified by logistic regression analysis. Outcomes were assessed immediately postvisit and at 2 weeks and 3 months. These included symptomatic improvement, functional status, unmet expectations, satisfaction with care, clinician-perceived patient difficulty, and health care utilization and costs. RESULTS: A depressive or anxiety disorder was present in 146 (29%) of the patients. Independent predictors of a mental disorder included recent stress, multiple physical symptoms (ie, 6 or more), higher patient ratings of symptom severity, lower patient ratings of their overall health, physician perception of the encounter as difficult, and patient age less than 50. Patients with depressive or anxiety disorders were more likely to have unmet expectations postvisit (20% versus 8%, P < 0.001), be considered difficult (26% versus 11%, P < 0.0001), and report persistent psychiatric symptoms and ongoing stress even 3 months following the initial visit. Psychiatric status was not associated with symptomatic improvement, health care utilization, or costs. CONCLUSION: Simple clinical clues in patients with physical complaints identify a subgroup who may warrant further evaluation for a depressive or anxiety disorder. Such disorders are associated with unmet patient expectations and increased provider frustration.

Adult↗
PubMed1997

Increasing the use of advance directives in medical outpatients.

OBJECTIVE: We studied whether a simple educational intervention would increase patient completion of advance directives and discussions on end-of-life issues. DESIGN: Randomized, controlled trial. SETTING: Outpatient clinic of a teaching hospital. SUBJECTS: One hundred eighty-seven outpatients of a primary care internal medicine clinic. INTERVENTION: Study subjects attended a 1-hour interactive seminar and received an informational pamphlet and advance directive forms. Control subjects received by mail the pamphlet and forms only. MEASUREMENTS AND MAIN RESULTS: Completion of the advance directive was the main measurement. There were no significant differences in baseline characteristics of either group. Follow-up at 1 month revealed advance directive completion in 38% of study versus 24% of control subjects (p = .04), and discussions on advance planning in 73% of study versus 57% of control subjects (p = .02). Patients most likely to complete the documents were white, married, or attendees at the educational seminar. CONCLUSIONS: Interactive group seminars for medical outpatients increased discussions and use of written advance directives.

Adult↗
PubMed1997

A prospective study to assess the effect of ambulatory teaching on patient satisfaction.

PURPOSE: To assess the effect of ambulatory teaching on patients' satisfaction. METHOD: In 1996, 103 adult patients presenting to the Walter Reed General Medicine Walk-in Clinic completed a patient-satisfaction questionnaire immediately following their visits, during which they were initially seen by a trainee (third-year medical student or intern) and then seen by a faculty preceptor. The questionnaire included five items from the validated Medical Outcomes Study (MOS)-9 questionnaire as well as two open-ended questions. Fourteen staff physicians, 13 students (49% of the visits), and 11 interns (51% of the visits) participated in the study. Satisfaction was analyzed by level of training, and the responses from the study patients were compared with the responses from 372 usual-care (i.e., non-teaching) patients from the same clinic, using the chi-squared test. RESULTS: The study patients were typically pleased with their encounters, rating their overall satisfaction as excellent (61%), very good (29%), or good (9%). Nearly two thirds of the patients rated their satisfaction with waiting time to be very good or excellent. Compared with the usual-care patients, the study patients reported equal or greater satisfaction for all five MOS-9 items. Ninety-five percent of the study patients said they would be willing to be seen by a trainee-staff team on future visits. There was no difference in patient satisfaction by trainee level. The study patients cited enhanced interaction (45%), enhanced education (34%), and improved care (26%) as benefits of trainee-involved care, and increased waiting time (18%) and worse care (5%) as drawbacks. CONCLUSION: The results of this study suggest that ambulatory teaching does not adversely affect patient satisfaction, regardless of trainee level, and that patients who have been seen by trainee-staff teams are willing to experience such encounters again.

Adult↗
PubMed1997

Bedside teaching.

BACKGROUND: Clinical teachers have been exhorted to "return to the bedside" so that the three critical parties-teacher, trainee, and patient-can participate together in the educational encounter. The presence of the patient is deemed essential for the optimal demonstration and observation of physical examination, medical interviewing, and interpersonal skills, as well as role-modeling professional and humanistic behavior. METHODS: This essay reviews the challenges inherent in bedside teaching and proposes strategies to enhance both the effectiveness and efficiency of such teaching. RESULTS: Practical suggestions are provided regarding teaching issues (time constraints, group accommodation, selectivity, demonstration, observation, case presentations), learning climate for both teacher and learners, hospital and patient barriers, and selected other issues. CONCLUSIONS: Despite changes in the clinical setting and financing of medical education, patient-centered teaching will remain essential to the training of future clinicians. Techniques described in this paper can be useful in facilitating such bedside teaching.

Attitude of Health Personnel↗
PubMed1997

Patient satisfaction and quality of care.

As the Department of Defense initiates Tricare, its new system of integrated health delivery, outcome assessment will become increasingly important. Traditional outcomes have focused on disease and its more serious consequences, disability and death. Patient satisfaction is only recently emerging as an important measure of the quality of health care delivery. In this paper, we focus on patient satisfaction, exploring its historical roots, its evolution as an outcome measure, and its potential utilities and weaknesses in quality assessment.

Humans↗
PubMed1996

Cost savings using a stepped-care prescribing protocol for nonsteroidal anti-inflammatory drugs.

OBJECTIVE: To lower nonsteroidal anti-inflammatory drug (NSAID) costs while maintaining quality patient care and clinician satisfaction. DESIGN: Before and after 21-month trial with one study site and two control sites and a questionnaire that was sent to 203 clinicians. SETTING AND SUBJECTS: Two military medical centers and two affiliated primary care clinics. All beneficiaries filling outpatient NSAID prescriptions. INTERVENTIONS: An NSAID prescribing protocol was implemented requiring a trial of either ibuprofen or indomethacin before new prescription of more expensive NSAIDs. One control center used an NSAID computer cost-prompt and the other had no intervention. MAIN OUTCOME MEASURES: The proportion of expensive NSAIDs prescribed at each institution and total NSAID costs adjusted for prescription volume. Clinician acceptance and patient impact were assessed by the questionnaire. RESULTS: Study site clinicians (n=158) reported very few protocol-related patient care problems. A minority (9%) of study site clinicians considered the protocol very bothersome, and only 2% felt it should be discontinued. Quarterly use of expensive NSAIDs at the study site fell from 34% to 21%, decreasing costs by 30% (P<.001). In contrast, the site with a computer cost-prompt had only a 5% decrease in NSAID costs, while costs at the site with no intervention increased 2%. CONCLUSIONS: For drugs with similar benefits and adverse effects, a "stepped formulary" approach requiring an initial trial of one of the less expensive agents can maintain physician prescribing choices and satisfaction while lowering costs.

Anti-Inflammatory Agents, Non-Steroidal↗