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At least 181 records · Page 10Linked to original sources
PubMed2005

Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much?

BACKGROUND: For patients with a chronic disease, increased cost-sharing for medications may lead to unintended consequences, including reduced use of medications essential for control of their disease. OBJECTIVE: The objective of this study was to estimate the effects of small ($1-6 per 30-day supply), moderate ($7-10), and large (>$10) increases in medication cost-sharing on 12-month trends in oral hypoglycemic (OH) use among adults with type 2 diabetes. METHODS: We conducted a quasiexperimental study using a time series with comparison group design. Data were obtained from computerized membership, benefit, and pharmacy dispensing data of 5 managed care organizations (MCOs). A total of 13,110 12-month episodes of OH use and a medication cost-sharing increase ("intervention") were matched with 13,110 that had no increase. The dependent variable was OH average daily dose (ADD) standardized to each episode's mean OH ADD in the 6-month preintervention period. The principal independent variable was change in cost per 30-day OH supply between the 6-month pre- and postintervention periods. Effects of changes in cost-sharing on OH ADD were estimated using segmented time series regression. RESULTS: Episodes with >$10 increase in cost-sharing had significantly (alpha=0.05) decreased OH ADD in the postintervention period. At 6 months after this increase, OH ADD had decreased by 18.5% from that predicted from the preintervention trend. Episodes with a $1 to $10 increase in cost-sharing and those with no increase in cost-sharing had significant linear increases in OH use over the 12-month period. CONCLUSIONS: Large increases in medication cost-sharing were associated with immediate and persistent reductions in OH use. Small and moderate increases had little effect on OH use in the 6-month period after the increase.

Adolescent↗
PubMed2000

The direct and indirect effects of cost-sharing on the use of preventive services.

OBJECTIVE: To test empirically a model for estimating the direct and indirect effects of different forms of cost-sharing on the utilization of recommended clinical preventive services. DATA SOURCES/SETTINGS: Stratified random sample of 10,872 employees, 18-64 years, who had belonged to their plan for at least one year, from seven large companies that were members of the Pacific Business Group on Health (PBGH) in 1994. DATA COLLECTION: The 1994 PBGH Health Plan Value Check Survey. 1994 PBGH data on requirements for employee out-of-pocket patient cost-sharing for 52 different health plans. DESIGN: Five equations were derived to estimate the direct and indirect effects of two forms of cost-sharing (copayments and coinsurance/deductibles) in two forms of managed care (HMOs and PPO/indemnity plans) on four clinical preventive services: mammography screening, cervical cancer screening, blood pressure screening, and preventive counseling. Probit models were used to estimate elasticities for the indirect and direct effects. PRINCIPAL FINDINGS: Both forms of cost-sharing in both plan types had negative and significant indirect effects on preventive counseling (from -1 percent to -7 percent). The direct effect of cost-sharing was negative for preventive counseling (-5 percent to -9 percent) and Pap smears (from -3 percent to -9 percent) in both HMOs and PPOs, and for mammography only in PPOs (-3 percent to -9 percent). The results of the effects on blood pressure screening are inconclusive. CONCLUSIONS: Both the direct and indirect effects of cost-sharing negatively affected the receipt of preventive counseling in HMOs and PPOs. As predicted, the direct negative effect of cost-sharing was greater than the indirect effect for Pap smears and mammography. Eliminating cost-sharing for these services may be important to increasing their utilization to recommended levels.

Adolescent↗
PubMed2004

[Study on the relationship between hepatitis C virus infection and sharing injection equipment, sexual behavior among injecting drug users].

OBJECTIVE: To study hepatitis C virus (HCV) transmission through different modes of sharing injection equipment and sexual behavior among injecting drug users (IDUs) in Liangshan of Sichuan province. METHODS: A community-based survey was conducted to investigate past and current demographic data, injection equipment sharing patterns and sexual behavior of IDUs. Blood samples were also taken to test for HCV. The survey was conducted between Nov 8 and Nov 29, 2002. 379 subjects were screened through outreach recruitment and peer informing. SPSS (11.5) was used for data analysis. RESULTS: HCV prevalence was 71.0% (269/379). Needles or syringes sharing in the past three months and past syphilis infection were strongly associated with HCV transmission after univariate analysis using chi-square test. Trend analysis indicated that HCV infection rate increased along with the increase of needles or syringes sharing, sharing of rinse water and the number of peers sharing the equipments. Data from multivariate logistic regression showed that sharing of needles or syringes and history of syphilis infection were significantly associated with HCV transmission. No significant difference was found between HCV infection and sexual behavior after univariate analysis using chi-square test. CONCLUSION: Further sero-epidemiological prospective cohort studies should be conducted to clarify the relationship between different modes of sharing injection equipment, sexual behavior and HCV infection.

Adult↗
PubMed1992

Physician response to the United Mine Workers' cost-sharing program: the other side of the coin.

The effect of cost sharing on health services utilization is analyzed from a new perspective, that is, its effects on physician response to cost sharing. A primary data set was constructed using medical records and billing files from a large multispecialty group practice during the three-year period surrounding the introduction of cost sharing to the United Mine Workers Health and Retirement Fund. This same group practice also served an equally large number of patients covered by United Steelworkers' health benefit plans, for which similar utilization data were available. The questions addressed in this interinsurer study are: (1) to what extent does a physician's treatment of medically similar cases vary, following a drop in patient visits as a result of cost sharing? and (2) what is the impact, if any, on costs of care for other patients in the practice (e.g., "spillover effects" such as cost shifting)? Answers to these kinds of questions are necessary to predict the effects of cost sharing on overall health care costs. A fixed-effects model of physician service use was applied to data on episodes of treatment for all patients in a private group practice. This shows that the introduction of cost sharing to some patients in a practice does, in fact, increase the treatment costs to other patients in the same practice who remain under stable insurance plans. The analysis demonstrates that when the economic effects of cost sharing on physician service use are analyzed for all patients within a physician practice, the findings are remarkably different from those of an analysis limited to those patients directly affected by cost sharing.

Cost Sharing↗
PubMed2003

Trends in infant bed sharing in the United States, 1993-2000: the National Infant Sleep Position study.

BACKGROUND: Bed sharing with parents has been described as both beneficial to infant well-being and as a potentially lethal situation. OBJECTIVE: To examine trends in bed sharing between infants and caregivers, and the factors that influence this behavior. DESIGN: Annual nationally representative telephone surveys conducted between 1993 and 2000. SETTING: The 48 contiguous United States. PARTICIPANTS: Nighttime caregivers of infants born within 7 months prior to interview between 1993 and 2000. Approximately 1000 interviews were conducted each year for a total sample of 8453 nighttime caregivers. MAIN OUTCOME MEASURES: Where and with whom the infant usually slept at night in the preceding 2 weeks. RESULTS: Forty-five percent of infants spent at least some time at night on an adult bed in the last 2 weeks. Between 1993 and 2000, the proportion of infants usually sharing an adult bed at night increased from 5.5% to 12.8%. More than 90% of infants who "usually" slept on an adult bed shared it with their parents. In a multivariate analysis, factors associated with increased probability of routine bed sharing included: maternal age less than 18 years (odds ratio [OR] = 2.26; 95% confidence interval [CI], 1.22-4.21), maternal race or ethnicity reported as black (OR = 4.04; 95% CI, 3.04-5.36) or as Asian or "other" (OR = 2.72; 95% CI, 1.74-4.22), household income less than $20,000 (OR = 1.49; 95% CI, 1.15 = 1.92), living in the Southern states compared with living in the Midwest (OR, 1.59; 95% CI = 1.23, 2.06), and infant age less than 8 weeks (OR = 1.60; 95% CI, 1.10-2.33). Living in the Mid-Atlantic compared with the Midwest (OR = 0.63; 95% CI, 0.44-0.90), and being born with low birthweight and preterm (OR = 0.32; 95% CI, 0.14-0.74) were associated with decreased probability of routine bed sharing. CONCLUSIONS: Bed sharing as a routine practice is growing in the United States. Given that this practice seems to be widespread and strongly influenced by cultural factors, more studies of the consequences of bed sharing are needed to inform health care providers and parents on the risks and benefits.

Adolescent↗
PubMed1992

Biomechanical effect of a two-segment anterior cruciate ligament graft with separate femoral attachments and differing levels of prescribed load sharing.

The objective of this study was to analyze the biomechanical effect of varying the level of prescribed load sharing between two segments of an anterior cruciate ligament (ACL) graft, and of separating the femoral attachments of these segments. Total anterior-posterior (AP) laxity was measured using an instrumented spatial linkage. Forces in graft segments were measured using buckle transducers. The two-segment graft was formed using the middle third of the patellar tendon with bone blocks and a synthetic augmentation device. Proximal fixation was obtained using a fixture which allowed changing the individual locations of the femoral attachments of the tendon and augmentation segments. Distal fixation was achieved using a force-setting device which allowed the loads in each segment to be set to prescribed levels. Total graft force, load sharing, and total AP laxity were recorded during the application of 100-N AP tibial loads at 0 degrees, 30 degrees, 60 degrees, 90 degrees, and 110 degrees flexion, for various combinations of load sharing set at extension and locations of femoral attachment sites. The load sharing, total graft force, and AP laxity during AP loading at the five test flexion angles were not significantly affected by changing the prescribed level of load sharing set at extension for a given femoral attachment configuration. However, varying the separate hole locations of the graft segments for a given level of load sharing significantly affected load sharing, total graft force, and AP laxity. If the tendon graft was located posteriorly (on the medial surface of the lateral femoral condyle) and the augmentation segment proximally, the augmentation carried a greater portion of the total force in flexion. If the augmentation segment was changed to a more posterosuperior location and the tendon posteroinferior, the tendon carried a higher percentage of the total force in flexion. AP laxity in most reconstruction states was significantly greater than in the normal joint with an intact ACL. The nature of the load sharing between the graft segments under AP tibial load over the flexion range can be controlled by the appropriate choice of the segments' femoral attachment locations.

Analysis of Variance↗
PubMed2004

The determinants and effect of shared care on patient outcomes and psychiatric admissions - an inner city primary care cohort study.

OBJECTIVE: The aim of this study was to determine the factors associated with receipt of different levels of shared care, and the effect of shared care on patient outcomes. METHOD: A total of 349 patients with severe mental illness were selected from general practice lists. Patient functioning was assessed using standardised questionnaires, and GPs completed a questionnaire about patients' shared care arrangements at baseline (response-rate 79%). Patients were followed up at 12 months. RESULTS: Receipt of high shared care was associated with greater patient satisfaction with services and social functioning at baseline (p < 0.005). Patients receiving high shared care showed greater improvements in SF-12 mental health scores at follow-up compared to low shared care groups (p = 0.02). This effect was abolished after adjustment for age, sex and psychiatric diagnosis. CONCLUSION: Receipt of high shared care was not associated with demographic or clinical characteristics. High shared care had limited value for patients in terms of improved clinical, social or general health functioning over one year.

Adult↗
PubMed2005

Patients' attitudes towards sharing their health information.

OBJECTIVES: The current policies of the governments of Australia and New Zealand encourage the use of electronic information systems to exchange patient information between various stakeholders. This research investigated (1) the attitudes of patients toward sharing their medical information and (2) whether patients considered themselves to be well-informed about the uses that are made of their information. METHODS: A questionnaire survey of adult primary-care patients was conducted in five clinics within a medium sized New Zealand city. Outcome measures were the proportions of respondents willing to share different categories of their information with different classes of recipients. Patients' evaluations of their knowledge about the uses made of their information were also collected. RESULTS: Over 200 responses were collected from five clinics. Respondents' attitudes toward sharing their information were found to be influenced by three factors. (1) Identity of recipient: whilst respondents were generally willing to have their information shared between health professionals, they were increasingly unwilling for it to be distributed to other stakeholders, such as administrators, researchers or other government departments. (2) Level of anonymity: respondents were more prepared to share anonymous information. (3) Type of information: respondents were increasingly unwilling to share their information as it takes on a more personal nature. Respondents were also found to be very poorly informed about the use of their information, 90% of respondents indicated that they had either incomplete or no knowledge of how their information was shared and 79% had no knowledge of the uses of their National Health Index (NHI) number. The findings also indicate that respondents would prefer to be consulted about the distribution of their information. CONCLUSIONS: These findings indicate that many respondents were unwilling to have their personal information distributed other than for purposes of clinical care and a sizeable proportion of the respondents would like to be consulted before their information is released. The high level of interest and concern that this research revealed among respondents, suggests that more attention should be directed towards ensuring that patients are fully informed about current information sharing practices. The findings also imply that the design and development of future systems should also incorporate sophisticated and flexible access control policies that can be adapted to meet the preferences of individual patients.

Access to Information↗
PubMed1999

Shared decision making in clinical medicine: past research and future directions.

CONTENT: Shared medical decision making is a process by which patients and providers consider outcome probabilities and patient preferences and reach a health care decision based on mutual agreement. Shared decision making is best used for problems involving medical uncertainty. During the process the provider-patient dyad considers treatment options and consequences and explores the fit of expected benefits and consequences of treatment with patient preferences for various outcomes. This paper reviews the literature on shared medical decision making. Several questions are considered. Although several studies suggest that patients do not want to be involved in decision making, these studies typically fail to separate decisions about technical aspects of treatment from preferences for outcomes. There is considerable evidence that patients want to be consulted about the impact of treatment. Studies on the acceptability of shared decision making for physicians have produced inconsistent results. Shared decision making is more acceptable to younger and better-educated patients. It remains unclear whether shared decision making requires expensive video presentations or whether the same results can be obtained with simpler methods, such as the decision board. We conclude that shared medical decision making is an important development in health care. More research is necessary to identify the effects of shared decision making on patient satisfaction and health outcomes. Further, more research is necessary in order to evaluate the most effective methods for engaging patients in decisions about their own health care.

Adult↗
PubMedDate not supplied

The inverse effects of load transfer and load sharing on axial compressive stiffness.

BACKGROUND CONTEXT: The goal of spinal instrumentation is to stabilize involved motion segments while fusion occurs. Although some degree of load sharing is necessary for fusion, the ability of the instrumentation system to transfer the load may vary. PURPOSE: The purpose of this study is to formulate a mathematical relationship between load sharing and load transfer of specific spinal instrumentation systems using a well-accepted mechanical model. STUDY DESIGN/SETTING: Forty-eight American Society for Testing Materials standard ultra high molecular weight polyethylene cylinders were used as per designation F 1717-96, standard test methods for static and fatigue for spinal implant constructs in a corpectomy model. METHODS: Twenty-four spinal assemblies consisting of anterior plates, anterior rod, and posterior rods were subjected to compression bending tests using a MTS Bionix servo-hydraulic material testing apparatus. Each implant was tested in compression bending with and without the addition of a titanium load-sharing cage. The force applied was the independent variable, and the displacement was the dependent variable. The stiffness was determined for each setup with and without the addition of an anterior load-sharing cage. RESULTS: The average axial compressive stiffness of a system increased by a factor of 8.5 with the addition of the load-sharing cage. An inverse relationship existed between the compressive stiffness of the construct and its relative increase achieved with the addition of the load-sharing cage. The compressive stiffness of the system with the addition of the load-sharing cage approached that of the anterior device itself as the system flexibility increased. The ability of instrumentation systems to load share or load transfer and their respective stiffness was determined. CONCLUSIONS: The 5-mm rod screw posterior system was compared with the 7-mm Ti posterior system with the addition of one and two devices for transverse traction (DTTs). The rods with the increased diameter had a stiffness of 1723 n/mm with one DTT and 1815 n/mm with two DTTs. The addition of an anterior cage had little effect on the stiffness of these systems. Anterior plate and screw/rod systems were analyzed and showed similar mechanical behavior to the 5-mm posterior rod/screw systems. A significant increase in stiffness was realized with the addition of an anterior cage. A means to determine the load sharing/transferring properties of a spinal instrumentation system is presented. This technique will allow the amount of load transferred from the fusion mass to the instrumentation to be predicted.

Compressive Strength↗
PubMed2001

Does the shared epitope genotype influence either the susceptibility to or the phenotype of corneal melting?

PURPOSE: To investigate the role of the shared epitope alleles in determining susceptibility to and the phenotype of corneal melting in patients with rheumatoid arthritis (RA). METHODS: The HLA class 1 and 2 genotype was determined for 17 patients with rheumatoid-associated comeal melting by the phototyping method. HLA-DR4 subtyping was performed by PCR sequence-based typing. The frequency of all the shared epitope alleles and, in particular, of the higher-risk *0401 and *0404 alleles, was compared with healthy controls and unrelated RA patients, with and without extra-articular manifestations. A comparison was also made between the shared epitope genotype of the corneal melt patients and local, ocular disease characteristics. RESULTS: Thirteen (76%) patients with corneal melt possessed at least one shared epitope allele and 5 (29%) possessed two alleles. The dominant alleles were variants of the DR4 family, notably the *0401, *0404 and *0408 alleles. Both the allele frequency and a double dose of shared epitope alleles were more common in the three RA patient groups than in the healthy, control group (p < 0.005). Although the frequency of the higher-risk alleles was similar in the three RA patient group, a trend existed for a double dose of higher-risk alleles to be more common in the patients with either corneal melt or other extra-articular manifestations (p > 0.2). No association was found between the number or type of shared epitope alleles and any of the ocular disease characteristics studied. CONCLUSIONS: The results of this study suggest that the shared epitope alleles do not influence the ocular disease phenotype of corneal melt in RA patients. Shared epitope determination of RA patients may help to identify those susceptible to either corneal melt or other extra-articular disease. RA patients with a double dose of higher-risk alleles may have an increased risk of corneal melt.

Alleles↗
PubMed2000

Shared governance--nurses making a difference.

AIM: This paper aims to describe how shared governance can be successfully integrated into existing management structures in a large medical directorate. It will show how the shared governance philosophy can lead to the creation of a culture where nurses feel important and valued and also consider its use as a foundation for the implementation of the nursing strategy. BACKGROUND: The hospital adopted shared governance in 1995 with the setting up of councils led by staff nurses. Shared governance advocates claim it broadens involvement of clinically-based nurses in the process of change through devolved decision-making thereby enhancing clinical practice and increasing staff moral and self-esteem. Key issues Shared governance is a cultural change that will develop the leadership and management skills of all grades of staff. Shared governance is not a quick fix for the profession; involvement of all staff needs time, persistence, determination and a strong commitment to training and development. CONCLUSION: The national nursing strategy puts nurses in a position to positively influence health care for the advantage of patients, however, for nurses to grasp this opportunity cultural change is required. This practical example of shared governance demonstrates how it can be used to create a proactive culture, focused on improving patient care. The nurturing and developing of clinically-based nurses provides them with the knowledge and skills to challenge the status quo and lead change. Thus, shared governance is an excellent foundation from which to develop the nursing strategy.

Decision Making, Organizational↗
PubMed2001

Sleep position and the use of soft bedding during bed sharing among African American infants at increased risk for sudden infant death syndrome.

UNLABELLED: Soft bedding increases the risk for death among prone infants. We compared the softness of beds and bedding and infant sleep position for infants sleeping alone and for those bed sharing. STUDY DESIGN: Questionnaires were used to record the bedding and sleep practices of 218 consecutive African American infants. Enrollment was prospective. Mechanical models were used in the homes of a subgroup to measure the softness of bedding and its propensity to cause rebreathing. Results were compared by using the Student t test, Mann-Whitney U test, and chi(2) analysis. RESULTS: In a cross-sectional sample of infants, at 8.2 +/- 3.3 weeks of age, 61% (133 of 218) had bed shared > or =1 of the previous 14 nights and 48.6% (106 of 218) had bed shared the night before. Breast-feeding rates were not different for bed sharers and those sleeping alone. The rates of maternal smoking for both groups were low (13.6% vs 11.8%). Comforters, pillows, and waterbeds were more commonly used beneath bed-sharing infants. Bed sharers were twice as likely to habitually be placed prone for sleep (18% vs 9%). In the subgroup studied in their homes (13 bed sharing, 19 alone), the shared beds were softer (P <.0001) and could cause more rebreathing (P =.007). CONCLUSIONS: Infants at increased risk for sudden infant death syndrome, by sociodemographic criteria, who also bed share are more likely to sleep prone and to use softer beds. These findings may explain part of the risk associated with bed sharing among US infants, a risk that appears to be independent of the effects of maternal smoking.

Black or African American↗
PubMed2006

Sharing of T cell receptors in antigen-specific responses is driven by convergent recombination.

Public responses where identical T cell receptors (TCRs) are clonally dominant and shared between different individuals are a common characteristic of CD8(+) T cell-mediated immunity. Focusing on TCR sharing, we analyzed approximately 3,400 TCR beta chains (TCRbetas) from mouse CD8(+) T cells responding to the influenza A virus D(b)NP(366) and D(b)PA(224) epitopes. Both the "public" D(b)NP(366)-specific and "private" D(b)PA(224)-specific TCR repertoires contain a high proportion ( approximately 36%) of shared TCRbetas, although the numbers of mice sharing TCRbetas in each repertoire varies greatly. Sharing of both the TCRbeta amino acid and TCRbeta nucleotide sequence was negatively correlated with the prevalence of random nucleotide additions in the sequence. However, the extent of TCRbeta amino acid sequence sharing among mice was strongly correlated with the level of diversity in the encoding nucleotide sequences, suggesting that a key feature of public TCRs is that they can be made in a variety of ways. Using a computer simulation of random V(D)J recombination, we estimated the relative production frequencies and variety of production mechanisms for TCRbeta sequences and found strong correlations with the sharing of both TCRbeta amino acid sequences and TCRbeta nucleotide sequences. The overall conclusion is that "convergent recombination," rather than a bias in recombination or subsequent selection, provides the mechanistic basis for TCR sharing between individuals responding to identical peptide plus MHC class I glycoprotein complexes.

Animals↗
PubMed2006

HLA and genomewide allele sharing in dizygotic twins.

Gametic selection during fertilization or the effects of specific genotypes on the viability of embryos may cause a skewed transmission of chromosomes to surviving offspring. A recent analysis of transmission distortion in humans reported significant excess sharing among full siblings. Dizygotic (DZ) twin pairs are a special case of the simultaneous survival of two genotypes, and there have been reports of DZ pairs with excess allele sharing around the HLA locus, a candidate locus for embryo survival. We performed an allele-sharing study of 1,592 DZ twin pairs from two independent Australian cohorts, of which 1,561 pairs were informative for linkage on chromosome 6. We also analyzed allele sharing in 336 DZ twin pairs from The Netherlands. We found no evidence of excess allele sharing, either at the HLA locus or in the rest of the genome. In contrast, we found evidence of a small but significant (P=.003 for the Australian sample) genomewide deficit in the proportion of two alleles shared identical by descent among DZ twin pairs. We reconciled conflicting evidence in the literature for excess genomewide allele sharing by performing a simulation study that shows how undetected genotyping errors can lead to an apparent deficit or excess of allele sharing among sibling pairs, dependent on whether parental genotypes are known. Our results imply that gene-mapping studies based on affected sibling pairs that include DZ pairs will not suffer from false-positive results due to loci involved in embryo survival.

Adolescent↗
PubMed2026

DIVAS: an R package for identifying shared and individual variations of multiomics data.

MOTIVATION: Multiomics data integration aims to identify biological patterns shared across molecular modalities. Most existing methods detect either jointly shared variation, across all modalities, or individual variation, unique to a single modality, but overlook partially shared variation, shared by only a subset of modalities. This is a critical limitation, because many biological mechanisms manifest in some but not all molecular modalities. RESULTS: We present an open-source R package implementing data integration via analysis of subspaces (DIVAS), a framework for systematically identifying jointly shared, partially shared and individual variations across multiple data types. DIVAS combines angle-based subspace analysis with inference through rotational bootstrap, hierarchically searching all combinations of modalities to decompose multiomics data into interpretable components with scores and loadings. In simulations with a known sharing structure, DIVAS recovered every component across a wide range of noise levels, whereas existing methods did not. Applied to multi-modal COVID-19 data, it reveals partially shared immune and metabolic dysregulation patterns underpinning disease severity that conventional approaches would miss. AVAILABILITY AND IMPLEMENTATION: DIVAS is available at https://github.com/ByronSyun/DIVAS, with documentation and vignettes. The COVID-19 case study vignette is available at https://byronsyun.github.io/DIVAS_COVID19_CaseStudy/.

Multiomics↗
PubMed1997

The association of HLA-DRB genes and the shared epitope with rheumatoid arthritis in Pakistan.

The association of particular HLA-DR alleles and the shared epitope with rheumatoid arthritis (RA) is now well established. The strength of these links varies between races. Furthermore, the proposition that the presence of the shared epitope is indicative of severe disease has been more difficult to sustain in non-Europeans. This study examines the frequency of HLA-DR and HLA-DRB1 amongst Pakistanis for the first time. Using the polymerase chain reaction (PCR) and sequence-specific oligonucleotide probes (PCR-SSOP) and primers (PCR-SSP), HLA-DR phenotype and genotype frequencies were ascertained in 86 RA hospital out-patients and 79 healthy controls matched for age, gender and ethnicity. HLA-DR1 and HLA-DR4 frequency was similar in patients and controls. HLA-DR10 occurred in 26 instances (15%) in RA and in eight (5%) controls (Pcorr = 0.048). HLA-DR2 was also increased in patients (P = 0.053) and its major subtype DR15 was significantly increased (Pcorr = 0.03). HLA-DR5 frequency was 5% in patients and 19% in controls (Pcorr = 0.002). The HLA-DR4 alleles possessing the shared epitope were more common in RA (Pcorr = 0.03) and this difference was enhanced by inclusion of other alleles possessing the shared epitope (Pcorr = 0.002). Shared epitope alleles were observed in 43 (50%) patients and 17 (22%) controls (Pcorr = 0.003). The shared epitope did not distinguish patients with more severe disease, as reflected by pain, joint deformities, disability, rheumatoid factor or X-ray damage. The distribution of HLA-DR alleles in Pakistanis with RA supports the shared epitope hypothesis. In common with other non-European racial groups, HLA-DR4 was not associated with RA. Unlike other groups, there was a weak link of RA with HLA-DR2. A protective effect of HLA-DR5 was apparent. In accord with some other studies, the shared epitope in this hospital out-patient population was not a marker for more severe disease.

Adolescent↗
PubMed2002

Medical students, clinical preventive services, and shared decision-making.

OBJECTIVE: Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. DESCRIPTION: Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. DISCUSSION: Our medical students appear quite willing to accept shared decision making as a skill that they should have in working with patients, and this was the primary focus of the newly implemented module. However, we have learned that students need to deepen their understanding of screening services in order to help patients understand the associated benefits and risks. The final videotaped interaction with a simulated patient about colorectal cancer screening has been very helpful in making it more obvious to faculty what students believe and know about screening for colorectal cancer. As the students are asked to discuss clinical issues with patients and discuss the pros and cons of screening tests as part of the shared decision-making process, their thinking becomes transparent and it is evident where curricular changes and enhancements are required. We have found that an explicit model that allows students to demonstrate a process for shared decision making is a good introductory tool. We think it would be helpful to provide students with more formative feedback. We would like to develop faculty development programs around shared decision making so that more of our clinical faculty would model such a process with patients. Performance-based assessments are resource-intensive, but they appear to be worth the added effort in terms of enhanced skills development and a more comprehensive appraisal of student learning.

Breast Neoplasms↗