Obtaining the Patient's Voice from within Three Patient-Centered Medical Homes.

The purpose of this qualitative program was to determine if a trend exists across three LSU medical homes according to patient feedback concerning their experiences within the medical home for ongoing disease management and quality healthcare; and to obtain recommendations for the most effective way to involve patients in shaping system policies, procedures, and practices consistent with patient and family-centered care principles. A total of 94 adult patients participated in either cognitive interviews (n = 45) or structured focus groups (n = 49) using the Nominal Group Technique (NGT). Exit surveys collected demographic information and feedback from patients about opportunities for their involvement in shaping medical homes. Cognitive interviews and NGT sessions both revealed some patient-perceived gratifications (i.e., friendliness and helpfulness of the clinic staff), and deficiencies (i.e., improving scheduling of appointments and reducing wait time in the clinic) within these medical homes. However, the perceived gratifications far exceeded the deficiencies found within each of three LSU medical homes.

Diabetes mellitus medication assistance program: relationship of effectiveness to adherence.

This retrospective study examines the effect of a medication assistance program (MAP) on HbA1c levels in an uninsured, low-income, type 2 diabetes population. It also examines the degree to which improvement in HbA1c level varied with adherence to medication regimens among those patients using the MAP. The MAP was found to have a mean effect of -0.60% on HbA1c levels. However, MAP users differed in how strictly they adhered to medication regimens, as measured by number of refill opportunities taken. The MAP's effect on HbA1c varied monotonically with adherence level, with greater adherence leading to greater HbA1c improvement. Never refilling the prescription (complete nonadherence) led to no change in HbA1c, while complete adherence led to an estimated -0.88% improvement in HbA1c. Further study is needed to investigate factors related to non-adherence within medication assistance programs and the effect of such programs on other patient outcomes.

The impact of disasters and their aftermath on mental health.

Hurricanes Katrina and Rita were the latest disasters involving trauma to individuals and displacement of significant populations. As a consequence, those of us in health care fields often are affected both as professionals with critical skills and as individuals with families under intense stress. This Commentary, which appears in the January 2006 issue of The Journal of Clinical Psychiatry (2006;67:7-14), provides first-hand insight into the "at-the-front" realities faced by primary care professionals as disasters evolve, as well as the preparations we can make with our families and the key priorities to be addressed in our professional roles with individuals, affected groups of people, and response systems. While it is rare for us to dually publish material, we deem the importance of this information to merit joint publication in The Journal of Clinical Psychiatry and The Companion.-Larry Culpepper, M.D.

Mortality benefit of a comprehensive heart failure disease management program in indigent patients.

BACKGROUND: Heart failure (HF) produces significant morbidity and mortality. Although HF disease management (HFDM) programs have been shown to decrease this morbidity, there is still a paucity of data on their effect on mortality. The objective of this study was to determine whether participation in an HFDM program would reduce mortality in an indigent population from rural Louisiana. METHODS: Proportional hazards modeling was used to determine whether patients participating in the HFDM program had improved survival compared with patients receiving traditional outpatient care at the same institution. Inclusion criteria consisted of an index hospitalization with discharge occurring between July 1, 1997, and May 30, 2002, hospital discharge diagnosis of HF, left ventricular systolic dysfunction documented during hospitalization, and at least 1 subsequent outpatient visit. Data from patients having participated in the HFDM program before their index hospitalization were excluded. RESULTS: Compared with patients who were given traditional care (n = 100), HFDM patients (n = 156) were younger (56.7 vs 60 years, P = .031), more likely to be African American (48.7% vs 33.0%, P = .014), more likely to be uninsured (47.4% vs 27%, P = .001), and more likely to have an ejection fraction of < or = 25% (73.1% vs 36%, P < .001). Overall comorbidity did not differ significantly between the groups. After controlling for differences in demographics, ejection fraction, and comorbidities, participation in the HFDM program was associated with a significant reduction in mortality compared with traditional care (adjusted hazard ratio .33, P < .001). CONCLUSION: In this indigent population, participation in an HFDM program was associated with decreased mortality compared with traditional follow-up care.

A critical analysis of physician-assisted suicide.

Physician-assisted suicide is a controversial practice that is gaining favor in some segments of today's society. I will analyze the proponents' arguments for physician-assisted suicide and discuss why I believe this is a practice that physicians should shun.