Physician-patient congruence regarding medication regimens.

OBJECTIVES: To characterize the degree of disparity between physicians' perceptions of older patients' medication regimen and patients' perceptions of their regimen. DESIGN: Prospective observational. Physicians and patients were blinded at index visit; after, trained medical students made home visits, collecting information about medications that was compared with physician questionnaires. SETTING: Community family medicine residency program. PARTICIPANTS: Patients age 65 and older presenting for routine visit, taking at least four prescription medications, and seen by index physician three or more times in the past year. Physicians were family medicine faculty and second- and third-year residents. MEASUREMENTS: Fifty physician-patient pairs were analyzed. Average age was 75 (standard deviation (SD) +/-5.5); patients averaged 7.0 prescription medications (range 3-17, SD +/-2.89). Three hundred seventy-five prescription medications were identified; the most commonly prescribed were antihypertensives (134/375; 36%). RESULTS: Congruence, defined as agreement between physician and patient regarding all prescription medications, dosages, and frequency, averaged 70% for faculty (range 53-89%) and 58% for residents (range 41-81%) (P = .08). Fourteen percent (7/50) demonstrated complete congruence; 74% (37/50) had at least one medication that either the physician was unaware the patient was taking or the physician thought the patient was taking but that was not part of the patient's regimen; 12% (6/50) had dose and/or frequency discrepancies. CONCLUSIONS: This study demonstrates significant disparity in a population where it is crucial for healthcare providers and patients to be in close agreement about intended medication regimens.

Plasma lipid response and nutritional adequacy in hypercholesterolemic subjects on the American Heart Association Step-One Diet.

OBJECTIVES: To determine the efficacy of the American Heart Association Step-One Diet for lowering blood lipid levels and to assess its nutritional adequacy in younger (< 50 years old) and older (> or = 50 years old) subgroups. STUDY DESIGN: A prospective cohort study; 383 subjects were instructed in the American Heart Association Step-One Diet. Adherence to the diet was assessed at 6 weeks. Eighty-seven subjects continued the diet for an additional 12 weeks. SETTING: General community participants: volunteers from community cholesterol screening programs and chart reviews at family practice clinics. STUDY PARTICIPANTS: Men and women, aged 20 to 70 years, with baseline low-density lipoprotein cholesterol levels between the 50th and 95th percentile, and excluded if receiving any medications that affect blood lipid levels or if there was a history of diabetes, gout, peptic ulcer, or liver disease. INTERVENTION: Instruction by a registered dietitian and adherence to the American Heart Association Step-One Diet for 6 (n = 383) and 18 weeks (n = 87). This diet involves an intake of total fat not to exceed 30% of calories, saturated fatty acids not to exceed 10% of calories, and dietary cholesterol limited to 300 mg/d. RESULTS: Subjects aged 50 to 70 years averaged a reduction in total cholesterol level and low-density lipoprotein cholesterol level of 4% after 6 weeks. At the end of 18 weeks, mean total cholesterol and low-density lipoprotein cholesterol levels in subjects younger than 50 years exceeded their baseline levels, and in those older than 50 years returned to baseline lipid levels. Inadequate intake of several micronutrients were reported, notably, zinc, calcium, and vitamins A, D, and E. CONCLUSIONS: When recommending the American Heart Association Step-One Diet to persons with hyperlipidemia, baseline dietary behavior should be assessed to determine whether that diet offers therapeutic advantage over the persons's self-selected diet. Follow-up should include monitoring of lipid response and nutritional adequacy. Special emphasis should be placed on selection of foods with appropriate micronutrient content.

A national survey of the home visiting practice and attitudes of family physicians and internists.

BACKGROUND: Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians. METHODS: Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care. RESULTS: Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement. CONCLUSIONS: Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.

Oat products and lipid lowering. A meta-analysis.

OBJECTIVES: To test the a priori hypothesis that consumption of oats will lower the blood total cholesterol level and to assess modifiers and confounders of this association. DATA SOURCES: A computerized literature (MEDLINE) search and the Quaker Oats Co identified published and unpublished trials as of March 1991. Raw data were requested for all trials. STUDY SELECTION: Trials were included in summary effect size estimates if they were randomized and controlled, if a formal assessment of diet and body weight changes occurred, and, if raw data were not received, if there was enough information in the published report to perform calculations. DATA SYNTHESIS: Twenty trials were identified. Using the methods of DerSimonian and Laird, a summary effect size for change in blood total cholesterol level of -0.13 mmol/L (-5.9 mg/dL) (95% confidence interval [CI], -0.19 to -0.017 mmol/L [-8.4 to -3.3 mg/dL]) was calculated for the 10 trials meeting the inclusion criteria. The summary effect size for trials using wheat control groups was -0.11 mmol/L (-4.4 mg/dL) (95% CI, -0.21 to -0.01 mmol/L [-8.3 to -0.38 mg/dL]). Calculation of Keys scores demonstrated that substituting carbohydrates for dietary fats and cholesterol did not account for the majority of blood cholesterol reduction. Larger reductions were seen in trials in which subjects had initially higher blood cholesterol levels (greater than or equal to 5.9 mmol/L [greater than or equal to 229 mg/dL]), particularly when a dose of 3 g or more of soluble fiber was employed. CONCLUSION: This analysis supports the hypothesis that incorporating oat products into the diet causes a modest reduction in blood cholesterol level.

A clinical trial of oat bran and niacin in the treatment of hyperlipidemia.

BACKGROUND: Previous studies have demonstrated the lipid-lowering potential of wax-matrix controlled-release forms of nicotinic acid, but questions have been raised about the risks associated with long-term use. This report describes a 38-week trial that was designed as a follow-up to a shorter 16-week clinical trial of wax-matrix controlled-release niacin. The present study also tested the hypothesis that niacin (1500 mg/d) and oat bran (56 g/d [2 oz/day]) may have a synergistic effect on improving serum lipid levels. METHODS: Ninety-eight subjects began the following protocol: oat bran alone (6 weeks), oat bran plus niacin (6 weeks), and niacin alone (32 weeks). Blood lipids, blood chemistries, nutritional variables, and side-effect profiles were monitored throughout the study. Sixty-nine (70%) subjects completed the trial taking the full dose of niacin (1500 mg/d); 8 subjects completed the trial taking a reduced dose of niacin (average 906 mg/d); 11 discontinued taking any niacin because of either intolerable side effects (n = 7) or liver enzyme abnormalities (n = 4). RESULTS: Generally, oat bran-niacin synergism was not found. Only 10% of subjects who completed the study showed greater than expected lipid improvement on combination therapy. From baseline to the end of the final phase, significant reductions (P less than .05) occurred for total cholesterol (-10%) and low-density lipoprotein cholesterol (-16%). High-density lipoprotein cholesterol rose significantly at the end of the oat bran plus niacin phase, but returned to near baseline by the end of the study. The liver enzymes alkaline phosphatase, lactate dehydrogenase, and aspartate aminotransferase all showed a tendency to rise throughout the study. CONCLUSIONS: The results of this 38-week trial suggest that the relatively inexpensive wax-matrix form of niacin is effective and reasonably well tolerated. Approximately 8% of subjects were unable to continue taking niacin because of side effects, and 4% discontinued taking niacin because of liver enzyme elevations. A small group of subjects (10%) experienced greater than expected lipid improvements (synergism) on combined oat-bran and niacin therapy. Liver function monitoring with long-term use of niacin is warranted.

A survey of Minnesota home care agencies' perceptions of physician behaviors.

A survey of Minnesota home care agencies assessed perceptions of and satisfaction with the home care practices, knowledge, and skills of Minnesota family physicians and other primary care physicians. We found that physicians did not make many home visits and that agencies were moderately dissatisfied with that practice. Family physicians visited significantly more frequently than other primary care physicians and, in rural areas, received significantly higher satisfaction ratings from agencies. The areas most frequently noted that could benefit from improvement of physician skills/knowledge regarding home care were: better home care clinical skills (38.5% of respondents), knowledge of home care technology and capabilities (37%), and knowledge of reimbursement policies and practice (29%).

Niacin revisited. A randomized, controlled trial of wax-matrix sustained-release niacin in hypercholesterolemia.

Two hundred one male and female subjects, aged 20 to 70 years, with elevated low-density lipoprotein cholesterol values (in the 75th to 95th percentiles), participated in a randomized, controlled, double-blind study using a new form of niacin (Enduracin), which employs a wax-matrix vehicle for sustained release. Four niacin treatment groups (daily doses of 2000, 1500, 1250, and 1000 mg) were compared with placebo- and diet-treated controls to determine side-effect profile and optimal range of efficacy. The groups given 2000 and 1500 mg demonstrated significant reductions in values of low-density lipoprotein cholesterol (-26% and -19.3%, respectively), total cholesterol (-18.4% and -13.3%), and total cholesterol-high-density lipoprotein cholesterol ratio (-20.4% and -19.4%) when compared with diet- and placebo-treated controls. Smaller improvements were seen in high-density lipoprotein cholesterol and triglyceride levels. Blood chemistry monitoring indicated that reduction in low-density lipoprotein cholesterol level strongly correlated with an increase in baseline levels of some enzymes for niacin-treated subjects. The improved side-effect profile of the wax-matrix form of niacin was particularly notable. The dropout rate due to side effects was only 3.4% and was coupled with good medication compliance.