Direct and indirect patient costs of dermatology clinic visits and their impact on access to care and provider preference.

The direct and indirect costs of dermatology clinic visits are infrequently quantified. Indirect costs, such as the time spent traveling to and from appointments and the value of lost earnings from time away from work, are substantial costs that often are not included in economic analyses but may pose barriers to receiving care. Due to the national shortage of dermatologists, patients may have to wait longer for appointments or travel further to see dermatologists outside of their local community, resulting in high time and travel costs for patients. Patients' lost time and earnings comprise the opportunity cost of obtaining care. A monetary value for this opportunity cost can be calculated by multiplying a patient's hourly wage by the number of hours that the patient dedicated to attending the dermatology appointment. Using a single institution survey, this study quantified the direct and indirect patient costs, including opportunity costs and time burden, associated with dermatology clinic visits to better appreciate the impact of these factors on health care access and dermatologic provider preference.

Fibromyalgia: can online cognitive behavioral therapy help?

BACKGROUND: Cognitive behavioral therapy (CBT) has proven useful in treating fibromyalgia, depression, and anxiety. Computerized delivery of CBT allows increased access to such therapy. This study assessed the effect of internet-based CBT on Fibromyalgia Impact Questionnaire (FIQ) composite scores and tender point assessments. METHODS: This 12-week randomized controlled trial included patients ≥18 years of age with 1990 American College of Rheumatology criteria for fibromyalgia and mild to moderate depression and anxiety. A total of 56 subjects were randomized into either a 6-week internet-based CBT group (MoodGYM) or a control group (standard care). We evaluated patients in both groups at 1-, 6-, and 12-week follow-up. The primary outcome measure was change in FIQ composite score. A secondary outcome measure was change in tender point assessment. RESULTS: The mean age of study participants was 55 years, and 88% were female. Mean FIQ scores were significantly lower in the MoodGYM group compared to the control group (P<0.05 for group differences at 6 and 12 weeks). Mean tender point scores were also significantly lower in the MoodGYM group (P<0.001 at 6 and 12 weeks). We found no significant difference in the FIQ scores across the 3 timepoints in the MoodGYM group, but tender points showed a significant negative trend from baseline to 12-week follow-up. CONCLUSION: Patients in the internet-based MoodGYM CBT program had lower FIQ and tender point scores at 6- and 12-week follow-up. Internet-based CBT could be beneficial in the treatment of mild to moderate depression and anxiety in patients with fibromyalgia by allowing increased access to CBT.

Patient Preferences for Doctor Attire: The White Coat's Place in the Medical Profession.

BACKGROUND: The white coat's place in the medical profession is a heavily debated topic. Five years after the bare-below-the-elbow policy took effect in England, we reexamined the evidence about coats' potential to transmit infection, reviewed previous studies, and explored our patients' opinions on doctor attire. METHODS: We administered a survey at 3 locations in the Ochsner Health System (hospital clinic, satellite clinic, and inpatient ward) in 2013. The survey assessed patient preference for doctors to wear white coats and included 4 images of the same doctor in different attire: traditional white coat, bare-below-the-elbow attire, a white coat with scrubs, and scrubs alone. Respondents rated images head-to-head for their preferences and individually for their confidence in the physician's skills and for their comfort level with the physician based upon the displayed attire. Participants' attitudes were then reassessed after they were given information about potential disease transmission. RESULTS: Overall, 69.9% of the 153 patients surveyed preferred doctors to wear white coats. When locations were compared, a statistically higher proportion of outpatients preferred coats (P=0.001), a trend most pronounced between hospital clinic (84%) and ward inpatients (51.9%). Patients disliked bare-below-the-elbow attire, scoring it lowest on the comfort and confidence scales (0.05 and 0.09, respectively). Information regarding risks of coat-carried infections did not influence respondents' opinions; 86.9% would still feel comfortable with a doctor who wore one. CONCLUSIONS: These findings suggest patients prefer white coats, and they contribute to greater comfort and confidence in their physicians, despite knowledge of theoretic concerns of disease transmission.

Evaluation of pediatricians' adherence to tobacco prevention, control, and treatment guidelines before and after an educational outreach program.

BACKGROUND: Tobacco use is the world's leading single preventable cause of death. Because children exposed to second- and third-hand smoke are at risk for smoke-related morbidity, pediatricians have an obligation to address tobacco use in their practices. The purpose of this study was to measure physician adherence to the American Academy of Pediatrics' guidelines on tobacco prevention, control, and treatment before and after the implementation of an educational outreach program. METHODS: Charts were randomly selected from pediatric clinics before and after the educational outreach. The intervention consisted of a review of the guidelines and available tools physicians could implement into their practices. We measured the rates of adherence to the guidelines before and after the educational outreach. RESULTS: We analyzed 213 charts (116 pre- and 97 posteducation). The proportion of families screened for tobacco smoke exposure was comparable between the pre- and postintervention groups (67.2% vs 59.8%, P=0.317). The postintervention group had a higher proportion of counseling compared to the preintervention group (51.5% vs 31.9%, P<0.05). We found no statistically significant change in the rate of screening or referral to smoking cessation services. CONCLUSION: Current guidelines to reduce tobacco use are underutilized. Educational outreach may increase the rate of counseling. Physician acceptance of guidelines is urgently needed to affect the tobacco epidemic.

The impact of achieving perfect care in acute coronary syndrome: the role of computer assisted decision support.

BACKGROUND: Attainment of every performance measure or perfect care (PC) is used as a tool for measuring hospital quality of care. We sought to describe the effect of achieving PC on subsequent outcomes in patients admitted with acute coronary syndrome (ACS) and to determine whether computerized physician order entry enabled with decision support (CPOE-DS) would enhance the likelihood of achieving PC and improvements in clinical outcomes. METHODS: Clinical inpatient data, performance measures and subsequent mortality was collected in 1,321 consecutive ACS patients admitted between January 1, 2009, to October 15, 2011, using either a standardized order set that followed consensus guidelines or orders generated via CPOE-DS. RESULTS: CPOE-DS generated orders were utilized in 642 (49%) patients while the remaining 679 (51%) of patients were admitted using standardized order sets. At baseline, CPOE-DS patients were younger (-3%, P = .006), had lower resting heart rates (-3%, P = .012), higher TIMI risk scores (+19%, P < .001), were less likely to have hypertension (85% vs. 90%, P = .014), and more likely to have ST-segment elevation myocardial infarction (17% vs 10%; P = .001) than patients admitted with standard orders. Patients admitted using CPOE-DS were 5.7 times more likely to achieve PC than those who were admitted with standard orders (P < .001). Independent predictors of survival included PC (HR, 0.45; P < .001), age ≥67 years (HR, 2.34; P < .001), and abnormal presenting heart rate (HR, 1.71; P = .046). CONCLUSIONS: Achievement of PC is a valid measure of quality of care in the hospitalized ACS patient and is associated with improved survival. CPOE-DS is feasible in the care process for ACS and can increase attainment of PC.

Impact of coenzyme Q-10 on parameters of cardiorespiratory fitness and muscle performance in older athletes taking statins.

Many older athletes take statins, which are known to have potential for muscle toxicity. The adverse effects of statins on muscles and the influence thereof on athletic performance remain uncertain. Coenzyme Q-10 (CoQ10) may improve performance and reduce muscle toxicity in older athletes taking statins. This trial was designed to evaluate the benefits of CoQ10 administration for mitochondrial function in this population. Twenty athletes aged ≥ 50 years who were taking stable doses of statins were randomized to receive either CoQ10 (200 mg daily) or placebo for 6 weeks in a double-blind, placebo-controlled, crossover study to evaluate the impact of CoQ10 on the anaerobic threshold (AT). Several secondary endpoints, including muscle function, cardiopulmonary exercise function, and subjective feelings of fitness, were also assessed. The mean (SD) change in AT from baseline was -0.59 (1.2) mL/kg/min during placebo treatment and 2.34 (0.8) mL/kg/min during CoQ10 treatment (P = 0.116). The mean change in time to AT from baseline was significantly greater during CoQ10 treatment than during placebo treatment (40.26 s vs 0.58 s, P = 0.038). Furthermore, muscle strength as measured by leg extension repetitions (reps) increased significantly during CoQ10 treatment, with a mean (SD) increase from baseline of 1.73 (2.9) reps during placebo treatment versus 3.78 (5.0) reps during CoQ10 treatment (P = 0.031). Many other parameters also tended to improve in response to CoQ10 treatment. Treatment with CoQ10 improved AT in comparison with baseline values in 11 of 19 (58%) subjects and in comparison with placebo treatment values in 10 of 19 (53%) subjects. Treatment with CoQ10 (200 mg daily) did not significantly improve AT in older athletes taking statins. However, it did improve muscle performance as measured by time to AT and leg strength (quadriceps muscle reps). Many other measures of mitochondrial function also tended to improve during CoQ10 treatment.