Comparison of Outcomes of Glaucoma Screening in Primary Care and Community Settings.

Purpose: To compare outcomes of glaucoma screening in primary care and community settings, including the follow-up rates of subjects with positive screening results. Methods: This was a comparative, prospective, non-randomized study. Subjects were recruited by medical students in community-based and primary care settings and screened for glaucoma using the same screening strategy. Results: Two hundred and fifteen total patients were screened, 117 in community settings and 98 in primary care settings. Positive screenings were seen in 34% of patients in the community setting group (n = 40) and 40% of patients in the primary care setting group (n = 39). Of the patients who screened positive, 74% completed their initial follow-up appointment in the primary care setting group compared with 47.5% in the community-based setting group (p = .015). In the primary care setting, 18% were lost to follow up compared with 42.5% in the community-setting (P = .018). African-Americans were more likely to follow-up (P = .025) and less likely to be lost to follow-up (P = .033) in the primary care setting compared with the community-based setting. Conclusion: Patients with a positive glaucoma screening result in a primary care setting are more likely to follow up than those in a community-based setting.

Health Variables Are Informative in Screening for Mild Cognitive Impairment Among Elderly African Americans.

To aid primary care providers in identifying people at increased risk for cognitive decline, we explored the relative importance of health and demographic variables in detecting potential cognitive impairment using the Mini-Mental State Examination (MMSE). Participants were 94 older African Americans coming to see their primary care physicians for reasons other than cognitive complaints. Education was strongly associated with cognitive functioning. Among those with at least 9 years of education, patients with more vascular risk factors were at greater risk for mild cognitive impairment. For patients with fewer than 9 years of education, those with fewer prescribed medications were at increased risk for dementia. These results suggest that in addition to the MMSE, primary care physicians can make use of patients' health information to improve identification of patients at increased risk for cognitive impairment. With improved identification, physicians can implement strategies to mitigate the progression and impact of cognitive difficulties.

Blood Pressure Variability and Cognitive Function Among Older African Americans: Introducing a New Blood Pressure Variability Measure.

BACKGROUND: Although blood pressure (BP) variability has been reported to be associated with cognitive impairment, whether this relationship affects African Americans has been unclear. We sought correlations between systolic and diastolic BP variability and cognitive function in community-dwelling older African Americans, and introduced a new BP variability measure that can be applied to BP data collected in clinical practice. METHODS: We assessed cognitive function in 94 cognitively normal older African Americans using the Mini-Mental State Examination (MMSE) and the Computer Assessment of Mild Cognitive Impairment (CAMCI). We used BP measurements taken at the patients' three most recent primary care clinic visits to generate three traditional BP variability indices, range, standard deviation, and coefficient of variation, plus a new index, random slope, which accounts for unequal BP measurement intervals within and across patients. RESULTS: MMSE scores did not correlate with any of the BP variability indices. Patients with greater diastolic BP variability were less accurate on the CAMCI verbal memory and incidental memory tasks. Results were similar across the four BP variability indices. CONCLUSIONS: In a sample of cognitively intact older African American adults, BP variability did not correlate with global cognitive function, as measured by the MMSE. However, higher diastolic BP variability correlated with poorer verbal and incidental memory. By accounting for differences in BP measurement intervals, our new BP variability index may help alert primary care physicians to patients at particular risk for cognitive decline.

Subjective Memory Change, Mood, and Cerebrovascular Risk Factors in Older African Americans.

OBJECTIVE: Subjective memory change (SMC) in older individuals may represent a harbinger of cognitive decline. This study examined the factors associated with SMC in older African Americans (AA), who have greater risk of developing dementia. We predicted that symptoms of depression and anxiety, as well as the total number of cerebrovascular risk factors (tCVRFs), but not performances on objective memory measures, would be positively associated with SMC. METHODS: Ninety-six AA completed brief cognitive testing and answered questions about mood and memory at their primary care appointment. Vascular data were obtained from medical records. RESULTS: Symptoms of depression and anxiety, but not performances on objective memory measures, were positively associated with SMC, t(χ2(1) = 16.55 and 12.94, respectively, both P < .001). In nondepressed participants, the tCVRF was important in distinguishing between those with and without SMC. CONCLUSIONS: In older AA, symptoms of depression or anxiety were associated with SMC. In nondepressed AA, the tCVRFs were important in distinguishing between those with and without SMC.

Real-time EBM: from bed board to keyboard and back.

BACKGROUND: To practice Evidence-Based Medicine (EBM), physicians must quickly retrieve evidence to inform medical decisions. Internal Medicine (IM) residents receive little formal education in electronic database searching, and have identified poor searching skills as a barrier to practicing EBM. OBJECTIVE: To design and implement a database searching tutorial for IM residents on inpatient rotations and to evaluate its impact on residents' skill and comfort searching MEDLINE and filtered EBM resources. DESIGN: Randomized controlled trial. Residents randomized to the searching tutorial met for up to 6 1-hour small group sessions to search for answers to questions about current hospitalized patients. PARTICIPANTS: Second- and 3rd-year IM residents. MEASUREMENTS: Residents in both groups completed an Objective Structured Searching Evaluation (OSSE), searching for primary evidence to answer 5 clinical questions. OSSE outcomes were the number of successful searches, search times, and techniques utilized. Participants also completed self-assessment surveys measuring frequency and comfort using EBM databases. RESULTS: During the OSSE, residents who participated in the intervention utilized more searching techniques overall (p < .01) and used PubMed's Clinical Queries more often (p < .001) than control residents. Searching "success" and time per completed search did not differ between groups. Compared with controls, intervention residents reported greater comfort using MEDLINE (p < .05) and the Cochrane Library (p < .05) on post-intervention surveys. The groups did not differ in comfort using ACP Journal Club, or in self-reported frequency of use of any databases. CONCLUSIONS: An inpatient EBM searching tutorial improved searching techniques of IM residents and resulted in increased comfort with MEDLINE and the Cochrane Library, but did not impact overall searching success.

Changing use of hormone therapy among minority women since the Women's Health Initiative.

OBJECTIVE: There has been a significant shift in the use of hormone therapy (HT) among nonminority women since the publication of results of the Women's Health Initiative (WHI). Little is known about how the WHI results affected minority populations. This survey measured patterns of HT use among inner city women after publication of the WHI results, identified factors involved in the decision to continue or discontinue HT, and characterized the symptom burden and the experience of women who attempted to discontinue HT. DESIGN: We conducted a cross-sectional survey of 101 English- and Spanish-speaking women in an inner city general internal medicine clinic from August 2003 to April 2004. All women had been taking HT at the time of the publication of the WHI results. The survey included questions on patient-reported experience with HT, symptoms of menopause, and use of alternative treatments. RESULTS: Overall, 101 of 142 (71%) eligible women agreed to participate. The mean age of participants was 60 years; 43% were African American and 46% were Hispanic. The mean duration of HT use was 9.6 years. Three quarters (74%) had heard about the WHI findings, and 87% had attempted to stop taking HT after their publication. The most common reason for attempting to stop HT was concern about an increased risk of cancer or a general increase in risk to health. Of those who stopped HT, the vast majority (85%) reported vasomotor symptoms, and 26% restarted HT, mostly to treat those symptoms. CONCLUSIONS: Nearly all minority women in this small sample attempted to stop HT use after the results of the WHI were published. Restarting HT for treatment of symptoms was common.

Using structured debate to teach a controversial topic: mammography for women in their 40s.

BACKGROUND: Screening mammography for women in their 40s is controversial, and counseling patients about it can be challenging. Debate is an educational tool that lends itself to teaching about controversial topics and improving communication skills but is underused in medical education. PURPOSE: The purpose of this intervention was to improve residents' willingness to discuss mammography with patients. METHODS: Second-year internal medicine residents participated in a 3-hr structured debate on screening mammography for women in their 40s. The intervention's effect was measured using pretest and posttest questionnaires. RESULTS: A total of 33 residents participated in 6 debates between January and June of 2003. Comparison of pretest and posttest questionnaires showed that participants became more comfortable discussing mammography screening and were more likely to discuss it with their patients after the debate. CONCLUSIONS: A structured debate resulted in residents reporting increased comfort level and willingness to discuss mammography with women in their 40s.