Physicians' survival predictions for patients with acute congestive heart failure.

BACKGROUND: Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units. OBJECTIVE: To assess how well physicians could predict the probability of survival for acutely ill patients with congestive heart failure, and in particular how well they could identify patients with small chances of survival. METHODS: This was a prospective cohort study done in the emergency departments of a university hospital, a Veterans Affairs medical center, and a community hospital. The study population was consecutive adults for whom new or exacerbated congestive heart failure, diagnosed clinically, was a major reason for the emergency department visit. Physicians caring for the study patients in the emergency departments recorded their judgments of the numeric probability that each patient would survive for 90 days and for 1 year. The patients vital status at 90 days and 1 year was ascertained by multiple means, including interview, chart review, and review of hospital and state databases. RESULTS: By calibration curve analysis, the physicians underestimated survival probability at both 90 days and 1 year, particularly for patients they judged to have the lowest probabilities of survival. Their predictions had modest discriminating ability (receiver operating characteristic curve areas, 0.66 [SE = 0.020] for 90 days; 0.63 [SE = 0.017] for 1 year). The physicians identified only 15 patients they judged to have a 90-day survival probability of 10% or less, whose survival rate was actually 33.3%. CONCLUSIONS: Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.

Variation of ictal electroencephalographic regularity with low-, moderate-, and high-dose stimuli during right unilateral electroconvulsive therapy.

BACKGROUND: Previous work has demonstrated changes in electroencephalographic (EEG) ictal morphology during electroconvulsive therapy (ECT) as stimulus intensity is increased from barely suprathreshold to moderately suprathreshold. Our study reports on the reactivity of seizure regularity ratings in 11 subjects receiving right unilateral (RUL) ECT as the stimulus is varied over a wider range of intensities from low to medium, then high dose. METHODS: The stimulus intensity of all 11 subjects was first increased from barely suprathreshold to moderately suprathreshold, and then randomized to either stay at a moderately suprathreshold dose or increase to a high dose. The regularity of the EEG ictal discharge was visually measured on a seven-point scale. RESULTS: We found that seizure regularity increases as the stimulus intensity moves from the barely suprathreshold to the moderately suprathreshold dosage, but did not increase further when the stimulus increased to a high dose. CONCLUSIONS: These results suggest that EEG regularity is unlikely to distinguish moderately suprathreshold from markedly suprathreshold stimuli during RUL ECT.

Effects of buspirone and alprazolam on the cognitive performance of normal elderly subjects.

OBJECTIVE: To increase understanding of the potential in elderly persons for disability related to behavioral side effects of anxiolytic medications, cognitive and psychomotor effects of clinical doses of buspirone and a popular intermediate-acting benzodiazepine, alprazolam, were examined in carefully screened, healthy elderly subjects. METHOD: Sixty subjects recruited through community organizations and newspaper advertisements and screened on the basis of history, physical examination, and laboratory studies were randomly assigned to one of three drug treatment groups. After 2 days of washout placebo, subjects were given 0.25 mg t.i.d. of alprazolam, 5 mg t.i.d. of buspirone, or placebo three times a day for a total of 14 days in a double-blind design. Behavioral assessments were completed beginning 1 hour after ingestion of medication on the second washout placebo day, day 1 of the treatment period, and day 14 of the treatment period. Tests included the continuous performance test, recall memory for word lists, digit-symbol substitution, retention of pictorial stimuli over 1 hour, the Profile of Mood States, and subjective ratings of mental status. RESULTS: Buspirone did not affect reaction time, vigilance, psychomotor speed, or memory function. Alprazolam had minimal effects on vigilance, psychomotor speed, and memory on the first treatment day and had no effects after repeated doses. CONCLUSIONS: Buspirone did not produce behavioral side effects that could lead to disability, and alprazolam had minimal side effects. Because the patients were carefully screened, it is unclear whether these medications in the doses used would have more side effects in less healthy elderly patients.

The incremental direct costs associated with behavioral symptoms in AD.

OBJECTIVE: To determine the incremental costs associated with behavioral symptoms in patients with AD. METHODS: A total of 128 patients with probable AD were enrolled into this study. Cognitive function and extrapyramidal features were assessed in patients with AD. Caregivers were interviewed to determine use of health care services, receipt of unpaid care, severity of behavioral symptoms (Neuropsychiatric Inventory [NPI]), and comorbid medical conditions in patients with AD. Healthcare utilization data were multiplied by unit costs to estimate direct formal costs. Unpaid caregiving hours were multiplied by an hourly wage to estimate direct informal costs. The annual incremental direct costs of additional behavioral symptoms were estimated with multiple regression equations. RESULTS: Annual, direct costs were significantly higher in patients with AD at or above the median score on the NPI (high NPI group), after adjusting for group differences in severity of cognitive impairment and comorbid conditions. Patients in the high NPI group had formal costs between US$3,162 and US$5,919 higher than the low NPI group and total direct costs between US$10,670 and US$16,141 higher, depending on the severity of cognitive impairments. Models for the entire sample estimated that a one-point increase in the NPI score would result in an annual increase of between US$247 and US$409 in total direct costs, depending on the value of unpaid caregiving. CONCLUSIONS: Behavioral symptoms in patients with AD significantly increase direct costs of care.

Clinical variables influencing treatment decisions for agitated dementia patients: survey of physician judgments.

OBJECTIVE: To better understand primary treatment recommendations and the variables that might influence treatment decisions of physicians who treat agitated dementia patients. DESIGN: A written cross-sectional survey of three physician groups (geriatric psychiatrists, primary care physicians, and neurologists) who typically treat agitated dementia patients in community settings. We used a written clinical vignette describing a home-bound, agitated dementia patient to ask respondents to provide information regarding their primary treatment recommendation and to estimate the degree to which clinically relevant variables might influence their treatment recommendation. Using principal component analysis, the original set of clinical variables was collapsed into a smaller set of composite factors that better defined the fundamental constructs of the variables that influenced decision making. Analyses compared primary treatment recommendations and factors influencing treatment recommendations by physician groups. PARTICIPANTS: The pool of survey respondents consisted of a random selection of 207 primary care physicians from western North Carolina, 147 geriatric psychiatrists obtained from the roster of the 1991 American Association for Geriatric Psychiatry, and 120 neurologists obtained from the roster of the American Board of Medical Specialties. The response rate was 65% for geriatric psychiatrists, 38% for primary care physicians, and 33% for neurologists. RESULTS: Differences in primary treatment recommendations by physician group were not found. Physicians, regardless of specialty, recommended neuroleptic medications as their primary intervention. When medication classes were collapsed into a single category, medications as a primary intervention exceeded 55% for all physician groups. Twenty-two percent of all respondents recommended psychosocial interventions as primary treatment strategies. The principal component analysis of clinical variables influencing treatment recommendations solved for five components that accounted for 64% of the variance. Comparing the five components by specialty groups failed to find significant differences, except for Factor 5, the "Hassle Factor." Primary care physicians were more likely to indicate that this component influenced their decision making than were the other physician groups. CONCLUSIONS: The findings indicate that physicians, regardless of specialty, are likely to use medication and to weight clinically relevant information in a similar fashion when managing agitated dementia patients.

Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders.

Most primary care physicians do not feel competent to treat alcohol- and drug-related disorders. Physicians generally do not like to work with patients with these disorders and do not find treating them rewarding. Despite large numbers of such patients, the diagnosis and treatment of alcohol- and drug-related disorders are generally considered peripheral to or outside medical matters and ultimately outside medical education. There is substantial evidence that physicians fail even to identify a large percentage of patients with these disorders. Essential role models are lacking for future physicians to develop the attitudes and training they need to adequately approach addiction as a treatable medical illness. Faculty development programs in addictive disorders are needed to overcome the stigma, poor attitudes, and deficient skills among physicians who provide education and leadership for medical students and residents. The lack of parity with other medical disorders gives reimbursement and education for addiction disorders low priority. Medical students and physicians can also be consumers and patients with addiction problems. Their attitudes and abilities to learn about alcohol- and drug-related disorders are impaired without interventions. Curricula lack sufficient instruction and experiences in addiction medicine throughout all years of medical education. Programs that have successfully changed students' attitudes and skills for treatment of addicted patients continue to be exceptional and limited in focus rather than the general practice in U.S. medical schools. The authors review the findings of the literature on these problems, discuss the barriers to educational reform, and propose recommendations for developing an effective medical school curriculum about alcohol- and drug-related disorders.

Positive ego and coping functions in chronic pain and depressed patients.

Three groups of elderly subjects (chronic pain patients, patients with major depression, and healthy individuals) were administered measures of self-esteem, ego defense mechanisms, and coping style to examine how these personality components are affected by illness. Ego defense mechanisms and self-esteem for all three groups were not found to be different and were positive except for depressed patients, who used greater levels of projection and demonstrated lower levels of self-esteem. Each subject group utilized equally problem-focused and emotion-focused coping styles. These findings from a preliminary study are consistent with previous research demonstrating stability of personality throughout the life span, and suggest that the psychological functioning of older individuals with chronic pain syndromes or depression remains positive and resilient.

Hospital utilization and readmission rates for geriatric and young adult patients with major depression: results from a historical cohort study.

Late-life depression may have different clinical features, hospital utilization patterns, and natural history, depending on whether the illness begins in midlife or late life. This historical cohort study examined three patient groups, late-onset geriatric depressed patients, early-onset geriatric depressed patients, and young adult depressed patients, to determine hospital utilization patterns, readmission rates, and whether specific clinical symptoms on admission predisposed patients to readmission. The two geriatric patient groups had similar demographic, medical comorbidity, and hospital utilization profiles, except that the early-onset geriatric depressed group had longer hospital lengths of stay. Hospital utilization patterns for the young adult patients were different from the geriatric patients, but in the expected direction, ie, less medical comorbidity and shorter lengths of stay. Patients with late-onset geriatric depression had the highest 24-month readmission rate (47.4%), followed by early-onset geriatric depression patients (23.1%) and young adult patients (16.7%). Delusional symptoms and agitation were similar across the three patient groups and, as expected, somatic complaints were more frequent in the geriatric patient groups. The relative risk for readmission was greatest for geriatric patients who were somatic. Readmission risk was increased for agitated late-onset geriatric depressed patients and young adult patients, but not for early-onset geriatric depressed patients. Delusional symptoms did not predict readmission for any patient group.

An international comparison of physicians' judgments of outcome rates of cardiac procedures and attitudes toward risk, uncertainty, justifiability, and regret.

OBJECTIVE: Compare U.K. and U.S. physicians' judgments of population probabilities of important outcomes of invasive cardiac procedures; and values held by them about risk, uncertainty, regret, and justifiability relevant to utilization of cardiac treatments. DESIGN: Cross-sectional study. SETTING: University hospital and VA medical center in the United States; two teaching hospitals in the United Kingdom. PARTICIPANTS: 171 housestaff and attendings at U.S. teaching hospitals; 51 physician trainees and consultants at U.K. hospitals. MEASURES: Judgments of probabilities of severe complications and deaths due to Swan-Ganz catheterization, cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG); judgments of malpractice risks for case vignettes; Nightingale's risk-aversion instrument; Gerrity's reaction-to-uncertainty instrument; questions about need to justify decisions; responses to case vignettes regarding regret. RESULTS: The U.S. physicians judged rates of two bad outcomes of cardiac procedures (complications due to cardiac catheterization; death due to CABG) to be significantly higher (p < or = 0.01) than did the U.K. physicians (U.S. medians, 5 and 3.5, respectively; U.K. medians 3 and 2). The median ratio of (risk of malpractice suit I error of omission)/(risk of suit I error of commission) judged by U.K. physicians, 3, was significantly (p=0.0006) higher than that judged by U.S. physicians, 1.5. The U.K. physicians were less often risk-seeking in the context of possible losses than the U.S. physicians (odds ratio for practicing in the U.K. as a predictor of risk seeking 0.3, p=0.003). The U.K. physicians had significantly more discomfort with uncertainty than did the U.S. physicians, as reflected by higher scores on the stress scale (U.K. median 48, U.S. 42, p=0.0001) and the reluctance-to-disclose-uncertainty scale (U.K. 40, U.S. 37, p < 0.0001) of the Gerrity instrument. There was no clear international difference in perceived need to justify decisions, or in regret. CONCLUSIONS: The results were not clearly consistent with the uncertainty hypothesis that international practice variation is due to differences in judged rates of outcomes of therapy or with the imperfect-agency hypothesis that practice variation is due to differences in physicians' personal values. The causes and implications of practice variations remain unclear.

Training tomorrow's clinicians today--managed care essentials: a process for curriculum development.

OBJECTIVE: To develop a managed care curriculum for primary care residents. DESIGN: This article outlines a 4-stage curriculum development process focusing on concepts of managed care organization and finance. The stages consist of: (1) identifying the curriculum development work group and framing the scope of the curriculum, (2) identifying stakeholder buy-in and expectations, (3) choosing curricular topics and delivery mechanisms, and (4) outlining the evaluation process. Key elements of building a curriculum development team, content objectives of the curriculum, the rationale for using problem-based learning, and finally, lessons learned from the partnership among the stakeholders are reviewed. RESULTS: The curriculum was delivered to an entering group of postgraduate-year 1 primary care residents. Attitudes among residents toward managed care remained relatively negative and stable over the yearlong curriculum, especially over issues relating to finance, quality of care, control and autonomy of practitioners, time spent with patients, and managed care's impact on the doctor-patient relationship. Residents' baseline knowledge of core concepts about managed care organization and finance improved during the year that the curriculum was delivered. Satisfaction with a problem-based learning approach was high. CONCLUSION: Problem-based learning, using real-life clinical examples, is a successful approach to resident instruction about managed care.

Bright light therapy: improved sensitivity to its effects on rest-activity rhythms in Alzheimer patients by application of nonparametric methods.

Sleep-wake rhythm disturbances in patients with Alzheimer's disease (AD) make a strong demand on caregivers and are among the most important reasons for institutionalization. Several previous studies reported that the disturbances improve with increased environmental light, which, through the retinohypothalamic tract, activates the suprachiasmatic nucleus (SCN), the biological clock of the brain. The data of recently published positive and negative reports on the effect of bright light on actigraphically assessed rest-activity rhythms in demented elderly were reanalyzed using several statistical procedures. It was demonstrated that the light-induced improvement in coupling of the rest-activity rhythm to the environmental zeitgeber of bright light is better detected using nonparametric procedures. Cosinor, complex demodulation, and Lomb-Scargle periodogram-derived variables are much less sensitive to this effect because of the highly nonsinusoidal waveform of the rest-activity rhythm. Guidelines for analyses of actigraphic data are given to improve the sensitivity to treatment effects in future studies.

Knowledge of mental health benefits and preferences for type of mental health providers among the general public.

OBJECTIVE: The study explored knowledge of mental health benefits and preferences for providers among the general public. METHODS: Analysis was based on a telephone survey of 1,358 adults randomly sampled throughout Michigan in 1997-1998. RESULTS: A large proportion of the respondents were uninformed about their mental health benefits. One-quarter of the sample were unsure if their health plan even included mental health services. Forty-three percent of the sample believed that mental health benefits were equal to benefits provided for general medical services. In answer to a survey question that summarized payment restrictions for psychiatric services and counseling under Medicare, nearly a quarter of older respondents indicated that they would not seek care even when needed. In the overall sample, the majority of respondents said they would initially seek care from their primary care physician for a mental health problem, although responses varied by age. Persons over age 65 were significantly more likely to seek assistance from their primary care doctor than were younger persons. CONCLUSIONS: The general public lacks information about important mental health benefits, and this lack of information may represent a barrier in their seeking care when needed. Given the overriding preference for primary care providers to treat mental health problems, particularly among older adults, mental health issues should be given more attention at all levels of primary care education.

Assessing and treating anxiety in elderly persons.

Although anxiety disorders appear to occur less frequently in elderly persons, subsyndromal anxiety and anxiety associated with other medical and psychiatric disorders are significant sources of morbidity. Theories of etiology of anxiety range from the psychodynamic to the neurobiologic. Treatment of anxiety syndromes hinges on a thorough diagnostic evaluation, with attention to the tendency of older adults to prefer somatic descriptors and to view psychiatric illness as stigmatizing. The efficacy of nonpharmacologic treatment strategies such as relaxation training and psychotherapy for elderly anxious patients has not been well researched, but these interventions have been reasonably successful with younger adult populations and avoid the potential for harmful side effects of medication. Pharmacologic treatment strategies can be effective when used with appropriate caution.

Using case vignettes to train clinicians and utilization reviewers to make level-of-care decisions.

Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function. This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Substance dependence and the use of pro re nata anxiolytic/hypnotic drugs in a hospital setting.

Patients hospitalized for treatment of psychiatric illness commonly receive pro re nata (p.r.n.) anti-anxiety and hypnotic agents. The relationship between illicit drug use and p.r.n. anti-anxiety/hypnotic drug use in hospitalized psychiatric patients has not been extensively examined. The purpose of the present study was to examine this relationship. A retrospective review of 99 randomly selected hospitalized patients abstracted information regarding the utilization of p.r.n. anxiolytic and hypnotic medications. Seventy percent of the patients surveyed evidenced substance dependence. The substance users utilized p.r.n. anxiolytics (t = 2.29, df = 81, p < .05) and bedtime hypnotics (t = 4.23, df = 90, p < .0001) more frequently than the nonusers. Hospitalized substance abusers appear to continue their substance abuse in the hospital, substituting prescription preparations for illicit drugs. Nevertheless, cumulative literature now suggests that p.r.n. anxiolytic and hypnotic agents play a critical role in the management of aggressive behavior and insomnia in patients hospitalized with psychiatric illness.

Managed Medicare: an overview for the primary care physician.

Medicare is looking to managed care to help solve its financial burden. Because managed care plans offer a number of advantages for Medicare enrollees, the number of plans and of enrollees are increasing dramatically. With some exceptions, the Medicare population appears to do as well or better in HMOs as in fee-for-service care, despite differences in utilization of services. For the primary care physician, the key to success in managed Medicare is finding and aggressively managing your frail or near frail patients. Basic tools for survival are the use of prevention strategies, screening of enrollees and targeting for needed services, geriatric assessment, use of alternate care settings to avoid or limit costly hospital care, and monitoring of medication use for compliance and adverse reactions.

Mental health services in managed care: quality questions remain.

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.