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BACKGROUND: In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. METHODS: We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. RESULTS: Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. CONCLUSION: Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.
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Transtornos Relacionados ao Uso de Opioides , População Rural , Humanos , Estados Unidos , Masculino , Adulto , Feminino , Pesquisa Qualitativa , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estigma SocialRESUMO
AIM: Barriers to retention in inpatient and residential care for persons who use drugs are understudied in the rural context. We sought to better understand barriers to retention in inpatient and residential drug treatment in a large, multi-site, geographically diverse sample of persons who use opioids and/or injection drugs in the rural U.S. METHODS: We conducted semi-structured individual interviews with persons currently using opioids and/or injection drugs in 9 U.S. states, including Illinois, Kentucky, Massachusetts, North Carolina, New Hampshire, Ohio, Oregon, Vermont, and Wisconsin. Content areas included substance use history and experiences with all modalities of drug treatment. We performed initial structural coding followed by an iterative "open-coding" process of itemizing and categorizing content within each code, and a multi-coder memoing process to summarize themes. We identified themes using three levels of the Social-Ecological Model (SEM): individual, interpersonal, and facility-level (organizational) barriers. RESULTS: Among 304 interviewed, over half (n = 166, 54 %) reported having experienced inpatient and residential treatment. Lack of treatment retention was driven by interrelated factors at all levels of the SEM. Person-level factors inhibiting retention included lack of readiness to stop using, which was particularly true for court-ordered treatment, and dislike of "freedom limitations". The sole interpersonal-level factor was the influence of other patients on re-initiation of drug use. Facility-level barriers included unaddressed withdrawal symptoms and lack of access to MOUD, staff relatability, inadequate staff training, and, particularly in residential treatment, lack of structure and supervision. Lack of preparation for coping with real-world triggers was seen as a barrier to engagement in ongoing treatment. CONCLUSION: Barriers to retention in inpatient and residential substance use treatment were present at three levels of the SEM. Interviews suggest much room for improvement in inpatient and residential drug treatment programs with respect to improving access to MOUD, tailoring content to better address social challenges in the rural context, and improving quality control measures with respect to staff and resident supervision.
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BACKGROUND: Illicit drug abuse causes much morbidity and mortality, yet little is known about physicians' screening and intervention practices regarding illicit drug abuse. METHODS: We mailed a survey to a national sample of 2000 practicing general internists, family physicians, obstetricians and gynecologists, and psychiatrists to assess their screening and intervention practices for illicit drug abuse. RESULTS: Of 1082 respondents (adjusted response rate, 57%), 68% reported that they regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55% reported that they routinely offer formal treatment referral, but 15% reported that they do not intervene. In multivariate logistic regression models, more optimal screening and intervention practices were associated with psychiatry specialty, confidence in obtaining the history of drug use, optimism about the effectiveness of therapy, less concern that patients will object, and fewer perceived time constraints. CONCLUSIONS: Most physicians reported that they ask patients about illicit drug use, but a substantial minority inadequately intervene in diagnosed drug abuse. Initiatives to promote physician involvement in illicit drug abuse should include strategies to increase physicians' confidence in managing drug problems, engender optimism about the benefits of treatment, dispel concerns about patients' sensitivity regarding substance use, and address perceived time limitations.
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Anamnese/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Psiquiatria/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Coleta de Dados , Medicina de Família e Comunidade/estatística & dados numéricos , Feminino , Ginecologia/estatística & dados numéricos , Humanos , Medicina Interna/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obstetrícia/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND: Neurologic complaints are common in adults infected with the human immunodeficiency virus, but little is known about which clinical features are associated with secondary causes of meningitis. METHODS: A retrospective cross-sectional study of adults infected with the human immunodeficiency virus who received a diagnostic lumbar puncture (LP) in the infectious disease clinic, emergency department, and inpatient wards of the Deaconess Hospital, Boston, Mass, from 1989 through 1992 to determine which clinical features available at the time of LP are correlated with definite or probable secondary meningitis. RESULTS: Of the 491 LPs, 90% were performed in whites, 93% in men, and 11% in injection drug users. Cerebrospinal fluid test results revealed secondary meningitis in 39 (7.9%) of 491 LPs performed on 322 individuals. Cryptococcal meningitis was the predominant type (27 cases); no bacterial or tuberculous meningitis was found. In multivariate analyses, a history of non-Hodgkin's lymphoma (adjusted odds ratio [OR], 4.3; 95% confidence interval [CI], 1.5 to 12.5), a history of herpes simplex virus infection (OR, 2.5; 95% CI, 1.2 to 5.0), nausea and/or vomiting (OR, 2.0; 95% CI, 1.03 to 4.0), headache in a person with the acquired immunodeficiency syndrome (OR, 2.1; 95% CI, 1.03 to 4.4), and cranial nerve abnormalities (OR, 5.1; 95% CI, 1.8 to 14.1) were positive correlates of opportunistic meningitis; current fluconazole use (OR, 0.3; 95% CI, 0.1 to 0.8) conferred a lower risk. CONCLUSION: In similar clinical settings, physicians and their human immunodeficiency virus-infected patients should consider these features when assessing the risk of secondary meningitis and the necessity for immediate LP.
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Infecções Oportunistas Relacionadas com a AIDS , Meningite/virologia , Adulto , Estudos Transversais , Feminino , Infecções por HIV/complicações , Humanos , Masculino , Prevalência , Estudos Retrospectivos , Sensibilidade e Especificidade , Punção EspinalRESUMO
This study examined the extent to which social relationships were associated with continued injection drug use and needle sharing among 252 methadone maintenance patients. Logistic regression analyses indicated that drug use was highest among persons who had a substance using live-in partner and among those with more drug-using social relationships. Among injectors, whites and those who had more people present during IV drug use were more likely to share needles, while those with more emotional support were less likely to do so. These findings suggest that personal relationships strongly influence continued injection drug use and that methadone programs should help patients develop social networks of non-users.
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Dependência de Heroína/tratamento farmacológico , Dependência de Heroína/psicologia , Metadona/uso terapêutico , Uso Comum de Agulhas e Seringas/psicologia , Abuso de Substâncias por Via Intravenosa/psicologia , Adulto , Análise de Variância , Feminino , Humanos , Relações Interpessoais , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Rhode Island , Apoio Social , Centros de Tratamento de Abuso de SubstânciasRESUMO
OBJECTIVE: To examine the extent to which linkage mechanisms (on-site delivery, external arrangements, case management, and transportation assistance) are associated with increased utilization of medical and psychosocial services in outpatient drug abuse treatment units. DATA SOURCES: Survey of administrative directors and clinical supervisors from a nationally representative sample of 597 outpatient drug abuse treatment units in 1995. STUDY DESIGN: We generated separate two-stage multivariate generalized linear models to evaluate the correlation of on-site service delivery, formal external arrangements (joint program/venture or contract), referral agreements, case management, and transportation with the percentage of clients reported to have utilized eight services: physical examinations, routine medical care, tuberculosis screening, HIV treatment, mental health care, employment counseling, housing assistance, and financial counseling services. PRINCIPAL FINDINGS: On-site service delivery and transportation assistance were significantly associated with higher levels of client utilization of ancillary services. Referral agreements and formal external arrangements had no detectable relationship to most service utilization. On-site case management was related to increased clients' use of routine medical care, financial counseling, and housing assistance, but off-site case management was not correlated with utilization of most services. CONCLUSIONS: On-site service delivery appears to be the most reliable mechanism to link drug abuse treatment clients to ancillary services, while referral agreements and formal external mechanisms offer little detectable advantage over ad hoc referral. On-site case management might facilitate utilization of some services, but transportation seems a more important linkage mechanism overall. These findings imply that initiatives and policies to promote linkage of such clients to medical and psychosocial services should emphasize on-site service delivery, transportation and, for some services, on-site case management.
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Instituições de Assistência Ambulatorial/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Instituições de Assistência Ambulatorial/organização & administração , Administração de Caso/organização & administração , Estudos Transversais , Feminino , Humanos , Masculino , Serviços de Saúde Mental/organização & administração , Modelos Organizacionais , Análise Multivariada , Atenção Primária à Saúde/organização & administração , Análise de Regressão , Serviço Social/organização & administração , Centros de Tratamento de Abuso de Substâncias/organização & administração , Meios de Transporte , Estados UnidosRESUMO
BACKGROUND: When human immunodeficiency virus (HIV)-infected patients present with neurologic problems, lumbar puncture and cerebrospinal fluid (CSF) analysis are often performed, usually to rule-out the presence of meningitis. However, the test characteristics of CSF analyses in this population are unknown. METHODS: To examine the diagnostic characteristics of CSF analyses for secondary causes of meningitis in HIV-infected adults, we performed a case-control study of 322 HIV-infected adults who received diagnostic lumbar puncture in an urban academic hospital from 1989 to 1992. Using multivariable logistic regression analyses, we determined the independent CSF correlates of cryptococcal and other types of secondary meningitis. RESULTS: Eighty percent were men who had sex with men, 89% were white, and 85% had AIDS. Thirty-seven case-subjects had a secondary cause of meningitis though none had bacterial or tuberculous meningitis. Excluding the india ink as a candidate variable, logistic regression analysis identified 2 independent CSF correlates of secondary meningitis: the leukocyte count (odds ratio [OR] per 10 cells, 1.2; 95% confidence interval [CI], 1.1 to 1.3), and the CSF-to-serum glucose ratio (OR per 0.10 units, 0.61; CI, 0.43 to 0.88). The areas (+/- SD) under the receiver operating characteristic curves were 0.76 +/- 0.05 and 0.72 +/- 0.05, respectively. CONCLUSIONS: In similar clinical settings, these findings may help clinicians assess the probability of secondary meningitis in HIV-infected patients when initial CSF results first become available.
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Infecções por HIV/líquido cefalorraquidiano , Meningite/líquido cefalorraquidiano , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Funções Verossimilhança , Masculino , Meningite/diagnóstico , Pessoa de Meia-Idade , Análise MultivariadaRESUMO
OBJECTIVES: To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes. METHODS: The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study. RESULTS: Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death. CONCLUSIONS: Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life.
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Revisão de Uso de Medicamentos/normas , Serviço Hospitalar de Emergência/normas , Erros de Medicação/estatística & dados numéricos , Ferimentos e Lesões/complicações , Acidentes por Quedas/prevenção & controle , Acidentes por Quedas/estatística & dados numéricos , Idoso , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/tratamento farmacológico , Chicago , Estudos de Coortes , Complicações do Diabetes , Diabetes Mellitus/tratamento farmacológico , Interações Medicamentosas , Revisão de Uso de Medicamentos/estatística & dados numéricos , Revisão de Uso de Medicamentos/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitais Universitários , Humanos , Incidência , Estudos Longitudinais , Masculino , Úlcera Péptica/complicações , Úlcera Péptica/tratamento farmacológico , Estudos Prospectivos , Qualidade da Assistência à Saúde , Qualidade de Vida , Doenças Respiratórias/complicações , Doenças Respiratórias/tratamento farmacológico , Medição de Risco , População UrbanaRESUMO
To determine whether certain types of transportation assistance improve outpatient treatment retention beyond thresholds shown to have therapeutic benefits, we analyzed data from 1,144 clients in 22 outpatient methadone maintenance (OMM) programs and 2,031 clients in 22 outpatient drug-free (ODF) programs in the Drug Abuse Treatment Outcomes Study (DATOS), a national, 12-month, longitudinal study of drug abuse treatment programs. Directors' surveys provided information about provision of car, van, or contracted transportation services or individual vouchers/payment for public transportation. Chart-abstracted treatment retention was dichotomized at 365 days for OMM and 90 days for ODF. Separate multivariate hierarchical linear models revealed that provision of car, van, or contracted transportation services improved treatment retention beyond these thresholds for both OMM and ODF, but individual vouchers or payment for public transportation did not. Future research should validate whether car, van, or contracted transportation services improve retention and other treatment outcomes in outpatient drug abuse treatment.
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Assistência Ambulatorial , Centros de Tratamento de Abuso de Substâncias , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Transporte de Pacientes/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Cooperação do Paciente , Pacientes Desistentes do Tratamento , Resultado do TratamentoRESUMO
Primary care and mental health services improve drug abuse treatment clients' health and treatment outcomes. To examine the association between clients' access to these services and the characteristics of drug treatment organizations, we analyze data from a national survey of the unit directors and clinical supervisors of 618 outpatient drug abuse treatment programs in 1995 (88% response rate). In multivariate models controlling for client characteristics and urban location, public units, units with more human resources, and methadone programs delivered more primary care services. Public units, Joint Commission on Accreditation of Health Care Organizations-accredited units, nonmethadone units, and units with more staff psychiatrists or psychologists delivered more mental health services. We conclude that organizational factors may influence drug abuse treatment clients' access to primary care and mental health services. Changes in the treatment system that weaken or eliminate public programs, over-burden staff, de-emphasize quality standards or lessen methadone availability may erode recovering clients' tenuous access to these services.
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Acessibilidade aos Serviços de Saúde , Atenção Primária à Saúde/organização & administração , Centros de Tratamento de Abuso de Substâncias/organização & administração , Estudos Transversais , Necessidades e Demandas de Serviços de Saúde , Inquéritos Epidemiológicos , Humanos , Análise MultivariadaRESUMO
OBJECTIVE: This study was undertaken to determine the diagnostic test characteristics of the alcohol screening strategy recommended in the National Institute on Alcoholism and Alcohol Abuse (NIAAA) "Physicians' Guide to Helping Patients with Alcohol Problems." METHOD: A research interview was performed on patients who presented to one urban emergency department (N = 395; 61% women). It asked three alcohol consumption questions, the CAGE questionnaire, and about past alcohol problems. The NIAAA-recommended screen was considered positive for alcohol consumption in excess of 14 drinks per week or 4 drinks per occasion for men, or 7 drinks per week or 3 drinks per occasion for women, or a CAGE score of 1 or greater. A sample of patients (n = 250) received the Composite International Diagnostic Interview substance abuse module, a gold standard interview, to determine lifetime or prior 12-month alcohol abuse or dependence; results were adjusted for verification bias. RESULTS: The prevalence of lifetime:alcohol abuse or dependence was 13%, for which the NIAAA strategy was 81% sensitive and 80% specific. The prevalence of alcohol abuse or dependence in the prior 12 months was 10%, for which the strategy was 83% sensitive and 84% specific. Its positive likelihood ratio exceeded that of the CAGE, augmented CAGE or consumption questions alone, and its negative likelihood ratio was the lowest. CONCLUSIONS: The screening strategy combining alcohol consumption and CAGE questions recommended in the NIAAA "Physicians' Guide" is valid, and has superior test characteristics compared to the CAGE alone, in this predominantly black (86%) emergency department population. Its brevity and simple interpretation recommend wider dissemination of the NIAAA "Physicians' Guide," although future research should examine its test characteristics in other clinical settings and with other populations.
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Alcoolismo/diagnóstico , Guias de Prática Clínica como Assunto , Detecção do Abuso de Substâncias/métodos , Inquéritos e Questionários , Adolescente , Adulto , Alcoolismo/epidemiologia , Intervalos de Confiança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , National Institutes of Health (U.S.) , Reprodutibilidade dos Testes , Detecção do Abuso de Substâncias/normas , Detecção do Abuso de Substâncias/estatística & dados numéricos , Estados UnidosRESUMO
Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between these units' organizational features and the degree to which they provided onsite primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with more dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services.
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Assistência Ambulatorial , Equipe de Assistência ao Paciente , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Adolescente , Adulto , Idoso , Criança , Terapia Combinada , Estudos Transversais , Diagnóstico Duplo (Psiquiatria) , Feminino , Infecções por HIV/prevenção & controle , Infecções por HIV/psicologia , Humanos , Masculino , Transtornos Mentais/psicologia , Transtornos Mentais/reabilitação , Metadona/uso terapêutico , Pessoa de Meia-Idade , Atenção Primária à Saúde , Transtornos Relacionados ao Uso de Substâncias/psicologia , Estados UnidosRESUMO
Patients recovering from substance use disorders are commonly seen in the primary care setting, and relapse is a serious long-term problem for these patients. Extrapolating from therapeutic strategies effective in specialty addiction treatment settings, this article outlines a practical approach to relapse prevention in the primary care setting. Working within a supportive patient-physician relationship, the primary care physician can help recovering patients decrease their susceptibility to relapse, recognize and manage high-risk situations, and use available self-help, pharmacological, and specialty resources. Drawing on the therapeutic relationship and skills they already possess, primary care physicians can have an important, productive, and satisfying role in the long-term management of patients in recovery from alcohol or other drug problems.
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Alcoolismo/prevenção & controle , Medicina de Família e Comunidade , Papel do Médico , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Adulto , Alcoolismo/terapia , Terapia Combinada , Humanos , Relações Médico-Paciente , Grupos de Autoajuda , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
OBJECTIVE: To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication. DESIGN: Survey of a national systematic sample of physicians. PARTICIPANTS: Five hundred family practitioners, 500 general internists, and 500 cardiologists. MEASUREMENTS AND MAIN RESULTS: Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%). CONCLUSIONS: Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.
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Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Cardiologia , Competência Clínica , Revisão de Uso de Medicamentos , Medicina de Família e Comunidade , Insuficiência Cardíaca/tratamento farmacológico , Medicina Interna , Adulto , Idoso , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Feminino , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Estados UnidosRESUMO
BACKGROUND: To determine if sex-risk days are also alcohol use days for active injection drug users. METHODS: Cross-sectional interview of 187 active injection drug users who scored positively (> or =8) on the Alcohol Use Disorders Identification Test who were recruited between February 1998 and October 1999 from a needle exchange program in Providence, Rhode Island. A sex-risk day was defined as "vaginal sex, anal sex or oral sex without a condom," measured by using a 30 day timeline follow-back procedure. RESULTS: The sample was 64% male and 87% white, and 85% met DSM-IV criteria for alcohol abuse/dependence. Of the total days analyzed (n = 5610), 19% were sex-risk days; on 52% of these days drinking also occurred. By using a generalized estimating equation model to cluster by subject, alcohol use was associated with sex-risk days (odds ratio, 1.76; 95% confidence interval, 1.35-2.29; p < 0.001), when we controlled for gender, age, race, education, cocaine use, injection frequency, exchanging sex for money or drugs, number of sexual partners, and perceived sexual risk of acquiring human immunodeficiency virus from partners. CONCLUSIONS: Alcohol use is associated with sex risk-taking behavior among injection drug users. A substantial majority of participants reported using alcohol before or during sexual relations, which temporally links alcohol use with human immunodeficiency virus injection risk.
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Consumo de Bebidas Alcoólicas , Programas de Troca de Agulhas/estatística & dados numéricos , Sexo Seguro , Abuso de Substâncias por Via Intravenosa/psicologia , Adulto , Estudos Transversais , Feminino , Humanos , MasculinoRESUMO
OBJECTIVE: To describe adult primary care physicians' and psychiatrists' approach to alcohol screening and treatment, and to identify correlates of more optimal practices. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry. MEASUREMENTS: Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales. MAIN RESULTS: Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object. CONCLUSIONS: Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols or offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians' screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement
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Alcoolismo/diagnóstico , Alcoolismo/prevenção & controle , Medicina de Família e Comunidade , Inquéritos Epidemiológicos , Psiquiatria , Adulto , Alcoolismo/epidemiologia , Estudos Transversais , Medicina de Família e Comunidade/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Relações Médico-Paciente , Psiquiatria/métodos , Estudos Retrospectivos , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To compare generalists' and cardiologists' estimates of baseline cardiovascular risk and the outcomes of preventive therapy. DESIGN: Cross-sectional mail survey using written case simulations of typical patients from primary prevention trials for hypercholesterolemia and isolated systolic hypertension, and tertiary prevention studies of coronary artery bypass surgery for chronic stable angina with left main coronary stenosis. PARTICIPANTS: Nationally representative sample of 599 practicing family physicians, general internists, and cardiologists selected from the American Medical Association masterfile. Among eligible physicians, 84 (44%) of 191 family physicians, 77 (40%) of 194 general internists, and 66 (34%) of 194 cardiologists responded. MEASUREMENTS: Estimates of risk at baseline and after therapy, and whether therapy generally would be recommended. RESULTS: For both primary prevention case simulations (scenarios), cardiologists provided lower, more accurate estimates of baseline cardiovascular risk and of absolute therapeutic benefit than either family physicians or general internists. The range of the generalists' estimates was extremely wide. Perceptions of relative risk reduction and treatment recommendations for the primary prevention scenarios did not differ among specialties. Overall, generalists who would not recommend primary preventive therapy in these scenarios appeared to give more accurate estimates than did generalists who would recommend such therapy. CONCLUSIONS: Many generalists have inflated perceptions of cardiovascular risk without treatment and of the benefit of risk-modifying medical treatment. Further study should assess the reasons for these misperceptions and their effect on counseling about primary preventive therapy.
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Cardiologia , Doenças Cardiovasculares/etiologia , Medicina de Família e Comunidade , Conhecimentos, Atitudes e Prática em Saúde , Medicina Interna , Avaliação de Processos e Resultados em Cuidados de Saúde , Adulto , Idoso , Angina Pectoris/complicações , Angina Pectoris/cirurgia , Ponte de Artéria Coronária , Doença das Coronárias/complicações , Doença das Coronárias/cirurgia , Estudos Transversais , Humanos , Hipercolesterolemia/complicações , Hipercolesterolemia/tratamento farmacológico , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Pessoa de Meia-Idade , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
The purpose of this study to determine predictors of revisit, hospital admission, or death among older patients discharged from the emergency department (ED). We performed a prospective study of patients aged 65 or older in an urban ED. The primary outcomes were ED revisit, hospital admission, or death 30 or 90 days after discharge from an index ED visit. Of the 463 eligible patients, 75 (16%) experienced ED revisit, hospitalization, or death within 30 days, and 125 (27%) within 90 days. In multivariate proportional hazards models, physical functioning and mental health in the lowest tertile, and lack of supplemental insurance predicted revisit, hospitalization, or death within 30 days after ED discharge. Poor physical functioning, missing mini-mental state examination, comorbidity, and ambulance transport to the initial ED visit predicted 90-day outcome. Problems with physical functioning, mental health and supplemental insurance are potentially remediable precursors of early morbidity among older patients after ED discharge. Future research should examine whether addressing these issues among the elderly population will lessen ED return visits, hospitalization, and mortality.
Assuntos
Serviço Hospitalar de Emergência , Serviços de Saúde para Idosos , Mortalidade , Avaliação das Necessidades , Readmissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Chicago/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Análise Multivariada , Áreas de Pobreza , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population. OBJECTIVES: The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs. RESEARCH DESIGN: This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview. MEASURES: Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment. RESULTS: Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001). CONCLUSIONS: Exclusive on-site delivery of medical services increased drug abuse treatment patients' utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.
Assuntos
Acessibilidade aos Serviços de Saúde/organização & administração , Relações Interinstitucionais , Encaminhamento e Consulta/organização & administração , Centros de Tratamento de Abuso de Substâncias/organização & administração , Transtornos Relacionados ao Uso de Substâncias/terapia , Cuidado Periódico , Seguimentos , Humanos , Modelos Lineares , Avaliação de Resultados em Cuidados de Saúde , Satisfação do Paciente , Estudos Prospectivos , Inquéritos e Questionários , Meios de Transporte , Estados UnidosRESUMO
STUDY OBJECTIVES: We sought to assess older patients' satisfaction with care in the emergency department and to identify factors associated with global satisfaction with care. METHODS: We performed a prospective cohort study of 778 patients 65 years of age and older presenting to an urban academic ED between 1995 and 1996, of whom 79% were black and 63% were female. A baseline survey at presentation to the ED asked for demographic information, medical history, and health-related quality of life information. A follow-up satisfaction survey asked patients to rate the care they received in the ED on a 5-point Likert scale (1=excellent, 5=poor). Overall satisfaction with care, dichotomized into responses of "excellent" versus all others, was the primary dependent variable in our bivariate analyses. RESULTS: Of respondents, 40% rated their ED care as "excellent." Variables significantly correlated with high satisfaction include having the perception of time spent in the ED as not "too long," having the emergency physicians and nurses clearly answer patients' questions, having a relationship of trust with an ED staff member, being told why tests were done, feeling involved in decisions about care as much as they wanted, having pain addressed fully, having a perception of greater health status, and having fewer comorbid conditions at the time of the ED visit. Results may be applicable only to urban academic EDs and may be limited by time elapsed between ED visits and follow-up surveys. CONCLUSION: To improve quality of care for older adults in the ED, physicians should be more attentive to older patients' concerns and questions, recognize and aggressively treat pain, and reduce the patients' perception of a long waiting time.