Publications

OBJECTIVE

To investigate family physicians' and pediatricians' practice of and perceived barriers to smoking cessation counseling among patients 18 years and younger.

DESIGN

Cross-sectional mail survey conducted between November 1, 1997, and January 31, 1998.

PARTICIPANTS

A stratified random sample selected from the 1997 American Medical Association Physician Masterfile of 1000 family physicians and pediatricians who practice in urban California, work at least 10% of the time in ambulatory care, and have at least 10% of patients 18 years and younger.

MAIN OUTCOME MEASURES

Physicians' adherence to 5 components of the National Cancer Institute's smoking cessation counseling recommendations (anticipate, ask, advise, assist, and arrange) and their perceived barriers to smoking cessation counseling.

RESULTS

A total of 429 physicians participated in the study. Physicians of both specialties were more likely to anticipate, ask, and advise patients about smoking than to assist with and arrange cessation activities. Family physicians were more likely than pediatricians to assist and arrange, including scheduling follow-up visits to discuss quitting (25.1% vs 11.7%; odds ratio [OR], 3.07; 95% confidence interval [CI], 1.22-7.73) and directing nursing staff to counsel patients (17.1% vs 10.9%; OR, 3.70; 95% CI, 1.30-10.60). The most common perceived barrier to counseling was the belief that children would provide inaccurate responses due to either the presence of parents (86.4%) or the fear that parents would be notified of their answers (74.0%). Pediatricians reported lack of counseling skills as a barrier to providing smoking interventions in greater proportion than did family physicians (24.9% vs 54.8%; OR, 0.29; 95% CI, 0.14-0.63; P<.001).

CONCLUSION

Improvement in smoking cessation counseling skills and practices is needed among physicians treating children and adolescents.

Intrahepatic cholestasis, or impairment of bile flow, is an important manifestation of inherited and acquired liver disease. In recent years, human genetic and molecular studies have identified several genes, the disruption of which results in cholestasis. ATP8B1 (FIC1), ABCB11 (BSEP), and ABCB4 (MDR3) are disrupted in forms of progressive familial intrahepatic cholestasis (PFIC) and related disorders. Mutations in BAAT, TJP2 (ZO-2), and EPHX1 have been identified in patients with hypercholanemia. A CLDN1 mutation was recently reported in patients with ichthyosis, leukocyte vacuoles, alopecia and sclerosing cholangitis (ILVASC), and North American Indian childhood cirrhosis (NAIC) is associated with a missense mutation in CIRH1A. Alagille syndrome patients carry mutations in JAG1, and mutations in VPS33B have been identified in patients with arthrogryposis, renal dysfunction and cholestasis syndrome (ARC). Identification of these genes, and characterization of the proteins they encode, is enhancing our understanding of the biology of the enterohepatic circulation in health and disease.

BACKGROUND

Sexually transmitted infections (STI) are common in developing countries. The World Health Organisation (WHO) estimates that in 1999, 340 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred. Human immunodeficiency virus (HIV) infection is also common in developing countries. UNAIDS estimates that over 95% of the 40 million people infected with HIV by December 1999 live in developing countries (UNAIDS 2003). The STI and HIV epidemics are interdependent. Similar behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of both infections, and there is clear evidence that conventional STIs increase the likelihood of HIV transmission. Several studies have demonstrated a strong association between both ulcerative and non-ulcerative STIs and HIV infection (Cameron 1989, Laga 1993). There is biological evidence, too, that the presence of an STI increases shedding of HIV, and that STI treatment reduces HIV shedding (Cohen 1997, Robinson 1997). Therefore, STI control may have the potential to contribute substantially to HIV prevention.

OBJECTIVES

To determine the impact of population-based STI interventions on the frequency of HIV infection, frequency of STIs and quality of STI management.

SEARCH STRATEGY

The following electronic databases were searched for relevant randomised trials or reviews:1) MEDLINE for the years 1966 to 2003 using the search terms "sexually transmitted diseases" and "human immunodeficiency virus infection"2) The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register, in the most recent issue of the Cochrane Library3) The specialist registry of trials maintained by the Cochrane Infectious Diseases Group.4) EMBASE The abstracts of relevant conferences were searched, and reference lists of all review articles and primary studies were scanned. Finally, authors of included trials and other experts in the field were contacted as appropriate.

SELECTION CRITERIA

Randomised controlled trials in which the unit of randomisation is either a community or a treatment facility. Studies where individuals are randomised were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. Trials were examined for completeness of reporting. The methodological quality of each trial was assessed by the same two reviewers, with details recorded of randomisation method, blinding, use of intention-to-treat analysis and the number of patients lost to follow-up, using standard guidelines of the Cochrane Infectious Diseases Group.

MAIN RESULTS

Five trials were included. Frequency of HIV infection: In Rakai, after 3 rounds of treatment of all community members for STIs, the rate ratio of incident HIV infection was 0.97 (95%CI 0.81 to 1.16), indicating no effect of the intervention. In Mwanza, the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (OR=0.58, 95% CI 0.42-0.70), corresponding to a 38% reduction (95%CI 15% to 55%) in HIV incidence in the intervention group. In the newest trial by Kamali et al, the rate ratio of behavioral intervention & STI management compared to control on HIV incidence was 1.00 (0.63-1.58, p=.98). These are consistent with Rakai data showing no effect of intervention. Frequency of STIs: In both Mwanza and Rakai, there was no significant reduction in gonorrhoea, chlamydia, urethritis, or reported STI symptoms among intervention communities. The prevalence ratio of syphilis between intervention and control groups in Rakai was 0.8 (95%CI 0.71-0.89), of trichmoniasis was 0.59 (0.38-0.91), and of bacterial vaginosis was 0.87 (0.74-1.02). In Mwanza, the prevalence of serologically diagnosed syphilis in the intervention community was 5% compared with 7% in the control community at the end of the trial (adjusted re7% in the control community at the end of the trial (adjusted relative risk 0.71 (95%CI 0.54-0.93). In Kamali et al, there was a significant decrease in gonorrhoea and active syphilis cases. Rate ratio for gonorrhoea was 0.29(0.12-0.71, p=0.016), active syphilis was 0.53(0.33-0.84,p=0.016). There was a trend towards significance with intervention on the use of condoms with the last casual partner; the rate ratio was 1.27(1.02-1.56,p=0.036). Quality of treatment: In Lima, following training of pharmacy assistants in STI syndromic management, symptoms were recognised as being due to an STI in 65% of standardised simulated patients (SSPs) visiting intervention and 60% of SSPs visiting control pharmacies (p=0.35). Medication was offered without referral to a doctor in most cases (83% intervention and 78% control, p=0.61). Of those SSPs offered medication, only 1.4% that visited intervention pharmacies and only 0.7% of those that visited control pharmacies (p=0.57) were offered a recommended regimen. Similarly in only 15% and 16% of SSP visits respectively was any recommended drug offered. However, education and counseling were more likely to be given to SSPs visiting intervention pharmacies (40% vs 27%, p=0.01). No SSPs were given partner cards or condoms. In Hlabisa, following the intervention targeting primary care clinic nurses (strengthened STI syndromic management and provision of STI syndrome packets containing recommended drugs, condom, partner cards and patient information leaflets), SSPs were more likely to be given recommended drugs in intervention clinics (83% vs 12%, p<0.005) and more likely to be correctly case managed [given correct drugs, partner cards and condoms] (88% vs 50%, p<0.005). There were no significant differences in the proportions adequately counseled (68% vs 46%, p=0.06), experiencing good staff attitude (84% vs 58%, p=0.07), and being consulted in privacy (92% vs 86%, p=0.4). There was no strong evidence of any impact on treatment-seeking behaviour, utilisation of services, or sexual behaviour in any of the four trials.

REVIEWERS' CONCLUSIONS

There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. The addition of the Kamali trial to the existing evidence supports the data from the Rakai trial of no effect. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. The Kamali trial shows an increase in the use of condoms, a marker for improved risk behaviors. Further community-based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment, as well as HIV, STI and other biological endpoints.

BACKGROUND

Randomized clinical trials (RCTs) are an important source of evidence for clinical practice, but finding and applying RCT reports to care is time consuming. Publishing RCTs directly into machine-understandable "trial banks" may allow computers to deliver RCT evidence more selectively and effectively to clinicians.

METHODS

Authors of eligible RCTs published in JAMA or the Annals of Internal Medicine between January 2002 and July 2003 were invited to co-publish their trial in RCT Bank, an electronic knowledge base containing details of trial design, execution, and summary results. Trial bank staff used Bank-a-Trial, a web-based trial-bank entry tool, to enter information from the manuscript into RCT Bank, obtaining additional information as necessary from the authors.

RESULTS

The author participation rate rose from 38% to 76% after the first co-published trial was available as an example. Seven diverse RCTs are now co-published, with 14 in progress.

CONCLUSIONS

We have demonstrated proof of concept for co-publishing RCTs with leading journals into a structured knowledge base. Phase II of trial bank publishing will introduce direct author submission to RCT Bank.

PURPOSE

EyePACS is an application for communicating and archiving eye-related patient information, images, and diagnostic data. We studied how users adopted the system in diverse clinical settings.

METHODS

53 clinicians and 142 students uploaded cases over 2.5 years from 6 pilot sites: a university teaching clinic, a university glaucoma clinic, an urban private optometric practice, a rural elderly care facility, a diabetic management program, and an eye hospital in India.

RESULTS

EyePACS collected 1,122 cases. Users employed it for informal "curbside" consults in 17% of cases. Other uses of the system were: 1) to replace telephone and fax referrals to a retinal specialist (10%), 2) as part of ocular teleconsultations and diabetic retinopathy screening (31%), 3) for education via digital grand rounds and evaluation of students (32%), and 4) for research (10%).

CONCLUSION

EyePACS has been used successfully for consults and education in diverse settings. The resulting database of digital cases serves as a searchable reference for clinicians.

BACKGROUND

There is growing recognition that physician use of electronic medical records (EMRs) is critical for improving quality of care in outpatient settings.

METHODS

We inter-viewed EMR physician champions from 20 solo/small group practices to understand different types of EMR users and their EMR-related costs and benefits.

RESULTS

Interviewees differed greatly in the EMR-related benefits they generated. These differences were associated with how they used the EMR, and the amount of effort they invested in making changes to complement EMR use. We defined five types of physician EMR users: Viewers, Basic Users, Strivers, Arrivers, and System Changers. The majority of interviewees were Strivers and Arrivers, physicians who have already invested substantial time in numerous process changes that help generate EMR-related benefits.

CONCLUSIONS

Incentives and comprehensive support services for facilitating complementary process changes could be important for moving physicians from one user group to another. Additional research is needed to verify this user typology and to further define the relationship between user types and EMR-generated financial and quality benefits.

Computer-based clinical decision support systems (CDSSs) have been championed for their potential to improve health-care quality. However, there has been no systematic study of the types of CDSSs that have been developed. In previous work, we developed the CDSS Taxonomy for comprehensively describing the technical, workflow, and contextual characteristics of CDSSs. We now use the CDSS Taxonomy to describe outpatient CDSSs evaluated in randomized controlled trials published between 1998 and 2002. 31 studies comprising 42 CDSS systems were included in our analysis. The majority of systems used rule-based reasoning engines to "push" explicit, individualized recommendations concerning non-urgent decisions to clinicians or patients, but not both. 71% of the systems required someone to manually enter data into the system or to process the system output for use by the target decision maker. The average kappa for coding agreement was > 0.6. Our findings demonstrate that outpatient CDSSs vary greatly in design and function. Many impose a data entry or output-processing burden on clinic staff. More complete reporting of CDSS characteristics is needed in the literature.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep-ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.