信息编号11024451至11024500间共50条。
☉ 11024451:成人麻疹并发肝损害48例临床分析
摘 要 目的：探讨成人麻疹的肝脏损害。方法：回顾性分析48例成人麻疹的肝脏损害表现。结果：ELISA法检测肝功能及各项肝炎病毒学指标。结论：成人麻疹的肝脏损害发生率高及早诊断合理治疗。
关键词 成人麻疹；肝脏损害；诊断
我科自2003年3月～2005年3月收治成人麻疹56例，并发肝损害48例，现报告如下。
1 临床资料
1.1 一般资料
本组56例均为住院患者...查看详细 (1653字节)
☉ 11024452:彩色多普勒超声诊断急性阑尾炎价值
摘 要 目的：探讨彩色多普勒超声诊断急性阑尾炎价值。方法：回顾性分析经彩色多普勒超声诊断并经手术及病理证实的急性阑尾炎120例，对其声像图进行分析。结果：各类型急性阑尾炎声像图改变具有特异性。结论：彩色多普勒超声可作为急性阑尾炎的首选诊断方法，具有重要临床诊断价值。
关键词 急性阑尾炎；彩色多普勒超声；声像图
回顾性分析近四年中经我科彩色多普勒超声诊断并经手术及病理证实的120例急性阑尾炎...查看详细 (3097字节)
☉ 11024453:SpO2监测在普外科术后病人的应用
关键词 外周脉搏血氧(SpO2)监测；外科手术；并发症
动脉血氧饱和度监测是预防普外科术后呼吸系统并发症的一项重要措施，对于老年病人、继往有呼吸系统疾病、行腹部大手术的病人尤其重要。我们利用脉搏血氧监测仪对术后高危病人外周脉搏血氧(SpO2)进行监测，探讨其在普外科病人术后的应用价值及临床意义。
1 对象与方法
1.1 病例选择
选取2005年10月～2005年12月我院普外科术后病人49例...查看详细 (2788字节)
☉ 11024454:贲门癌298例治疗体会
摘 要 目的：总结贲门癌298例治疗体会。方法：自2000年～2002年采用不同径路和不同的消化道重建方式手术治疗贲门癌298例。结果：本组病人均顺利手术切除，1年、3年生存率分别为80.2%、49.3%。结论：手术干预是目前治疗贲门癌的主要手段，根据具体情况选用不同的手术方式以及熟练使用吻合器是手术成功的关键。
关键词 贲门癌；吻合器；吻合口瘘
贲门癌是常见的消化道肿瘤，我科自2000年～2002年手术治疗贲门癌298例...查看详细 (5501字节)
☉ 11024455:AF钉治疗腰椎滑脱症29例回顾分析
摘 要 目的：总结用AF钉复位固定加椎间及后外侧联合植骨融合治疗腰椎滑脱症的优点及手术适应证。方法：通过对以该方法治疗的29例腰椎滑脱症进行系统回顾和术后随访，考察其近远期治疗效果。结果：根据术后体征变化及复查X片、CT的影像变化考察其疗效，优良率达93%。结论：应用AF椎弓根钉系统提拉复位短节段固定，结合广泛植骨融合治疗多种类型腰椎滑脱，具有复位良好，固定可靠，远期效果满意等优点，在临床值得推广。
关键词 AF钉；植骨融合；腰椎滑脱
腰椎滑脱症是临床常见的以慢性腰腿痛及双下肢功能障碍为主要表现的病症,多发生于L4/5及L5S1节段...查看详细 (6064字节)
☉ 11024456:191例健康人群破伤风抗体监测结果分析
摘 要〖HTK〗目的：了解我市健康人群中破伤风抗体水平，为制定破伤风防治措施提供科学依据。方法：按照分层随机抽样的方法，抽取长子县常住人口2岁～4岁、6岁～8岁、13岁～15岁、25岁～39岁健康人群为监测对象，进行破伤风抗体水平检测。结果：共检测191份血清标本。破伤风抗体阳性率为49.21%，(94/191)，GMT为0.0279IU/ml；不同年龄组保护性抗体阳性率以12岁～14岁组最高(82%)...查看详细 (3672字节)
☉ 11024457:76例急性重症胰腺炎治疗的临床体会
摘 要 目的：探讨急性重症胰腺炎(SAP)的诊断、治疗原则及方法，以提高患者的治愈率，减少病死率及并发症的发生。方法：回顾性分析我院76例SAP的诊断和治疗方法及其对病死率和并发症发生率的影响。结果：76例中，治愈58例(76.3%)、死亡18例(23.7%)。手术治疗组24例，死亡8例(33.3%)；非手术治疗组52例，死亡10例(19.2%)。本病的预后与早期诊断及治疗方法的选择密切相关。结论：彩色B超、CT检查有助于SAP的早期诊断...查看详细 (4762字节)
☉ 11024458:胆囊切除术后胆漏的原因与预防
摘 要 目的：探讨行胆囊切除术后发生胆漏的原因与预防。方法：对行胆囊切除术3 750例发生胆漏9例(0.24%)进行回顾性分析。结果：本组9例，胆囊管结扎线松脱2例；副肝管损伤4例；胆囊床肝实质肝管损伤1伤；肝总管损伤1例；胆总管损伤1例。经再次手术处理，均治愈。结论：只要在术前做好充分的准备，术中严格遵循胆囊切除术的操作规范，正确处理胆囊管和胆囊床，术后胆漏的并发症是可以避免的。
关键词 胆囊切除术；胆漏；预防
胆漏是胆囊切除术常见的严重并发症之一...查看详细 (4680字节)
☉ 11024459:产后无痛性甲状腺炎临床分析
关键词 产后甲状腺炎；自身免疫；抗甲状腺抗体
产后无痛性甲状腺炎(PPT)是一种自身免疫性甲状腺疾病，是产妇甲状腺功能异常的最主要原因。但临床表现多模糊而短暂，有明显的个体差异性，较易漏诊。现就本院2002年4月～2005年4月收治的11例产后无痛性甲状腺炎作一临床分析。
1 临床资料
1.1 一般资料
本组11例患者，年龄22岁～28岁，平均25.1岁。发病时间分别为产后1月～8月...查看详细 (3935字节)
☉ 11024460:侧脑室引流加腰穿脑脊液置换术治疗自发性脑室出血疗效观察
摘 要 目的：探讨自发性脑室出血的有效治疗方法。方法：对62例自发性脑室出血行单侧或双侧脑室外引流，术后应用尿激酶灌注，并辅以腰穿置换血性脑脊液以及其他综合治疗措施。结果：ADLⅠ(恢复正常)20例，ADLⅡ(生活自理)25例，ADLⅢ(需人帮助)9例，ADLⅣ(卧床不起)4例，ADLⅤ(植物生存)1例，死亡3例。结论：侧脑室外引流及尿激酶灌注加腰穿脑脊液置换术是治疗脑室出血安全、有效地方法。
关键词 脑室出血；侧脑室外引流；尿激酶灌注；脑脊液置换
自发性脑室出血是指有非外伤因素导致颅内血管破裂...查看详细 (3895字节)
☉ 11024461:不同吸入方式治疗小儿急性喉炎疗效对比
摘 要 目的:进一步探讨蒸汽雾化吸入和超声雾化吸入在小儿急性喉炎治疗中的疗效。方法:将2004年1月～2006年1月两年期间收治的小儿急性喉炎128例，随机分为治疗组和对照组。治疗组使用蒸汽雾化吸入,对照组使用超声雾化吸入,对治疗1d、2d后的疗效分别进行对比分析。结果：治疗1d后,治疗组：显效67.61%，有效29.58%，无效2.81%。对照组：显效26.31%，有效59.65%，无效14.04%...查看详细 (3260字节)
☉ 11024462:对产程中431例羊水胎粪污染的临床分析
摘 要 目的：探讨羊水胎粪污染的产科处理的时机与方法。方法：对2004年1月～2005年5月在我院分娩的羊水有胎粪污染的足月妊娠的产妇431例，进行回顾性分析，其中破膜时羊水粪染(A组)319例，产程中羊水由清亮变为胎粪污染(B组)112例，随机选择对同期产程中羊水清亮的430例足月妊娠的产妇作为对照组。结果：羊水胎粪污染的发生率26.34%，粪染组在母体合并症，胎监异常，脐血流异常，新生儿窒息及剖宫产率均高于对照组...查看详细 (4703字节)
☉ 11024463:第二产程中胎心异常的临床分析
摘 要 目的：探讨第二产程中胎心异常的临床意义。方法：本文对168例经阴道分娩的在第二产程中胎心变异异常的产妇和160例经阴道分娩在第二产程中胎心变异正常的产妇进行了对比分析，两组在第二产程中均采用了深圳京柏JDP-300k数码胎儿远程监护仪进行连续的胎心监测。结果：在第二产程中胎心变异有异常的阴道助产的比率比胎心变异正常的高18.1%，新生儿窒息的比率也高4.64%，脐绕颈比率高10%，同时发现在第二产程中胎心变异异常多伴有不同程度的羊水污染...查看详细 (3508字节)
☉ 11024464:骶管阻滞治疗妇女盆腔瘀血综合征76例分析
摘 要 目的：探讨骶管阻滞治疗妇女盆腔瘀血综合征的疗效。方法：将76盆腔瘀血综合征患者经骶管注入含0.5%布比卡因5mL、当归液2mL、山莨菪碱10mg、地塞米松5mg、维生素B1 100mg、维生素B650mg、维生素B12500μg复合液，用0.9%氯化钠稀释到20mL，1次/W，4次为一疗程，观察疗效并加以分析。结果：应用骶管阻滞治疗妇女盆腔瘀血综合征取得满意效果，临床治愈率84%，显效9%，好转7%...查看详细 (5271字节)
☉ 11024465:导乐陪伴式分娩在产程中的观察与探讨
摘 要 目的：探讨导乐(Doula)陪伴式分娩对提高产时服务质量与孕产妇保健的作用。方法：2004年3月～9月对74例初产妇(观察组)，在家属陪伴的同时采用导乐陪伴式分娩，与同期77例(对照组)仅有家属陪伴分娩的初产妇进行比较。结果：观察组孕妇对产痛明显减轻，总产程时间、产后出血量与对照组比较差异有显著性意义(P0.05)。出生1min Apgar评分，观察组4分～7分3例，新生儿窒息率4.1%；对照组0分～3分1例...查看详细 (5410字节)
☉ 11024466:干预预防儿童支气管哮喘发作的临床分析
摘 要 目的：探讨饮食护理干预对支气管哮喘患儿疗效的影响。方法：选择在我科治愈出院的82例支气管哮喘患儿，随机分为干预组和对照组，每组41例。对照组出院后采用常规药物治疗，干预组除常规治疗外，增加饮食干预。结果：两组患儿出院1年内，干预组复发率远远低于对照组(P0.05)，具有可比性。
1.2 方法
两组患儿均系痊愈出院。出院后均给予药物治疗即博利康尼每次0.065mg/kg口服...查看详细 (3049字节)
☉ 11024467:改良腹式筋膜内全子宫切除术96例临床分析
摘 要 目的：探讨改良腹式筋膜内全子宫切除术之优点及可行性.方法：对我院近3年收住院的改良腹式筋膜内全子宫切除术式与同期常规全子宫切除术式进行临床对比分析。结果：改良腹式筋膜内全子宫切除术开关腹简化、快捷，手术操作步骤减少，手术时间明显缩短，出血量少，并发症低，安全性高，术后恢复快。结论：改良腹式筋膜内全子宫切除术式优于常规全子宫切除术式，值得临床推广应用。
关键词 改良；筋膜内；常规；全子宫切除术
全子宫切除术是妇科最常用最基本的手术之一...查看详细 (5122字节)
☉ 11024468:复杂性腹腔镜胆囊切除术的处理体会
摘 要 目的：探讨腹腔镜胆囊切除术在几种复杂情况下安全可行的办法。方法：回顾分析了近4年37例复杂病例行腹腔镜胆囊切除术的临床资料和治疗结果。结果：37例腹腔镜胆囊切除，除3例中转开腹外，其余均在腹腔镜下手术成功，效果良好，无严重并发症发生。结论：腹腔镜胆囊切除术可适用于多种复杂病例，正确掌握中转指针是降低手术并发症的重要措施。
关键词 腹腔镜；胆囊切除术；复杂病例
随着腹腔镜手术适应证的逐渐拓宽...查看详细 (4891字节)
☉ 11024469:儿霉菌性肠炎50例诊治体会
关键词 小儿霉菌性肠炎；抗生素；治疗
近几年来，随着大剂量的抗生素、激素及免疫抑制剂的广泛应用，菌群失调的问题越来越突出，由此而导致的小儿霉菌性肠炎发病率明显增高。我院自2003年3月～2005年5月经临床确诊收治了50例小儿霉菌性肠炎的门诊和住院患儿,分析报告如下。
1 临床资料
1.1 一般资料
治疗组：男17例，女8例；>1岁婴儿14例，1岁～3岁幼儿11例...查看详细 (4104字节)
☉ 11024470:绝经后子宫内膜癌32例临床分析
摘 要 目的：总结绝经后子宫内膜癌的临床特点。方法：回顾性分析32例绝经后子宫内膜癌的临床资料。结果：绝经后子宫内膜癌以阴道出血为最突出表现，糖尿病是子宫内膜癌的高危因素，经阴道彩色多普勒超声检查是重要的检查手段，诊刮是术前确诊的主要方法。手术是最主要的治疗方法，次广泛子宫切除术可作为子宫内膜癌的基本术式。绝经后透明细胞癌、腺鳞癌等非子宫内膜样腺癌的比例明显升高，手术-病理分期较晚者多见，预后差，3年和5年生存率分别为67.8%和47.5%...查看详细 (7838字节)
☉ 11024471:经颅多普勒对脑动脉硬化的检测与分析
摘 要 目的:探讨用经颅多普勒检测脑动脉硬化及其程度的临床意义。方法:采用经颅多普勒超声检测仪对临床确诊为脑动脉硬化症的260例患者进行检测与比较，分析后得出结论。结果:脑动脉硬化患者可表现为不同的频谱形态学改变。收缩峰S2大于S1，S2与S1融合呈圆钝形者为120例，平均年龄为67岁，高阻波形者为140例，平均年龄为69岁。脉动参数增高及舒张末期流连降低者为100%，收缩期流速异常(增快或减慢)为152例...查看详细 (3161字节)
☉ 11024472:结节型甲状腺肿与甲状腺腺瘤346例回顾性病理分析
摘 要 目的：通过对以往“结甲”与甲状腺腺瘤回顾性病理分析，探讨误诊原因。方法：根据世界卫生组织的“结甲”及甲状腺腺瘤的诊断标准，对过去346例病例重新阅片。结果：346例病例中“结甲”293例，甲状腺腺瘤53例，将“结甲”误诊为甲状腺腺瘤183例。结论：上述两种疾病容易造成误诊，掌握疾病发生发展规律，严格诊断标准，综合判断，则可减少误诊的发生。
关键词 结节型甲状腺肿；甲状腺腺瘤；误诊分析
“结甲”是在弥漫性甲状腺肿的基础上伴有结节形成...查看详细 (3865字节)
☉ 11024473:高三尖杉酯碱为主治疗慢性粒细胞白血病的临床研究
摘 要 目的：进一步寻找可广泛应用的治疗方案，提高慢性粒细胞白血病(CGL)的治疗效果。方法：应用高三尖杉酯碱(HHT)为主，治疗Ph+的CGL患者16例。观察临床疗效，并与羟基脲(少数为白消安)维持者为对照组进行对比研究。结果：血液学改变：维持治疗前部分血液学缓解的15例患者中，12例(80.0%)获得CHR，其中2例曾间断治疗半年以上仍可维持CHR；CHR的1例患者能维持血液学缓解。总血液学缓解13例(86.7%)...查看详细 (6005字节)
☉ 11024474:肝组织石蜡切片技术的改进
关键词 肝组织；石蜡制片；组织学
组织学是借助显微镜来研究机体正常的组织结构，因此制备良好的组织教学切片，对组织学的实验教学至关重要。组织学教学切片制备一般采用石蜡切片，石蜡切片的关键在脱水、透明及浸蜡步骤。在制作肝脏石蜡切片时，若按常规石蜡切片步骤，肝组织蜡块在切片时较脆易碎，染色后镜下结构常呈脱水过度的表现，影响了肝脏正常组织结构的观察。为做出较好的肝组织切片，我们进行了反复实践，摸索出了肝组织石蜡切片制作的较理想方法...查看详细 (2447字节)
☉ 11024475:强脉冲光治疗面部色素性病变136例观察
摘 要 目的：探讨强脉冲光对面部色素性病变的治疗效果。方法：采用采韵光子嫩肤仪波长为560nm～1 200nm滤光片治疗136例面部色素性病变患者，治疗2次～6次，每次时间间隔为3W～5W，每位患者进行对比拍照、记录参数并进行临床疗效评估。结果：128例患者中各种病变的显效率分别：雀斑77.8%(70/90)，痤疮后色素沉着斑点80%(8/10)，扁平疣色素沉着80%(4/5)，老年斑62.5%(5/8)...查看详细 (4090字节)
☉ 11024476:尿道内切开术治疗后尿道狭窄或闭锁的远期疗效观察
摘 要 目的:观察腔内手术治疗后尿道狭窄或闭锁的远期疗效。方法：对96例后尿道狭窄或闭锁的患者应用尿道内切开术治疗，术后1年、3年、5年进行随访。结果：84例患者排尿通畅，12例需间断尿道扩张。结论:尿道内切开术对于后尿道狭窄或闭锁的患者，因其疗效肯定可作为首选方法。
关键词 尿道内切开术；后尿道狭窄；闭锁；治疗
自1995年9月～2004年9月间采用尿道内切开术治疗后尿道狭窄或闭锁的患者96例...查看详细 (2814字节)
☉ 11024477:沐舒坦气道冲洗对机械通气新生儿PaO2的影响
摘 要 目的：探讨沐舒坦气道冲洗疗法对机械通气新生儿PaO2的影响和疗效。方法：将入住NICU行机械通气的新生儿50例随机分为两组，即沐舒坦气道冲洗组(治疗组)和生理盐水冲洗组(对照组)，每组25例，治疗组每次应用沐舒坦1.5mg加入生理盐水1mL气道冲洗，1次/h，对照组单用生理盐水1mL气道常规冲洗，比较两组病人在气道冲洗前、气道冲洗3次后、10次后的血气分析主要数值如PaO2的变化。结果：沐舒坦气道冲洗与对照组相比...查看详细 (5189字节)
☉ 11024478:氯沙坦对老年心力衰竭患者血管内皮依赖性舒张功能的影响
摘 要 目的：探讨氯沙坦对老年心力衰竭患者血管内皮依赖性舒张功能的影响。方法：86例老年心力衰竭患者随机分成氯沙坦组(43例)及常规治疗组(43例)，比较治疗8W前后应用超声检测肱动脉流量介导性扩张的血管内皮依赖性舒张功能。结果：氯沙坦组治疗8W后内皮依赖性舒张功能明显改善，与治疗前比较，结果有显著性差异(P<0.05)。结论：氯沙坦可以改善老年心力衰竭患者血管内皮依赖性舒张功能。
关键词 老年；心力衰竭；血管内皮功能；氯沙坦
近年来...查看详细 (4742字节)
☉ 11024479:血栓通治疗糖尿病足临床观察
摘 要 目的：探讨血栓通辅助治疗糖尿病足的疗效。方法：对糖尿病足患者58例随机分为血栓通治疗组与对照组。结果：治疗组与对照组血液流变学各项参数水平指标均有显著性差异(P<0.01)。此外FBG、INS、CP水平、疗效评价二组之间也有显著性差异(P<0.05)。结论：血栓通治疗糖尿病足疗效显著。
关键词 糖尿病；胰岛素；血栓通
糖尿病足(diabetic foot，DF)是指糖尿病血管病变和(或)神经病变和感染等因素...查看详细 (3454字节)
☉ 11024480:血塞通联合低分子量肝素钙治疗不稳定型心绞痛疗效观察
摘 要 目的：观察血塞通注射液联合低分子量肝素钙治疗不稳定型心绞痛(UA)的临床疗效及安全性。方法：选择同期入院71例UA患者，随机分为治疗组、对照组，两组均予西医常规处理，治疗组加用血塞通注射液与低分子量肝素钙注射液。结果：治疗组总有效率91.8%，心电图改善，总有效率89.1%。两组比较有显著性差异(P0.05mV，主要T波加深>50%。
1.5 统计学处理
数据以均数±标准差(x±s)表示...查看详细 (4434字节)
☉ 11024481:体检与就诊者中乙型肝炎病毒感染率比较分析
摘 要 目的：了解本地区乙型肝炎病毒在不同人群中的感染情况。方法：采用酶联免疫吸附试验(ELISA)法对乙肝表面抗原(HBsAg)进行检测；连续检测法测定丙氨酸氨基转移酶(ALT)判断肝脏功能。结果：健康体检者3894例，HBsAg阳性84例，阳性率2.2%；来院就诊及住院患者10 847例，HBsAg阳性855例，阳性率7.9%。就诊中3岁～10岁3 021例，阳性18例，阳性率0.9%；11岁～87岁8826例...查看详细 (5547字节)
☉ 11024482:实时FQ-PCR与时间分辨荧光免疫分析法检测乙型肝炎分析
摘 要 目的：探讨实时荧光定量聚合酶链反应(FQ-PCR)定量检测乙型肝炎病毒(HBV-DNA)与时间分辨荧光免疫分析法对乙型肝炎免疫标志物(HBV-M)检测对乙型肝炎实验室诊断的敏感性。方法：采用两种方法分别对800例本院传染科住院及门诊可疑病人血清标本进行检测。结果：用FQ-PCR 检测800例，HBV-DNA阳性例数602，阳性率 87.81%，用时间分辨荧光免疫分析法检测800例，HBV-M的阳性例数477...查看详细 (4785字节)
☉ 11024483:2003年山西某县体表重大出生缺陷监测
摘 要 目的：了解山西省泽州县目前体表出生缺陷患病水平和缺陷种类。方法：对全县26个乡镇的孕产妇进行跟踪体表重大出生缺陷监测。结果：2003年共监测到孕满20W以上的出生4 116名，发现各类出生缺陷85例，出生缺陷发病率为206.5/万。有5种出生缺陷发病率高于10/万，分别为：无脑儿(75.3/万)、脊柱裂(65.6/万)、脑积水(55.9/万)、唇裂(19.4/万)和唇裂伴腭裂(17.0/万)。神经管畸形病例60例...查看详细 (4166字节)
☉ 11024484:一起小学生甲Ⅰ亚型流感暴发的调查
摘 要 目的：探讨甲Ⅰ亚型流感暴发的发病趋势。方法：对2005年11月对长治市城区某小学发生的一起甲Ⅰ亚型流感暴发疫情进行了调查，并对出现发热、咳嗽等上呼吸道感染症状的流感样病例进行流行病学个案调查。结果：本次暴发罹患率为4.55%，发病集中一年级，年龄6岁～7岁，发病75例，占总发病人数的74.26%；病程为5d～10d，无住院病例。结论：健全疫情报告制度、及时采取有效措施、开展防病知识的宣传教育是预防和控制学校传染病暴发疫情的关键...查看详细 (3704字节)
☉ 11024485:预防性光疗对早产儿黄疸防治的临床观察
摘 要 目的：探讨预防性光疗对早产儿黄疸的影响。方法：对64例生后24h内入院的早产儿使用经皮黄疸仪早期监测黄疸，如果黄疸指数大于6mg/dL(102μmol/L)，或每日黄疸指数增加3mg/dL(51μmol/L)，即予单面蓝光灯照射8h～12h，停16h～12h，直至黄疸消退。结果：所有患儿经皮黄疸仪所测黄疸指数均小于10 mg/dL (171μmol/L)，经抽血检验总胆红素峰值均小于171μmol/L...查看详细 (4074字节)
☉ 11024486:影视阴道镜对宫颈疾病诊断的临床应用
摘 要 目的：为提高宫颈癌的早期诊断水平，探讨影视阴道镜在宫颈病变诊断中的可行性和实用性。方法：我院于2000年9月～2005年12月对1 450例门诊病人进行阴道镜检查，并以改良式Reid阴道镜评分法，在评分的基础上，接受病理学检查392例。结果：病理确诊为宫颈上皮内瘤变者(CINⅠ～ CINⅢ)135人、宫颈癌39例、其中原位癌20例，早期浸润癌镜19例，余为慢性宫颈炎伴鳞化及腺性乳头状糜烂。与阴道镜结果对照...查看详细 (3943字节)
☉ 11024487:农村高血压患者健康知识及需求的调查分析
摘 要 目的：了解农村高血压患者健康知识水平及对就医帮助需求，以便针对性开展健康教育。方法：采用现场问卷调查法对农村高血压患者进行调查。结果：农村高血压患者健康知识知晓率总体较低为22%～62%，就医帮助需求较高达68%～100%。结论：加强农村健康教育工作势在必行。
关键词 高血压；健康教育；需求
高血压已成为当今社会的常见病、多发病，由此引发的心脑血管疾病给人们健康带来严重威胁...查看详细 (3790字节)
☉ 11024488:Ambroxol Air Passage Wash’s Effect for PaO2 of Mechanical Ventilation Neonate
Ambroxol Air Passage Wash’s Effect for PaO2 of Mechanical Ventilation Neonate
Abstract Objective：To discuss the influence and curative effect of mechanical ventilation neonate PaO2 via Ambroxol air passage wash treatment. Methods The mechanical ventilation neonate in NICU was randomly divided into two groups, which was Ambroxol air passage wash group (treatment group) and normal saline wash group (control group). Each group had 25 cases. Treatment group’s patients were washed air passage using Ambroxol 1.5mg add normal saline 1ml each time. Control group’s patients were washed air passage using normal saline 1ml. Two groups’ main value of blood-gas analysis of pre-washing, after 3 times washing, 10 times washing were analyzed. The main value included PaO2.Results PaO2 of pre-washing had not significant different in two groups, which of 3 times washing later had different and 10 times washing later had significant different. Conclusion Ambroxol air passage wash can improve the ventilation efficiency of mechanical ventilation neonate....查看详细 (4458字节)
☉ 11024489:抽动障碍与链球菌感染关系研究新进展
关键词 抽动障碍；链球菌感染；PANDAS
抽动障碍(tic disorder,TD)是一种好发于儿童和青少年时期的具有明显遗传倾向的神经精神障碍，主要表现为不自主的、反复的、快速的、无目的的一个或多个部位肌肉运动性或发声性抽动，如眨眼、挤眉、努嘴、耸肩和清嗓等，并可伴有注意缺陷多动障碍(ADHD)、强迫性动作和思维或其他行为症状。最新的流行病学调查表明，抽动障碍在儿童和青少年中患病率为0.15%～1.1%(Kadesjo 2000)...查看详细 (7693字节)
☉ 11024490:医疗机构消毒质量监测与卫生调查结果分析
摘 要 目的：对医疗机构消毒工作进行监测、评价。方法：采用GB规定方法对医院内各类检测点进行采样、检验。结果：医院污水消毒排放超标率为52.94%，室内空气超标率为39.57%，物体表面细菌超标率为5.93%，医护人员手细菌超标率为10.29%，一次性使用医疗用品微生物指标超标率为2.91%，一次性使用卫生用品微生物指标超标率为9.09%，使用中消毒剂细菌超标率为1.564%，紫外线灯辐照强度和压力蒸汽灭菌器均为100.00%合格...查看详细 (5400字节)
☉ 11024491:Patients’ Perceptions of Cholesterol, Cardiovascular Disease Risk, and Risk Communication Strategies
ABSTRACT
PURPOSE Despite some recent improvement in knowledge about cholesterol in the United States, patient adherence to cholesterol treatment recommendations remains suboptimal. We undertook a qualitative study that explored patients’ perceptions of cholesterol and cardiovascular disease (CVD) risk and their reactions to 3 strategies for communicating CVD risk.
METHODS We conducted 7 focus groups in New England using open-ended questions and visual risk communication prompts. The multidisciplinary study team performed qualitative content analysis through immersion/crystallization processes and analyzing coded reports using NVivo qualitative coding software.
RESULTS All participants were aware that "high cholesterol" levels adversely affect health. Many had, however, inadequate knowledge about hypercholesterolemia and CVD risk, and few knew their cholesterol numbers. Many assumed they had been tested and their cholesterol concentrations were healthy, even if their physicians had not mentioned it. Standard visual representations showing statistical probabilities of risk were assessed as confusing and uninspiring. A strategy that provides a cardiovascular risk-adjusted age was evaluated as clear, memorable, relevant, and potentially capable of motivating people to make healthful changes. A few participants in each focus group were concerned that a cardiovascular risk-adjusted age that was greater than chronological age would frighten patients.
CONCLUSIONS Complex explanations about cholesterol and CVD risk appear to be insufficient for motivating behavior change. A cardiovascular risk-adjusted age calculator is one strategy that may engage patients in recognizing their CVD risk and, when accompanied by information about risk reduction, may be helpful in communicating risk to patients.
INTRODUCTION
Despite recent advances in the diagnosis and treatment of cardiovascular disease (CVD), it remains the leading cause of death in the United States.1 In 1985 the National Heart, Lung, and Blood Institute launched the National Cholesterol Education Program (NCEP), which issued the Adult Treatment Panel (ATP I, II, and III) clinical guidelines aimed at reducing the burden of CVD through improved cholesterol management.2–4 The NCEP produced educational kits for clinicians and patient-oriented media programming including the "Know Your Cholesterol Numbers, Know Your Risk" campaign.5,6
Cholesterol knowledge is reported to have improved since the 1980s,7,8 but important information gaps remain. One study reported that from 1983 to 1995, there was an increase in the percentage of Americans who had heard of high blood cholesterol levels, who had been informed of their levels, and who knew their total cholesterol number.9 From 1983 to 1995, the percentage of the public who had heard of high blood cholesterol levels rose from 77% to 93%, and the percentage who were told their cholesterol values rose from 21% to 65%. Furthermore, the percentage who reported that they knew their level increased from 3% to 49%.9 Other studies, however, showed that only about one third of the population reporting an elevated total cholesterol concentration or using cholesterol-lowering medications were aware they had hypercholesterolemia,10 and that whereas some individuals underestimate their risk of developing a disease,11,12 others overestimate risk.13 Even with some improvements in knowledge, patient acceptance of and adherence to cholesterol treatment recommendations remain suboptimal,9,14,15 as inaccurate perceptions of vulnerability to a disease can inhibit prevention behaviors.16–18
Information alone may not promote behavior change. Strategies are necessary to engage patients with how cholesterol levels relate to their CVD risk,19,20 as well as mechanisms to address the impact of low functional health literacy on understanding.21,22 Functional health literacy goes beyond written communication to include innumeracy and a person’s ability to comprehend oral communication.23 Almost one half of all adults in the United States have literacy levels that impede their ability to understand health information and apply it to decision making.22 Recent studies of patient-physician communication found innumeracy to be a major barrier to use of standard bounded probabilities (ie, 0 to 1, 0% to 100%) for comprehension of risk information.24,25 One promising method for overcoming some of these barriers is to use visual displays of numerical information26–28 or to use analogies for expression of probability.29 Recent thought on low health literacy also emphasizes strategic actions within health care systems22 to ameliorate some of the consequences,23,30,31 including use of new strategies for patient education.
As part of a project to enhance implementation of the ATP III guidelines in primary care practice, we conducted exploratory, qualitative research about patients’ perceptions of cholesterol, CVD risk, and risk communication strategies. We report findings from that study in this article.
METHODS
Study Design, Participants, and Data Collection
The authors were part of a multidisciplinary group of primary care researchers with different theoretical groundings and distinct methodological perspectives: an anthropologist (REG), an epidemiologist (DP), a family physician/anthropologist (JB), 2 family physicians (CE, RG), a research assistant (RC), and a behavioral psychologist with a specialty in e-Health (DA). This group included both predominately qualitative (REG, JB) and predominantly quantitative (CE, DP, DA, RG) researchers, as well as a family physician who held a clear belief in the efficacy of interventions around cholesterol (CE) and one who was more skeptical (JB). We discussed these biases and preferences openly during research development, implementation, and analysis phases, and considered the potential effect on our interpretation of data.
Between January and March 2003, we conducted 7 focus groups with 50 adults in the northeastern United States.32–34 We used focus groups to benefit from the interactive discussion among participants these groups foster; participants respond not only to direct questions from the moderator but also to questions and ideas posed by other participants.
Participants were recruited from primary care practices and through a newspaper advertisement calling for adults to discuss physician-patient communication. We advertised this broader aim of our study to avoid limiting recruitment to those who were especially motivated to talk about cholesterol. To meet the study inclusion criteria, the participants had to be older than 18 years and able to speak English.
The tape-recorded focus groups were held in a hospital conference room or in community locations. Before beginning each 2-hour discussion, participants signed an informed consent that was approved by the hospital’s human subjects protection review board. They received $25 in cash for their participation.
The groups were moderated by an anthropologist (REG) using a guide of open-ended questions supplemented by spontaneous probes . The subset of topics reported in this article are knowledge and perceptions of cholesterol, perceptions of risk associated with cholesterol, and assessment of CVD risk communication methods. To compare patients’ reactions to 2 standard visual risk communication strategies26–28 and HeartAge (our developing strategy for communicating cardiovascular risk-adjusted age), we evaluated their responses to 3 visual representations of risk for a 10-year coronary heart disease event probability according to the Framingham Heart Study data.35 The NCEP published in its 2001 evidence-based consensus ATP III guidelines a prediction equation for the 10-year coronary h eart disease risk (recognized myocardial infarction, silent myocardial infarction, coronary insufficiency, and coronary heart disease death) by evaluating the multivariate risk associated with age, sex, current cigarette smoking, total cholesterol concentration, high-density lipoprotein cholesterol concentration, and systolic blood pressure (treated or not treated).4 This equation is based upon the 10-year follow-up of 2,489 men and 2,856 women from the original Framingham cohort and the first cycle of the Framingham Offspring study, aged 30 to 74 years at baseline in 1971 to 1974. This risk equation has been shown to be valid in multiple ethnic cohorts.36
For the visual displays, we presented data for a 42-year-old man with a high 10-year risk (0.25) of coronary heart disease based on the Framingham Heart Score. Participants were shown the following: (1) First they were shown a crowd chart27 depicting 100 stick figures with 25 shaded to represent the proportion expected to experience a coronary heart disease event during the next 10 years and then an identical chart with the risk for a same-aged man who had no risk factors (0.01 probability, 1 figure shaded), which visually depicted both absolute and relative risk reductions. (2) Then they were shown a simple vertical bar graph comparing the current risk (0.25) as a full column with a column to represent the risk for a same-aged man who had no risk factors (0.01), which visually depicted relative risk reduction. (3) Finally, they were shown a simple horizontal bar chart displaying cardiovascular risk-adjusted age that we called HeartAge, which had 2 bars representing ages from 0 to 76 years. The first bar represented the individual’s true chronological age (42 years) and the second bar showed how this individual compared with the average age of a same-sex person in the Framingham Heart Study having the same 10-year probability of experiencing a CHD event. For the demonstration case, the 42-year-old had the same risk as a 70-year-old.
Data Analysis
The coauthors conducted preliminary analyses on an ongoing basis as each focus group transcript was completed. We recognized we were reaching data saturation when we began to hear repetitive comments, with few new data generated in the final groups. After completion of the focus groups, from May through December 2003, we met regularly to conduct an in-depth analysis using the immersion/crystallization method.37 This involved repeatedly listening to the audiotapes and reading and discussing the transcripts to identify emerging themes and salient topics. After we developed an initial codebook and clarified definitions, the transcript texts were subjected to line-by-line coding with the qualitative software NVivo.38 The codebook was modified by team consensus as the need for new codes emerged. We used the coded reports to facilitate further analysis discussions, develop links between themes, finalize data interpretation, and identify supporting quotations. Searches for alternative interpretations were conducted and discussed before final decisions were made about how to report and discuss the findings.
RESULTS
Participant characteristics are displayed in Supplemental Table 1. Of the 7 focus groups, 2 were held in affluent communities; for 1 group we recruited from a primarily low-income clinic, though all groups included mixed income and education levels. Participants with college or higher degrees did not always have correspondingly higher income than those with less education, though for some a lower income might have been due to being currently retired. Overall, participants were aged 27 to 84 years; household yearly income ranged from less than $10,000 to more than $60,000; and education ranged from high school to postgraduate and professional degrees.
Knowledge and Perceptions About Cholesterol
Definitions of Cholesterol All participants were aware that high cholesterol levels adversely affect health, though many were surprised that they only recently heard about this issue. Participants’ explanations included that cholesterol is a newly discovered health problem, that the recent plethora of medication advertisements raised awareness, and that doctors only lately became concerned about cholesterol. Table 1 lists participants’ perceptions about cholesterol.
There were similarities across socioeconomic groups in the ways participants described cholesterol and their confusion about what cholesterol is, though some with higher education provided more accurate descriptions and focused on the more complex aspects of cholesterol risk. For example, a man who showed a good understanding of cholesterol still wondered:
"Since I’ve been on the medication a while, is it maintaining status quo? My concern is it may reduce the risk factor, but what’s the relationship between the residual clogging you might have and the fact that you’re taking medication?"
Some participants associated cholesterol with blood pressure, variously assuming that if one is low the other will be low, that high cholesterol levels cause the same physical symptoms as high blood pressure, and that high cholesterol levels and high blood pressure cause each other. Although many used appropriate words to talk about cholesterol, not all conceptualizations of biological processes were accurate. Some spoke of levels of cholesterol (high/low), while many across groups referred to cholesterol in absolute terms. As a participant admitted, "I don’t even know what it’s made up of. But I know some people have it and some people don’t."
Desire for Information Many participants wanted information about cholesterol that was clear and unchanging. They were frustrated by shifting health messages regarding diet and were reluctant to believe dietary recommendations. Some purposively avoided thinking about cholesterol, whereas others simply remained uninformed. For example, a man who was currently taking cholesterol-lowering medication had not received explanations from his physician, and he consistently forgot to ask questions. He disclosed, "I don’t know what it is. I don’t know where it comes from. I don’t know where it goes."
Diet Many participants told stories about a sibling or friend who eats "whatever he wants" and has normal cholesterol values, whereas others who eat a healthful diet have high cholesterol values. Nevertheless, despite prevailing doubts about the accuracy of dietary recommendations, most participants acknowledged some association of diet with high cholesterol levels. Fats were frequently mentioned, and some participants in every group cited health consequences of saturated fats or the benefits of certain oils. Participants also cited food- and preparation-related factors as contributing to high cholesterol levels: chemicals in animal feed; pesticides on plants; and foods that are not fresh and natural, that are pasteurized, have preservatives, and are processed, frozen, and canned. Participants often conflated general issues about food quality and lifestyle with concerns about diet and cholesterol.
Participant 1: "This is my problem with the high cholesterol: They say fried foods, fatty foods, eggs. My grandfather lived to be 96 years old, North Carolina. He smoked, drank, and eat fried foods every day."
Participant 2: "Yeah, but the food was different in those days than it is nowadays."
Participant 1: "How is the food different? Pork, pig feet, chittlins, ham hocks, bacon."
Participant 2: "Yeah, but the foods aren’t natural anymore."
Participant 3: "I would look at it another way. In our society we’re sitting down. For me, I’ve sat down all day at my desk working, so, where your grandfather was, what did he do all day? He was outside working."
Overweight and Heredity Many assumed that only overweight and older people are affected by cholesterol. Younger and thinner participants were surprised when others in the groups stated that anyone might have high cholesterol levels, and they found it difficult to overcome their limited view of the risk of high cholesterol levels.
"I associate high cholesterol with high weight gain, although I know very slender people can have very high cholesterol. But somehow in my mind’s eye ... I associate it with being overweight."
Stories emerged about overweight people with normal cholesterol levels who have thin siblings with high cholesterol levels. Participants talked about the impact of heredity on cholesterol and their ambivalence about heredity because familial patterns are inconsistent.
"There’s a possibility [high cholesterol is] genetically inherited, ... and then if they are predisposed to this, if they do not do certain controls, then their chances are they may follow their family that may have died at a young age because of cholesterol rather than cardiac infarction or even a heart attack. But maybe we can, I think we can control it."
HDL and LDL Few participants were familiar with the terms "HDL" (high-density lipoprotein) and "LDL" (low-density lipoprotein), though many had heard of "good" and "bad" cholesterol. Although some understood that one type should be high and the other low, participants’ greater familiarity with the generalized term "cholesterol" and their recognition that high (total) cholesterol levels are unhealthy resulted in confusion about cholesterol being both good and bad, with goals for high and low numbers.
"Cholesterol to me has like a negative connotation to it, whether it’s good or bad. Why didn’t they just come up with another word?"
"Blood pressure should be low. Cholesterol should be low. Everything should be low."
Cholesterol Numbers In the 2 focus groups with the most highly educated participants, almost all knew their total cholesterol number. There were a few in each of the other groups who knew their total number, and they were usually motivated by having serious cholesterol problems or a family history of high cholesterol. An additional few in each group knew that they had been tested; they could not recall the number, but they did know whether it was high or not. Only a few participants in the entire sample knew their HDL and LDL numbers, though a few in each group knew whether their levels of good and bad cholesterol were problematic.
"I don’t even know my numbers. I just know it was high, and he put me on medication for it."
"I know the good is high and the bad is low. The exact numbers always escape me. "
Perceptions of Risk Associated With Cholesterol
Cholesterol Numbers and CVD Risk Perceptions Throughout the focus groups, participants claimed that cholesterol numbers were not an effective means to understand their risk for CVD and indicated that they did not personally relate to the abstractions that the cholesterol numbers represented. None of the participants recognized the NCEP slogan, "Know your cholesterol numbers; know your risk," and none found it compelling.
The level of risk that participants ascribed to high cholesterol varied, with some viewing it as a serious disease in itself, and others considering it a contributor to disease. Some prioritized taking blood pressure medication over cholesterol-lowering medication. Most viewed high cholesterol levels as less serious than high blood pressure because of the views that cholesterol can be managed while blood pressure cannot, blood pressure leads more directly to a heart attack, they have known about high blood pressure for longer, and they continue to hear more from physicians about blood pressure. Participants reasoned:
"Cholesterol doesn’t kill like blood pressure."
"They don’t make it an issue like they do heart disease. Cholesterol, I would say, is down on the bottom of the totem pole as far as most people are concerned of it being a high-risk factor that could kill you."
Cholesterol Testing Participants assumed that doctors regularly test cholesterol as part of a complete physical examination even if patients are not aware that it is being done. This belief was especially strong among individuals whose physicians had ordered blood tests. Even though their physicians never spoke with them about cholesterol, nor informed them of their numbers, they assumed that their cholesterol level was normal:
"I never asked, so maybe they are testing my cholesterol. They just told me if there was anything wrong, they would let me know."
Response to 3 Risk Communication Visuals
The crowd chart was disliked by all participants. Many found the crowd chart confusing, and even those who understood the message assessed the presentation as unconvincing. Typical evaluations of the crowd chart were "busy," "your mind starts to lose the comprehension of the dots," "it doesn’t have any oomph," and that it took a lot of thought to understand. The traditional bar graph showing the relative probability was viewed by most as lacking impact, "too dry," "too statistical," geared toward "scientific medical-types," and removed from personal experience. A few participants who were comfortable with statistics viewed the chart as a reasonable way to present risk information.
The third presentation, based on cardiovascular risk-adjusted age, was assessed by almost all participants as engaging and memorable. Reactions included "it’s catchy," "it grabs you," "it’s an eye-opener," "it’s a wake-up call," and "it raises your consciousness." A few participants in each focus group, however, warned that patients might become alarmed if their calculated risk of a heart attack or dying of heart disease is similar to that of an older person. These statements generated considerable discussion among the participants. Some supported the idea that the message is simply frightening, and others countered that it is nevertheless important for people to have this information and that it may motivate them to change their behaviors. Some suggested that the cardiovascular risk-adjusted age strategy would be most useful and least alarming if it was accompanied by information about reducing one’s risk for CVD. A few participants were skeptical about the validity of the age calculations and wanted more information about the variables used in the underlying formula.
Even among those who expressed concerns, participants found the concept of cardiovascular risk-adjusted age to be more engaging than the percentages provided by probability and relative risk reduction charts. They believed that remembering an age number would be easier than remembering cholesterol levels or percentages, and they were more likely to remember the calculated age changes from year to year. Some believed that the information about risk akin to an older person would be motivating enough to consider life changes to improve their cholesterol numbers and heart health. Table 2 includes participants’ reactions to the cardiovascular risk-adjusted age strategy that exemplified many responses.
DISCUSSION
Common themes throughout all the focus groups involved participants’ inadequate knowledge and awareness about cholesterol and its association with CVD risk. Participants expressed surprise that they knew so little about cholesterol and that they may never have been tested. These results are consistent with recent findings that two thirds of patients younger than 40 years, as well as one half of the Hispanic and African American patients surveyed, reported never having received a cholesterol screening recommendation from their physicians.39,40 A low rate of screening recommendations generally may be reinforcing the perception among our participants that their cholesterol levels had been measured as part of regular physical examinations, even if their physicians did not talk about it.
Participants used words commonly associated with cholesterol, though their descriptions of biological processes and CVD risk often contained inaccuracies. Participants with the highest education more completely described what cholesterol is and how it creates risk for heart attack and stroke, though some confusion remained. While one study found that from 1986 to 1995 the percentage of persons who knew that a desirable total cholesterol level is less than 200 mg/dL increased dramatically,9 other studies support our findings that only a small portion of patients know their own cholesterol levels and risk for coronary heart disease41,42 despite being generally knowledgeable about the health risks of high cholesterol.41
Giving patients more medical information may not mitigate the influence that prevailing beliefs have on patients’ views of medical issues.14,43–45 Furthermore, the trend in cholesterol education toward increasingly complex explanations (that include total, HDL, LDL, triglycerides, and non-HDL cholesterol) may not lead to optimal understanding of cholesterol and may, at the same time, be insufficiently motivating for patients to work with their physicians to reduce cholesterol-related CVD risk. Similarly, the "Know Your Cholesterol Numbers; Know Your Risk"6,9 campaign may also be suboptimal, as most participants in our study did not know their cholesterol numbers and, possibly more importantly, did not think knowing their numbers would motivate them to personalize their risk profile and engage in behavior change.
Results of this study are limited by the small geographic area from which participants were recruited. In addition, it is not possible with focus groups to obtain the detailed accounts of participants’ perspectives that result from individual interviews. We did, however, choose to use focus groups to benefit from the interactive discussion.
To engage patients’ focus on cholesterol-related CVD risk and facilitate meaningful communication with physicians,14 cholesterol education tools must be able to arouse the emotion necessary to enhance use of the teachable moment provided by cardiac risk factor assessment. Our focus group participants’ reactions to 3 risk communication strategies indicate they preferred a method that engaged their attention in a manner to which they could personally relate. The personal element, therefore, may be critical for alerting patients to how they, as individuals, can be affected by CVD risk and may be important for motivating patients to talk with their physicians and change behaviors to improve their cholesterol levels. A cardiovascular risk-adjusted age strategy uses a calculation based on probability estimates and converts it into a concept using age that participants found meaningful, easy to understand, and memorable. Some, however, were concerned that the emotion aroused by the risk-adjusted age strategy may be frightening, indicating that such an approach must be accompanied by clear messages regarding how individuals can work with their physicians to reduce their CVD risk. The strategy avoids vaguely elastic terminology, such as "likely," "rare," and "chance of occurrence," and it may help overcome the barriers of interpretation of numbers for patient-physician communication.24,27,46,47 Our participants’ interest in the cardiovascular risk-adjusted age strategy is consistent with other observations that although patients often desire more information than they are getting from their clinicians, their wish is not for raw data, complicated medical explanations, or population estimates. Rather, they seek personally meaningful information that may prove helpful as they make their health care and lifestyle decisions.27 If physicians can achieve this essential initial step of truly engaging patients with the notion of their own cholesterol-related CVD risk, then patients may be better prepared to understand and internalize the elements of traditional cholesterol education that our participants found to be confusing or irrelevant. The findings from this research, then, pose a question for debate concerning the type and amount of detailed information most appropriate for motivating behavior change. This study suggests a way forward and may help clarify our cholesterol education efforts.
ACKNOWLEDGMENTS
We would like to acknowledge the assistance of Jerome McMurray and Jennifer Vancura with focus group logistics and data management.
FOOTNOTES
Conflicts of interest: none reported
Funding support: This research was supported by the National Institutes of Health, Bethesda, Maryland; grant # NIH-NHLBI R01 HL70804.
Received for publication March 25, 2005. Revision received November 15, 2005. Accepted for publication November 28, 2005.
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☉ 11024492:Perceived Vulnerability to Heart Disease in Patients with Familial Hypercholesterolemia: A Qualitative Interview Study
ABSTRACT
PURPOSE Knowledge about the ways patients perceive their vulnerability to disease is important for communication with patients about risk and preventive health measures. This interview study aimed to explore how patients with a diagnosis of heterozygous familial hypercholesterolemia understand and perceive their vulnerability to coronary heart disease.
METHODS We did a qualitative study of 40 patients with familial hypercholesterolemia who were recruited through a lipid clinic in Norway. We elicited participants’ perceptions about their vulnerability to heart disease in semistructured interviews. Data were analyzed by systematic text condensation inspired by Giorgi’s phenomenological method.
RESULTS We found that participants negotiated a personal and dynamic sense of vulnerability to coronary heart disease that was grounded in notions of their genetic and inherited risk. Participants developed a sense of their vulnerability in a 2-step process. First, they consulted their family history to assess their genetic and inherited risk, and for many a certain age determined when they could expect to develop symptoms of coronary heart disease. Second, they negotiated a personal sense of vulnerability by comparing themselves with their family members. In these comparisons, they accounted for individual factors, such as sex, cholesterol levels, use of lipid-lowering medications, and lifestyle. Participants’ personal sense of vulnerability to heart disease could shift dynamically as a result of changes in situational factors, such as cardiac events in the family, illness experiences, or becoming a parent.
CONCLUSIONS Patients with a diagnosis of familial hypercholesterolemia negotiate a personal and dynamic sense of vulnerability to coronary heart disease that is grounded in their understanding of their genetic and inherited risk. Doctors should elicit patients’ understanding of their family history and their personal vulnerability to individualize clinical management.
INTRODUCTION
Communicating with patients about their risk of future disease and preventive health measures is challenging for the doctor.1 A strong predictor of patients’ readiness for medical treatment and preventive behavior is their perceived vulnerability to disease.2–6 The family history forms a basis upon which a person assesses his or her own vulnerability to common chronic diseases,7,8 and the family history is becoming increasingly important as a medical devise to predict risk of future disease.9 How do patients with a well-defined genetic disorder relate to their family history? How do patients with a diagnosed familial risk understand and perceive their vulnerability to future disease?
Heterozygous familial hypercholesterolemia is an autosomal dominant genetic condition, characterized by elevated low-density lipoprotein (LDL) cholesterol and elevated total plasma cholesterol levels.10 Familial hypercholesterolemia is caused by a defect in the gene for the LDL receptor, and the condition is strongly associated with coronary heart disease. A recent risk estimate is that 50% of untreated men aged 50 years and 30% of untreated women aged 60 years will develop coronary heart disease.10 Research suggests that many patients do not achieve treatment goals.11 Several factors are shown to be associated with an increased perceived vulnerability in patients with familial hypercholesterolemia: the pattern of heart disease in the family; high cholesterol levels; and experiencing symptoms of angina, anxiety, and depression.12–15 A better understanding of how patients with familial hypercholesterolemia resolve their vulnerability to coronary heart disease may foster an individualized and improved clinical management.
The aim of this study was to explore how patients with a diagnosis of familial hypercholesterolemia understand and perceive their vulnerability to coronary heart disease. Our point of departure as medical doctors is a commitment to a patient-centered and biopsychosocial medicine, in which health professionals need to recognize patients’ agendas and get insight into patients’ own appraisal of their health-related risks and resources.16–18
The study was approved by the Regional Committee for Medical Research Ethics (Health Region East, Norway).
METHODS
Participants
Our sampling strategy aimed at a sample of mainly young and asymptomatic participants with familial hypercholesterolemia who had diverse social backgrounds, family histories of coronary heart disease, and times since diagnosis. Participants were recruited from a specialist clinic for metabolic lipid disorders in Norway. The clinic has a scheme for diagnosing familial hypercholesterolemia and treating these patients. The patients are mostly referred by their family doctor for diagnosis and evaluation based on their elevated lipid values, their family history of hypercholesterolemia, and coronary heart disease in their family. The Norwegian health service is predominantly publicly financed. Equal access according to need is a basic principle, and family doctors play a crucial role in the health service.19 Norwegian attitudes and practices related to health, lifestyle, and drugs are not considered to differ substantially from common health-related values in modern Western societies.
Patients were approached through an invitation letter distributed by medical professionals at the clinic. The sample size of 40 participants was a result of data saturation as consecutive interviews yielded diminishing returns of new information. Participants’ characteristics are displayed in Table 1; their mean age was 31 years. Seven participants had developed symptoms coronary heart disease, such as myocardial infarction or angina pectoris. Thirty-five participants used lipid-lowering medications.
Interviews
Semistructured, face-to-face, tape-recorded, qualitative interviews, lasting 45 to 90 minutes, were conducted by the first author. The 40 participants were interviewed in the interviewer’s office (30), in interviewees’ homes (8), and in the interviewees’ work offices (2). The interviews were conducted from June 2000 until March 2002. All participants were informed about the purpose of the study and that they could stop the interview at any point without giving a reason. Written informed consent and an agreement that quotes from the interviews could be used anonymously were obtained from all participants.
An interview guide was developed on the basis of 8 weeks of fieldwork that involved informal conversations with patients and observation of consultations between health professionals and patients in the clinic. The interview questions were open-ended and covered issues about health and disease, addressing how participants perceived and managed their own risk of heart disease (Table 2). Emerging themes and hypotheses from the first interviews were explored in subsequent interviews.
Analysis
Audiotapes of the interviews were transcribed verbatim by the first author and analyzed qualitatively. The first author and the last author read 10 transcripts independently and developed a coding frame for the analysis. The first author coded all transcripts, and all authors independently read the material and contributed in negotiating the final categories and their contents. Material about participants’ perceived vulnerability to coronary heart disease was identified and used for systematic text condensation, according to the principles of Giorgi’s phenomenological analysis,20 modified by Malterud.21 The analysis followed 4 steps: (1) reading all the material to obtain an overall impression and bracketing previous preconceptions; (2) identifying units of meaning representing different aspects of participant’s perceived vulnerability, and coding for these units; (3) condensing and summarizing the contents of each of the coded groups; and (4) generalizing descriptions and concepts concerning perceived vulnerability to coronary heart disease. Quotes from the interviews were translated from Norwegian to English by the first author in the process of writing this article.
RESULTS
Most participants conveyed opinions about their vulnerability to coronary heart disease. Some were reluctant to discuss their own vulnerability, and a few said they had not reflected much on it. We found that participants negotiated a personal and dynamic sense of vulnerability to coronary heart disease that was grounded in notions of their genetic and inherited risk. Participants developed a sense of their vulnerability in a 2-step process. First, they consulted their family history to assess their genetic and inherited risk, and for many, a certain age determined when they could expect to develop symptoms of coronary heart disease. Second, they negotiated a personal sense of vulnerability through comparisons between themselves and their family members. In these comparisons, they accounted for such factors as sex, cholesterol levels, use of lipid-lowering medication, and lifestyle. Participants’ personal sense of vulnerability to heart disease could shift dynamically as a result of changes in situational factors, such as cardiac events in the family, illness experiences, or becoming a parent. We elaborate further on these findings below.
Genetic and Inherited Risk
Participants consulted their family history when they assessed their genetic and inherited risk of coronary heart disease. Biographic data about family members, such as the age, lifestyle, cardiac events, and cardiac deaths, formed a basis on which participants recounted their genetic risk. Participants attributed most importance to first- and second-degree relatives they knew or assumed had familial hypercholesterolemia, particularly if the participant had witnessed the illness or death of a close relative. The pattern of coronary heart disease among family members with familial hypercholesterolemia was used to develop a notion of how long one could expect to live without experiencing symptoms of heart disease. One participant explicitly described her impression of the genetic risk as the "family statistics" of heart disease. Her mother had been struck by a heart attack and died in her mid-30s. The participant was struck by a heart attack at the same age as her mother but received medical treatment and was subsequently followed up. She held this age pattern as a baseline and used it as a predictive device when commenting on her son’s genetic risk of coronary heart disease.
"For [my son] it means that he could risk getting his first heart attack at the age of 35. This is our family’s statistics. Someone else would perhaps suffer from it when they were 45 ... in other families the heart attacks doesn’t come before you are in the mid-50s" (participant 5, woman, 51 years).
This reasoning is limited to offspring who have familial hypercholesterolemia and is not considered valid for children without the condition. A less-severe family history influenced participants’ understanding of their genetic and inherited risk. One woman thought that her genetic risk was moderately low because her grandfather lived until he was 60 years.
"I know it’s not that bad, because my grandfather didn’t die before he was 60 years old" (participant 22, woman, 30 years).
While many participants had a fairly accurate idea of their inherited risk or family statistics, others conveyed a vague notion of their genetic and inherited risk. Some questioned the trustworthiness of their family statistics as a predictive device after experiencing considerable variation in the onset of heart disease among family members assumed to have familial hypercholesterolemia.
"In my family ... some have died early, in their 40s or their 50s. But many have become 80, so it’s not given that I have to pass away early" (participant 33, woman, 21 years).
There were also participants who noted that they belonged to a different generation, and because their lifestyle and food habits were different, they questioned the predictive value of the pattern of heart disease in their family.
Negotiating a Personal Sense of Vulnerability
When negotiating a personal sense of vulnerability to heart disease, participants used their concept of genetic and inherited risk as a starting point and then compared themselves with relatives they knew or assumed had familial hypercholesterolemia. In such comparisons they accounted for individual factors, such as sex, cholesterol levels, use of lipid-lowering medication, and management of risk factors related to lifestyle (diet, exercise, smoking, and stress). A quote from the interview with a man aged 41 years who had no symptoms of heart disease offers a good illustration.
"My uncle is about 60 years old. He got his first heart attack when he was at my age, 40 years old. The difference between him and me is that I don’t smoke, my lifestyle is healthy, and I take exercise. He has never taken any physical exercise, so I think I have an advantage there" (participant 1, man, 41 years).
When comparing himself with his uncle, he accounted for known risk factors and the advantages he had being a physically active nonsmoker. Typically, a certain age represented "what you could expect" given a genetic risk. A specific age was often referred to as the point at which a person could expect to develop symptoms of coronary heart disease. A woman who lost her 53-year-old father when she was 22 years old expressed how she felt about her vulnerability at that time.
"I was 22 years old and I was pregnant. It was hard ... I was convinced that I would not be any older than [my father]. It was just like 53 years represented a limit" (participant 34, woman, 57 years).
Participants accounted for how they managed their condition by adding or subtracting years from a certain age that reflected their genetic and inherited risk. They were usually optimistic when they appraised their lifestyle and the effect of using medication. A statement by one participant, whose father died of a heart attack at 36 years, serves as an illustration:
"In a way I think I’ll live longer ... but let’s say that I’ll be 50 years old when I ought to start thinking about it, if we take into account that I have used medication since I was 8 or 9 years old" (participant 37, man, 28 years).
He conveyed that 36 years was when he could expect symptoms to occur given his genetic risk. When accounting for use of a lipid-lowering medication since he was a child, he added 14 years to this baseline.
There were also participants who emphasized the negative impact of their own lifestyle in comparisons with family members, as illustrated by the reasoning of a woman aged 34 years who weighed different risks against each other.
"My own risk compared with my mother’s is quite similar ... she has almost not smoked, and I have smoked, but she started using medication later than I did. I feel that these things that haven’t been done right weigh up for each other" (participant 32, woman, 31 years).
The Dynamics of Perceived Vulnerability
Participants’ perception of personal vulnerability to heart disease could change dynamically with time and was influenced by several factors, such as the psychosocial context, cardiac events or deaths, illness experiences, approaching a perceived age limit, or becoming a parent.
The Psychosocial Context
Participants’ accounts indicated they contacted the health service at a time in their life when they could manage the psychological, social, and practical consequences of recognizing their personal vulnerability to heart disease. A woman who had a diagnosis of familial hypercholesterolemia, and whose grandfather died of a heart attack at 50 years, waited for several years before she started lipid-lowering treatment:
"The reason was our 2 children, who were often ill. We went in and out of the hospital with their asthma and allergy, and pneumonias.... My husband ... traveled all the time, so I almost had more than I could put up with at that moment" (participant 23, woman, 31 years).
A patient’s life situation represented a broader psychosocial context in which a range of vulnerabilities were perceived and dealt with and could be a barrier to diagnosis and treatment. Patients might not have the energy needed to recognize their vulnerability to heart disease, or they might give the condition a lower priority than other competing obligations or risks.
Cardiac Events or Death
Cardiac events or deaths in the family could lead a person to reassess a family history, which in turn could change that person’s understanding of genetic and inherited risk. One illustration of such a dynamic shift is a woman who had attributed family members’ heart trouble to "bad luck" until 2 of her cousins had heart disease diagnosed in their 30s:
"Two of my cousins were diagnosed with heart trouble before they were 40. Then I thought: ‘We have to do something’ ... then I knew it was inherited" (participant 4, woman, 47 years).
This quote illustrates how cardiac events in the family may heighten an awareness that heart disease is running in the family, which can be a trigger to seek health care.
Illness Experiences
Personal illness experiences can influence how patients perceive their vulnerability to heart disease. A person who experienced cardiac symptoms would feel more vulnerable, but other severe illnesses could also initiate a dynamic shift in perceived vulnerability. An example is a woman with a severe family history of coronary heart disease who had neglected her hypercholesterolemia for 10 years, until she experienced being severely ill with pancreatitis:
"When I was 22 years old, they told me that I would get my first heart attack before I was 40. I didn’t really care at that time. I checked it from time to time, but I didn’t really take it seriously before 1999. Then I started using medication,... without that pancreatitis, I don’t think I would have thought much about it. That episode really scared me" (participant 35, woman, 36 years).
Severe illness probably increased an awareness of her health, which in turn influenced her perceived vulnerability to heart disease.
Approaching a Perceived Age Limit
Growing older can change a person’s perceived vulnerability. As participants approached the age at which they would expect to develop symptoms of coronary heart disease, they might have felt an increased sense of vulnerability. A woman whose mother had died from a heart attack in her mid-30s was anxious about what would happen when she approached the same age. "I was very anxious of what would happen as I approached 35 years" (participant 5, woman, 51 years).
Becoming a Parent
Becoming a parent or planning to have children can initiate a shift in a person’s perceived vulnerability. A woman, the mother of a 2-year-old girl, felt that becoming a parent had given her an increased sense of vulnerability.
"It’s something about having children and all of a sudden growing up, having to take responsibility.... If I were to die, it would be a crisis for [my daughter]" (participant 32, woman, 31 years).
Her sense of social responsibility for her daughter was one reason why she started using a lipid-lowering medication 10 years after familial hypercholesterolemia initially was diagnosed. Becoming a parent may give a person an increased awareness of the future. Foreseeing the social consequences of an early cardiac death may be a trigger for a person to recognize a vulnerability to heart disease.
DISCUSSION
Validity and Transferability
This study explored how patients with a diagnosis of familial hypercholesterolemia understand and perceive their vulnerability to coronary heart disease. Participants were recruited through a clinic for metabolic lipid disorders. We have no indication that we selected for worriers or patients with multiple risk factors in our sample, but our sample probably included patients who felt positively about medical treatment. Those who were not motivated to seek medical treatment of their genetic lipid disorder would not have enrolled as patients. Consequently, there were few participants in our sample who had a fatalistic attitude about their condition.
Referral and regular monitoring in a specialist clinic may have modified patients’ understanding of their family histories. Even so, our results suggest that our participants developed and revised their notion of inherited risk before they made contact with the health service. The experience of cardiac events in the family may have fueled the notion of having a family history of heart disease.
Most participants in our sample were young and asymptomatic. Older participants provided valuable insights about how growing older and experiencing symptoms of heart disease might influence patients’ perception of their vulnerability.
Our sampling strategy allows us to study perceived vulnerability to coronary heart disease in a group of patients with the same rare genetic disorder. We should, however, be cautious about arguing that our findings are transferable to and valid for patients in family practice.
What This Study Adds to Previous Knowledge
We know that individuals consult their family history when assessing their personal vulnerability to disease.7,8,22 Earlier research has described a person’s tendency to draw a distinction between their inherited risk and their personal vulnerability to disease.23 Studies exploring how persons understand their inherited disposition to disease suggest that they count affected relatives and use similarities in looks, personality, or mannerism to assess whether they have inherited a certain constitution or disposition.8,23,24 In our study, we found that participants seldom made reference to physical or mental similarities. One explanation might be that they were well aware that familial hypercholesterolemia is caused by a single-gene mutation, which is inherited independently of other traits, so they did not need to speculate on the basis of indirect evidence of inheritance; either they had the gene or they did not. The age pattern for onset of coronary heart disease in the family, referred to by some as the family statistics, was the predominant feature they used when developing their personal sense of vulnerability.
Our findings are consistent with research that points out associations between a perceived increased vulnerability and such factors as the pattern of heart disease in the family, high cholesterol levels, and experiencing symptoms of angina.2–6 Our study adds to previous knowledge by showing how patients with a diagnosis of familial hypercholesterolemia develop a dynamic and personal sense of vulnerability to coronary heart disease that is grounded in notions of their inherited risk. We found several situational factors that can initiate a dynamic shift in perceived vulnerability: cardiac events in the family, experiencing symptoms of coronary heart disease or other serious illness, and changes in life situation. We observed that someone who could be fatalistic earlier in their life can develop an increased sense of vulnerability and increased motivation for medical treatment.
Implications for Clinical Practice
For those with familial hypercholesterolemia, a family history of premature coronary heart disease is among the most important determinants of early and severe cardiac events.25 The clinical severity of familial hypercholesterolemia varies considerably among families, and information from the family history is usually more relevant than average risk estimates when assessing an individual patient’s risk. Research indicates that patients are more motivated to seek medical treatment if they are given personally relevant information rather than information about average risks.26 Doctors should therefore assess each patient’s risk of coronary heart disease individually, on the basis of clinical data and information from the family history. Research indicates that doctors and patients may assess the patient’s family history differently.27,28 Doctors should therefore gain insight into the patient’s perception of the family history and share their medical view of the information in the patients’ family history with the patient. The goal of such a dialogue is to clarify misunderstandings and provide a common ground for a shared understanding and decision making.
In clinical practice it may be difficult to find time to obtain, organize, visualize, and analyze the patient’s family medical history. Genograms can help doctors organize and continuously update family history information, and numerous tools are available to help patients record and organize their family histories.9,29,30
Our study shows that patients’ personal sense of vulnerability to coronary heart disease emerges from unique biographical and social contexts and may shift dynamically with time. An understanding of the patient’s psychosocial context and knowledge about how the patient understands a family history can offer important clues as to the patient’s readiness for preventive behavior. Doctors need to be sensitive to their patients’ individual preferences while recognizing that these preferences can change with time.
FOOTNOTES
Conflicts of interest: none reported
Funding support: The research project has been funded by the Norwegian Research Council (grant number 130435/330), and with the aid of the EXTRA funds from the Norwegian Foundation for Health and Rehabilitation (grant number 2003/2/0239).
Received for publication September 14, 2005. Revision received December 19, 2005. Accepted for publication January 10, 2006.
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Walter FM, Emery J, Braithwaite D, Marteau TM. Lay understanding of familial risk of common chronic diseases: a systematic review and synthesis of qualitative research. Ann Fam Med. 2004;2:583–594.
Walter FM, Emery J. ‘Coming down the line’-- patients’ understanding of their family history of common chronic disease. Ann Fam Med. 2005;3:405–414.
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van Maarle MC, Stouthard ME, Bonsel GJ. Risk perception of participants in a family-based genetic screening program on familial hypercholesterolemia. Am J Med Genet A. 2003;116:136–143.
Senior V, Marteau TM, Weinman J. Perceptions of control over heart disease in people with an inherited predisposition to raised cholesterol. Psychol Health Med. 2005;10:16–30.
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Hunt K, Emslie C, Watt G. Barriers rooted in biography: how interpretations of family patterns of heart disease and early life experiences may undermine behavioural change in mid-life. In: Graham H, ed. Understanding Health Inequalities. Buckingham: Open University Press; 2001:113–126.
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☉ 11024493:Annals Journal Club: It’s Time to Get RADICAL
With this issue of Annals of Family Medicine, we launch a new feature to help readers build learning communities to improve health through enhanced understanding of primary care. We call it the Annals Journal Club, but this is not your old journal club. Rather, we encourage you to use this feature to develop your own RADICAL journal club. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act and Learn. We invite diverse groups, including students, residents, faculty members, practicing clinicians, health care workers, patients, and others to create forums for discussion and action.
Journal clubs have a long history as a structured forum to teach critical appraisal, transmit clinical information, and stimulate interest in research.1–5 Journal clubs include many local adaptations, but those that enjoy high attendance and longevity are more likely to involve food, mandatory attendance, strong perceived importance by a leader, formal teaching of critical appraisal skills, an emphasis on original research articles, and promotion independent of faculty.6,7 A recent systematic review identified 3 "best practices" for journal clubs: (1) use of a structured checklist, (2) explicit written learning objectives, and (3) a formalized meeting structure and process.8
These traditional approaches work well for many groups; however, the crises in our health care systems call for moving beyond tradition. It is time to use our evolving generalist evidence base to nurture the radical thinkers and leaders that must emerge if we are to build a future that assures equitable, quality, sustainable, personalized, integrated health care. The Annals Journal Club can be one forum where those who care will meet, share, learn and create change.
With each issue, the Annals Journal Club will select an article or articles and will identify questions to ignite reflection and conversation. We offer the Annals online discussion forum, called TRACK, as a way for local journal clubs to share their insights and conversation themes, and we will highlight commonalities or uniquely important ideas in our regular editorial synthesis called On TRACK. Comments submitted within 3 weeks after publication of an issue of Annals will have the greatest chance of being referenced in On TRACK.
Starting with this issue, journal club questions will appear on the inside back cover of the print version of Annals. In the online Annals, links to the questions are located at the top of the article and in the table of contents. Typically, questions will address the following 8 domains:
Issues addressed by the article—What is the research question? Why does it matter? How does it fit with what already is known? How can it help solve important problems for practice or policy?
Design of the study—Is the study design appropriate for the question and what already is known about the question?
Study methods—To what degree can the findings be accounted for by:
How participants were selected?
How key variables were defined and measured?
Confounding (false attribution of causality because two variables discovered to be associated actually are associated with a third factor)?
How information was interpreted?
Chance (as indicated by inferential statistics)?
Main findings—Does this study advance current knowledge?
Generalizability—How transportable are the findings to other settings, particularly to my patients, practice and community?
Implications—How can the information be used to change practice, policy or training?
Constituencies—Who are the constituencies for the findings, including patients, and how might they be engaged in interpreting or using the findings?
Next steps/new questions—What are the next steps in interpreting or applying the findings? What new questions arise and how might they be best answered?
Although we recognize that organizers will need to run the journal club in a way that works locally for their particular participants, we suggest a few ground rules:
Schedule regular meetings of your RADICAL Journal Club every other month, shortly after the Annals of Family Medicine is published free online (the fourth Tuesday of alternating months: January, March, May, July, September, November).
Share the expectation that everyone will read the article in advance. If necessary, make time at the beginning of the session for people to read.
Identify an enthusiastic and reliable convener, but treat leadership of the group process as a shared responsibility. Try to engage a variety of participants, including clinicians from different fields, other health care workers, patients, researchers, administrators and content experts.
If your journal club develops insights that might be useful to others, consider identifying a participant to succinctly write the transportable lessons from your discussion and post them on the Annals TRACK online discussion, as a student journal club did several months ago.9,10
Use the Annals Journal Club questions as a springboard for your own discussion, but do not be limited by them. Come up with your own; make it real for your local context, but think about the big picture too. Find the meaning for your situation and the problems and opportunities you see.
Create a conversation. Listen, talk, share, explore. Seek expertise and insights from all sources. Have fun.
Consider what individual or collective action you wish to take and TRACK to report what happens.
The word radical derives from radix, meaning root. We hope the Annals Journal Club and its RADICAL approach will nourish the deep roots of generalism and primary care and uproot that which needs challenging and change. It is time to get RADICAL. In summary:
Read the article critically
Ask the key questions for yourself
Discuss the meaning and shared interpretation
Inquire into other sources of knowledge and insight.
Collaborate with others who know or care about the issues.
Act by sharing a TRACK posting and working to change practice, policy, training, or research.
Learn from what others share on TRACK and from your actions and collaborations and restart the cycle.
FOOTNOTES
Conflicts of interest: none reported
REFERENCES
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Buzanowska K, et al. Journal club discussion on prevalence of primary HIV infection and the cost-effectiveness of expanded HIV testing.
Stange KC. Practical and contextual issues. Ann Fam Med. 2005;3:556–557....查看详细 (7660字节)
☉ 11024494:In This Issue: Communication in the Era of ’Personalized‘ Medicine
COMMUNICATION
I n this issue, we launch a new feature: the Annals Journal Club.1,2 this new journal club takes a RADICAL approach, stimulated by the need for local forums to address important problems in primary care, and for a venue for interaction between these groups.
We initiate the Annals Journal Club with 2 qualitative studies that relate to patient perceptions of risk and the implication of these perceptions for communication. Frich and colleagues find that patients with familial hypercholesterolemia use a 2-step process to develop a personal sense of vulnerability to coronary heart disease.3 Goldman et al study patients’ reactions to 3 strategies for communicating risk and find that cardiovascular risk-adjusted age may be a useful strategy for communicating about risk and motivating behavior change.4 As expectations grow about the ability to tailor diagnosis and treatment on the basis of genetic risk,5–12 these front-line studies show the need to understand and include patient perceptions in any planning for (genetically) "personalized medicine."13,14
Both Goldman et al and Frich et al find that earlier-than-usual age at disease onset is a commonly understood indicator of risk for adult diseases. "Risk age," compared with chronologic age, can be a powerful, personalized way of communicating the impact of risk factors and of risk-reducing measures. Premature disease in a family (eg, a heart attack in a middle-aged person) can motivate preventive measures but might also let relatives who have outlived that age feel "exempt" from the risk or prevent younger relatives from engaging in risk reduction until they are closer to the age at which family members have been affected. A dialog focused on age may be a productive way for clinicians to discuss prevention with patients at risk.
Several other studies raise issues that relate to communication between patients and clinicians. Williams et al discover that among patients in Veterans Affairs general medicine clinics whose screening tests are positive for alcohol misuse, the majority are ready to change their behavior.15 In addition, greater alcohol misuse severity is associated with greater readiness to change. These findings counter common stereotypes and should motivate clinicians to ask about alcohol use, to expect motivated patients, and to have systems available to follow up on positive patient responses.
In an international study that compares physicians in the United States and the Netherlands,16 different physician perceptions of their role, family wishes, and knowledge of the patient may explain more aggressive treatment of demented nursing home patients with pneumonia. Thus, the personal, social/societal, and relationship context for communication and decision making can have profound effects on the kind of care that is delivered.
Finally, an essay depicts the transforming effect of a physician’s limited ability to communicate.17 The personal experience of the restrictive effect of communication problems leads to lessons about communicating with patients who don’t speak the same language.
CESAREAN DELIVERY AND PATIENT CHOICE
In this issue, Zweifler et al report on the decline in vaginal births after cesarean sections (VBAC) in California.18 They show that this trend was already underway before a change in American College of Obstetricians and Gynecologist guidelines that might have restricted access to VBAC. Leeman and Plante19 write a provocative essay urging that systems of childbirth care preserve women’s options to choose vaginal birth—eg, after a previous cesarean delivery—amid discussions of elective primary cesarean delivery without labor. In March 2006 the National Institutes of Health convened a State-of-the-Science Conference regarding Cesarean Delivery on Maternal Request (CDMR). The report of this conference, confirmed the nationwide trend for decreasing rates of VBAC and the record-high cesarean delivery rate of 29.1% in 2004. The NIH panel concluded that the incidence of CDMR is unknown but probably contributes to the increase in primary cesarean births. They also concluded that there is insufficient evidence to evaluate its risks and benefits compared with planned vaginal delivery. The conference also proposed research questions to gather further evidence on this controversial topic.
ARTICLES OF POLICY, PRACTICE, AND RESEARCH INTEREST
In a case study of an interesting natural experiment, the leaders of 4 practice-based research networks with very different ways of organizing show how different initial conditions and processes for running a network are associated with different outcomes.20
In another natural experiment, Guirguis-Blake and colleagues21 use the National Practitioner Data Bank to examine the effect of caps in total and noneconomic damages on malpractice insurance payments across all 50 states and the District of Columbia. Amidst wide interstate variation, caps on total and noneconomic damages are associated with lower malpractice payments. The findings provide support for the effectiveness of certain forms of malpractice reform on payments.
A systematic review by Gartlehner and colleagues finds benefit from inhaled corticosteroids for patients with moderate or severe chronic obstructive pulmonary disease, but not for mild disease.22
Lack of trust is at the heart of human participant protection and privacy efforts, laws, and regulations. A new measure of patient trust in medical researchers is found to have good psychometric properties.23 The association with racial differences supports a large body of research showing that African American patients and many other minority groups have lower trust in researchers.24–31 This lower trust is based on many historical and current reasons,24,26,32,33 and is a major reason for lower participation of minority groups in medical research,24,26,27 and the resulting limited relevance of much medical research to minority groups.34,35 The development of a measure is a step toward furthering understanding and solution of this problem.
ACKNOWLEDGMENTS
We are grateful to Esa Davis, MD, MPH, and Sonja Haywood, MD, for their help in preparation of this editorial.
FOOTNOTES
Conflicts of interest: none reported
REFERENCES
Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: it’s time to get RADICAL. Ann Fam Med. 2006;4:196–197.
Annals Journal Club: A RADICAL approach. Ann Fam Med. 2006;4: iii.
Frich JC, Ose L, Malterud K, Fugelli P. Perceived vulnerability to heart disease in patients with familial hypercholesterolemia: a qualitative interview study. Ann Fam Med. 2006;4:198–204.
Goldman RE, Parker D, Eaton C, et al. Patients’ perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies. Ann Fam Med. 2006;4:205–212.
Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7:104.
Lunshof JE, Pirmohamed M, Gurwitz D. Personalized medicine: decades away? Pharmacogenomics. 2006;7:237–241.
Ferrara J. Personalized medicine: challenges in assessing and capturing value in the commercial environment. Expert Rev Mol Diagn. 2006;6:129–131.
Svinte M. The promise of personalized medicine: a conversation with Michael Svinte. Interview by Michael Millenson. Health Aff (Millwood). 2006;25:w54–60.
Kalow W. Pharmacogenetics and pharmacogenomics: origin, status, and the hope for personalized medicine. Pharmacogenomics J. 2006.
Ginsburg GS, McCarthy JJ. Personalized medicine: revolutionizing drug discovery and patient care. Trends Biotechnol. 2001;19:491–496.
Liotta LA, Kohn EC, Petricoin EF. Clinical proteomics: personalized molecular medicine. JAMA. 2001;286:2211–2214.
Langreth R, Waldholz M. New era of personalized medicine: targeting drugs for each unique genetic profile. Oncologist. 1999;4:426–427.
Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7:104. Epub 2006 Feb 27.
Langreth R, Waldholz M. New era of personalized medicine: targeting drugs for each unique genetic profile. Oncologist. 1999;4:426–7.
Williams EC, Kivlahan D, Saitz R, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med. 2006;4:213–220.
Helton MR, van der Steen JT, Daaleman TP, Gamble G, Ribbe M. A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumonia. Ann Fam Med. 2006;4:221–227.
Gordon PR. Thoughts on communication. Ann Fam Med. 2006; 4:264–265.
Zweifler JA, Garza A, Hughes S, Stanich M, Hierholzer A, Lau M. Vaginal birth after cesarean in California: before and after a change in guidelines. Ann Fam Med. 2006;4:228–234.
Leeman LM, Plante L. Patient choice vaginal delivery? Ann Fam Med. 2006;4:265–268.
Thomas P, Graffy J, Wallace P, Kirby M. How can primary care networks help integrate academic and service initiatives in primary care? Ann Fam Med. 2006;4:235–239.
Guirguis-Blake JM, Fryer GE, Phillips RL, Szabat R, Green LA. The US medical liability system: evidence for legislative reform. Ann Fam Med. 2006;4:240–246.
Gartlehner G, Hansen R, Carson S, Lohr K. The efficacy and safety of inhaled corticosteroids in patients with COPD: a systematic review and meta-analysis of health outcomes. Ann Fam Med. 2006;4:253–262.
Mainous AG III, Smith D, Geesey ME, Tilley B. Development of a measure to assess patient trust in medical researchers. Ann Fam Med. 2006;4:247–252.
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☉ 11024496:Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines
ABSTRACT
PURPOSE In 1999 the American College of Obstetricians and Gynecologists (ACOG) adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC). This study assesses trends in VBAC in California and compares neonatal and maternal mortality rates among women attempting VBAC delivery or undergoing repeat cesarean delivery before and after this guideline revision.
METHODS The 1996 through 2002 California Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital.
RESULTS Attempted VBAC deliveries decreased significantly from 24% before to 13.5% after guideline revision (P 2,500 g was the only significant predictor of neonatal mortality emphasizes the continuing need for detecting complications and referring when necessary.
Our finding of higher VBAC neonatal mortality rates confined to infants of very low birth weight is similar to that of a previous report.21 One possibility is that women with previous cesarean sections who have precipitous premature deliveries are classified as VBAC, even if they had planned to have a repeat cesarean section, which is supported by the higher rates of "successful" VBAC deliveries for infants of very low birth weight when compared with infants of other birth weights. Women who give birth precipitously have less time to receive antenatal steroids that improve neonatal mortality in infants of very low birth weight.22 Additionally, physicians and patients may be reluctant to subject pregnant women to an operative procedure if the newborn is unlikely to be viable. The finding that women with very low birth weight newborns who attempted a VBAC but ultimately had a cesarean section (failed VBAC) had similar neonatal mortality rates as women giving birth to very low birth weight infants by repeat cesarean section suggests the differences in neonatal mortality rates for infants of very low birth weight may be less a function of attempting a VBAC or electing to have a repeat cesarean section than a reflection of factors such as those described above.
This analysis reinforced important findings from previous studies of VBAC deliveries. No significant difference was found in maternal deaths for women who attempted a VBAC compared with those who had an elective repeat cesarean section.23–26 A much larger sample would be needed, however, to have the power to detect differences in maternal mortality. The proportion of older women and black women who attempted a VBAC delivery did not decrease after the 1999 revision to the same extent as the proportion of women from other age and racial/ethnic groups, a finding consistent with national VBAC trends.27
Our analysis of birth certificate information did not permit us to assess important neonatal or maternal morbidities, including neonatal hypoxic-ischemic encephalopathy or maternal uterine rupture. A recent prospective, nonblinded, multicenter observational study found higher rates of neonatal hypoxic-ischemic encephalopathy and maternal uterine rupture for women who underwent a trial of labor after cesarean (TOLAC) than women whose babies were delivered by repeat cesarean section.26 Our results agreed with those of Landon et al in finding no differences in neonatal mortality for term infants delivered by TOLAC or repeat cesarean section. Similarly, we both found no differences in maternal mortality, nor did Landon et al find higher rates of hysterectomy despite the higher rates of uterine rupture in their TOLAC group.26 Our study is not directly comparable with the Landon et al study, because there were differences in data collection methods (birth certificate analysis vs prospective chart review), population (State of California vs academic health centers), rates of successful VBAC (83% vs 73%), and sample size (311,989 repeat cesarean deliveries with 74,243 attempted VBAC, compared with 15,801 repeat cesarean deliveries and 17,898 TOLAC). Landon et al included higher proportions of women who were younger than 30 years, black, and on government aid in their TOLAC group. Landon et al classified women who arrived dilated 4 cm or more in the TOLAC group, which could have selected for women at higher risk because of less compliance with labor and delivery instructions or limited prenatal care.
Our study was further limited by other factors. Our results depended on proper coding of birth certificates, which are subject to misclassification.28 We were unable to determine whether there was under-ascertainment of VBAC or whether ascertainment occurred differently in patients with adverse outcomes. Birth certificate data are limited to what is routinely collected. Information not systematically collected includes gestational age or use of antenatal steroids, which are of particular importance in delivery outcomes for infants of very low birth weight. Birth certificate data of maternal mortality records only death within 72 hours, much less than the World Health Organization’s standard definition of maternal death within 42 days. Finally, it might be difficult to generalize our results to populations outside California, since California births may occur in settings more or less ethnically diverse or rural than others, and the successful VBAC rate for all women with previous cesarean births in California in 2002 was 8.0%, compared with the national rate of 12.6%.2 Even so, California’s 528,000 births in 2002 constituted 13.1% of the 4,022,000 US deliveries in that year.2
Our findings warrant further investigation. We recommend an assessment of the response of rural hospitals to the 1999 ACOG guideline revision, the capacity of rural hospitals to accommodate cesarean deliveries, and the risk status of mothers who give birth at rural or urban hospitals. We also recommend a study of neonatal mortality and morbidity associated with very low birth weight for women with previous cesarean sections that accounts for precipitous or unplanned VBAC deliveries.
During the last decade, the pendulum in the United States has swung dramatically away from VBAC deliveries and toward repeat cesarean section.29 The ACOG 1999 VBAC guideline revision reflects concern for VBAC delivery safety and may have accelerated this trend, particularly at rural hospitals. Our findings suggest that women expecting to give birth to normal– or large–birth-weight infants can anticipate similar neonatal mortality with a VBAC or a repeat cesarean section. These findings, based on 386,232 California births after previous cesarean delivery, do not contradict the AAFP TOLAC statement. Concerns, however, regarding medicolegal consequences of complications, such as uterine rupture, which we were unable to assess using birth certificate data, may continue to temper patient and physician enthusiasm for VBAC deliveries. We recommend that a balanced presentation of risks and the encouraging outcomes found in this analysis be included in discussions with pregnant patients who have had a previous cesarean section. An evidence-based approach to VBAC delivery incorporating these findings may lead to further refinements in guidelines for medically managing women with a previous cesarean delivery.
ACKNOWLEDGMENTS
We wish to thank Norman Hearst, MD, MPH; Kathleen Ramos, PhD; and Sean Schafer, MD, for commenting on our manuscript.
FOOTNOTES
Conflicts of interest: none reported
Received for publication August 10, 2005. Revision received December 14, 2005. Accepted for publication December 26, 2005.
REFERENCES
Scott JR. Avoiding labor problems during vaginal birth after cesarean delivery. Clin Obstet Gynecol. 1997;40:533–541.
Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2002. Natl Vital Stat Rep. 2003;52:1–113.
National Institutes of Health. Cesarean childbirth. NIH Consensus Statement Online.. Accessed: 23 August 2004.
Healthy People 2000. Washington, DC: US Department of Health and Human Services; 1990.
Vaginal delivery after a previous cesarean birth. Washington, DC: American College of Obstetricians and Gynecologists. ACOG Committee on Obstetric Practice; 1994. Opinion No. 143.
ACOG Practice Patterns. Vaginal delivery after previous cesarean birth. Washington, DC: American College of Obstetricians and Gynecologists; 1995. Practice bulletin No. 1.
Flamm BL. Vaginal birth after cesarean: what’s new in the new millennium? Curr Opin Obstet Gynecol. 2002;14:595–599.
Clinical management guidelines for obstetrician-gynecologists: vaginal birth after previous Cesarean delivery. Washington, DC: American College of Obstetricians and Gynecologists. ACOG Committee on Practice Bulletins; 1999. Practice Bulletin No. 5.
Harer WB, Jr. Vaginal birth after cesarean delivery: current status. JAMA. 2002;287:2627–2630.
ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol. 2004;104:203–212.
Wall E, Roberts R, Deutchman M, et al. Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section. Leawood, Kan: American Academy of Family Physicians; 2005.
Raynor BD. The experience with vaginal birth after cesarean delivery in a small rural community practice. Am J Obstet Gynecol. 1993;168:60–62.
Holland JG, Dupre AR, Blake PG, Martin RW, Martin JN, Jr. Trial of labor after cesarean delivery: experience in the non-university level II regional hospital setting. Obstet Gynecol. 1992;79:936–939.
Cameron B, Cameron S. Outcomes in rural obstetrics, Atherton Hospital 1991–2000. Aust J Rural Health. 2001;9(Suppl 1):S39–S42.
California Office of Statewide Health Planning and Development. Annual Hospital Utilization Pivot Profiles, 1999–2001. Accessed: 10 October 2003.
California Department of Health Services Health and Welfare Agency. Certificate of Live Birth - VS-10A Medical Data Supplemental Work Sheet.
Armitage P, Berry G, Matthews JNS. Statistical Methods in Medical Research. 4th ed. Oxford: Blackwell Science Ltd; 2002.
Flamm BL. Once a cesarean, always a controversy. Obstet Gynecol. 1997;90:312–315.
Vaginal birth after cesarean birth--California, 1996–2000. MMWR Morb Mortal Wkly Rep. 2002;51:996–998.
Pinette MG, Kahn J, Gross KL, et al. Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine. J Matern Fetal Neonatal Med. 2004;16:37–43.
Riva HL, Teich JC. Vaginal delivery after cesarean section. Am J Obstet Gynecol. 1961;81:501–510.
Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH Consens Statement. 1994;12:1–24.
Socol ML. VBAC--is it worth the risk? Semin Perinatol. 2003;27:105–111.
Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362:1779–1784.
Guise JM, Berlin M, McDonagh M, et al. Safety of vaginal birth after cesarean: a systematic review. Obstet Gynecol. 2004;103:420–429.
Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004;351:2581–2589.
Menacker F, Curtin SC. Trends in cesarean birth and vaginal birth after previous cesarean, 1991–99. Natl Vital Stat Rep. 2001;49:1–16.
Green DC, Moore JM, Adams MM, et al. Are we underestimating rates of vaginal birth after previous cesarean birth? The validity of delivery methods from birth certificates. Am J Epidemiol. 1998;147:581–586.
Grady D. Trying to avoid 2nd Caesarean, many find choice isn’t theirs. New York Times. November 29, 2004: A1, A19....查看详细 (25963字节)
☉ 11024497:A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia
ABSTRACT
PURPOSE We wanted to explore factors that influence Dutch and US physician treatment decisions when nursing home patients with dementia become acutely ill with pneumonia.
METHODS Using a qualitative semistructured interview study design, we collected data from 12 physicians in the Netherlands and 12 physicians in North Carolina who care for nursing home patients. Our main outcome measures were perceptions of influential factors that determine physician treatment decisions regarding care of demented patients who develop pneumonia.
RESULTS Several themes emerged from the study. First, physicians viewed their patient care roles differently. Dutch physicians assumed active, primary responsibility for treatment decisions, whereas US physicians were more passive and deferential to family preferences, even in cases when they considered families’ wishes for care as inappropriate. These family wishes were a second theme. US physicians reported a perceived sense of threat from families as influencing the decision to treat more aggressively, whereas Dutch physicians revealed a predisposition to treat based on what they perceived was in the best interest of the patient. The third theme was the process of decision making whereby Dutch physicians based decisions on an intimate knowledge of the patient, and American physicians reported limited knowledge of their nursing home patients as a result of lack of contact time.
CONCLUSION Physician-perceived care roles regarding treatment decisions are influenced by contextual differences in physician training and health care delivery in the United States and the Netherlands. These results are relevant to the debate about optimal care for patients with poor quality of life who lack decision-making capacity.
INTRODUCTION
Dementia—a progressive illness of cognitive, functional, and physical deterioration—is a major cause of morbidity and mortality.1 The sequelae of advanced dementia frequently lead to pneumonia, which can be a terminal event in long-term care settings.2,3 The development of pneumonia in elderly patients with dementia often raises multiple ethical and clinical issues for physicians, and there is wide variation in the care of these patients across cultures. For example, in Dutch long-term care settings, demented residents who develop pneumonia are rarely hospitalized but are treated empirically and symptomatically within the nursing home.4 In the United States, however, many patients acquiring pneumonia in long-term care facilities are transferred to acute-care hospitals.5–7 Often the result is aggressive care involving use of diagnostic interventions, intravenous antibiotics, and rehydration therapy7,8 despite evidence that treatment in a hospital rather than the nursing home does not improve outcomes, such as mortality9,10
The wide variation between US and Dutch approaches to this care has been attributed to contextual differences on 2 levels: the system of organizing nursing home care, and the legal and social understanding of end-of-life decision making.8 These contextual differences are frequently embedded in both professional and family values regarding end-of-life decision making. A qualitative study of US family members of nursing home residents with dementia, for example, found families had painful emotional needs that dominated decision making.11 In both cultures, however, physicians are still ultimately responsible and accountable for this care, because a physician’s order is necessary for initiating and coordinating care between acute-care hospitals and long-term care. To understand the variation in this care further, we conducted an exploratory study to determine which factors Dutch and US physicians perceive as important in their treatment decisions regarding nursing home patients with dementia who become acutely ill with pneumonia.
METHODS
We used a qualitative research design with semistructured interviews conducted by the principal investigator (MRH). Purposeful sampling in the United States and the Netherlands identified 2 sets of physicians who care for nursing home patients. In both countries, we sought physicians who represented a wide range of clinical experience, worked in both rural and urban settings, and varied in their care approaches at the end of life. We anticipated that 12 physicians in each country would be sufficient to reach a threshold level of data saturation. An interview guide was used to direct exploration of factors that potentially influence medical decision making, as well as physicians’ thoughts and experiences in this area of clinical care. Participants were asked to describe and reflect on 2 actual cases of pneumonia in nursing home patients with dementia: one in which a curative or aggressive approach was undertaken, and one in which a palliative or comfort care approach was chosen.
The interviews were conducted in English, tape recorded, professionally transcribed, and checked for accuracy by the principal investigator, who is a family physician. Initial coding was performed by the principal (MRH) and coinvestigator (TPD), and the interviews were read to identify emerging patterns using editing analysis in which meaningful segments of text are coded to construct and interpret common themes.12 Concurrent independent analyses were performed by an American anthropologist with expertise in qualitative research (GRG) and a Dutch epidemiologist experienced in Dutch physician decision making and nursing home care (JTS). All investigators subsequently met and iteratively reviewed the codes and categories to reach consensus. Themes were compared within and across interviews, as well as within and across cultures. All data were analyzed using qualitative research software (QSR N6).13 The study was approved by the University of North Carolina Committee on the Protection of the Rights of Human Subjects.
RESULTS
Our participants all cared for patients with dementia who resided in nursing homes. The US physicians were board-certified in their specialty, 8 in family medicine and 4 in internal medicine, with 6 having additional training in geriatrics. The average age was 46 years (range 35 to 57 years); 4 were women. The Dutch physicians were trained in nursing home medicine, which is a separate specialty in the Netherlands, and had an average age of 44 years (range 33 to 60 years); 5 were women. Our analysis of the interviews resulted in the identification of 3 domains or thematic areas influencing physician decision making for demented nursing home patients who develop pneumonia. By the last few interviews, data saturation was achieved, namely, no new themes or ideas emerged.
Physician Patient Care Role
The physician’s patient care role was an implicit and overt set of expectations and assumptions regarding the physician’s diagnostic strategies and provision of care. US physicians described a passive knowledge of the patient typified by a reliance on technology, a proxy assessment by nursing home staff or emergency department physicians, and discontinuity. These physicians reported often not knowing their nursing home patients because of the infrequency of visits or lack of time or opportunity to get to know the patients and their families.
"My interactions with the family are hit or miss. As doctors, we sneak in and we sneak out. The nurses know them very well, but I don’t have occasion to have that much interaction with them" (US physician 5).
"If you haven’t talked to the family as much as you liked to, you might not be on the same page, and sometimes it seems safer to send them [the patients] to the ER and at least they get a good evaluation there with good x-rays, and then maybe the discussions can be made there" (US physician 6).
In contrast, Dutch physicians depicted a contextual knowledge of the patient encompassing a relationship of continuity, personal and first-hand understanding, and appreciation of the patient’s quality of life and functional status.
"What I try to do in each patient is to carefully look at how he is, try to get an idea how he feels, how he functions in the ward, how he relates still to other people, how happy he or she is" (Dutch physician 10).
As a result of this knowledge, the Dutch physicians reported they seldom use chest radiographs, blood tests, or technology in their assessment; instead, they rely on clinical signs and symptoms and their physical examination. This reliance on clinical acumen by Dutch physicians was tied to a perceived duty to protect the patient from medical interventions.
"I feel very representative of medical society that has offered so many things that it is my duty to bring them out of the pace of the medical path we have come along until now, and to bring them more to human insight" (Dutch physician 12).
Although Dutch physicians highly value family input, they saw their role as assuming responsibility for the decision and were less willing to render care they saw as inappropriate, even if it is against family wishes.
"Before I make the decision, I want to know how the family thinks about the problem, or how the family thinks mother or father would think about this problem. I make it clear that they don’t have to make the decision. I make the decisions. And I think they quite often see that as a relief" (Dutch physician 7).
This sense of responsibility was linked to relieving the patient’s suffering and not engaging in practices they saw as futile. Dutch physicians voiced a role as the filter between family wishes and the treatment decision, where family wishes were considered but the physician’s decision ultimately prevailed.
"If I have the feeling that I’m not only prolonging suffering but also making suffering worse, then I will be very strong and say ‘no’" (Dutch physician 12).
In contrast, American physicians were more likely to report their role as one that provided information to the family in a passive and deferential fashion.
"If I had my druthers, I suppose I would transport very, very few patients out of the nursing home. But it’s really not my decision. I’m there as a medical provider, and these decisions about how much care each individual patient is going to receive is really made by the family for these demented folks. I am there to provide information" (US physician 9).
Family’s Patient Care Wishes
Family wishes, or the preferences regarding care, were important in both cultures, but American physicians were more deferential to the family, often citing the possibility of threat from the family.
"It’s not appropriate to send the patient to the hospital to treat the pneumonia. But when push comes to shove, if I advise not doing it—let the patient just die in peace—and the family says, ‘No, we want them to go to the hospital,’ they go to the hospital because I don’t want to be sued" (US physician 4).
Although a few Dutch physicians mentioned a concern for disciplinary action that families could potentially take against them, their inclination to do what was best for the patient superseded those fears.
"She was very demented, could not drink or eat, didn’t know anything, and was not conscious. I didn’t want to transport her to the hospital anymore, and despite what the family wanted, that was my decision. That is a decision that you sometimes have to make, as a doctor" (Dutch physician 3).
Process of Physician Treatment Decision
Physician treatment decisions resulted from a process that included an interpretation of the patient’s course of illness, quality of life, functional status, and perceived resuscitation preferences, followed by negotiation with the family. American physicians described the patient’s quality of life as often as Dutch physicians; however, they were less likely to reflect upon it in their decision making and more likely to acknowledge the discomfort they felt arriving at decisions they did not believe were appropriate:
"Many times I feel that instead of prolonging life, which I take very seriously, many times I feel like all I’m doing is postponing death" (US physician 4).
American physicians tried to inform families of their opinion regarding appropriate care but ultimately were deferential, letting families direct the course of care they wanted, despite the physician’s preferences.
"You need to understand if we do go back to the hospital, we’re going to unleash a medical evaluation apparatus that means multiple testing, and it’s hard to control that. I tell them I’m not sure this is the thing that’s best for your loved one. I try to go through it and then I usually defer" (US physician 11).
Although Dutch physicians kept family members involved in the decision-making process and helped families grieve and cope, their sense of responsibility to the patient was primary. As a result, the process was physician driven.
"I am used to really taking time and effort, really trying to connect to the family member that is trying to do his or her best for our patient ... by investing time and really trying to connect with someone, really telling what my viewpoint is. And in my experience that almost every time leads to the fact that you all together come to the right decision" (Dutch physician 6).
"It is a matter of trying to keep everyone satisfied, as though you are in a rocking boat and trying to maneuver through the whole process, and everyone at the end of the process has the feeling that that was a nice piece of maneuvering and has a good feeling about it" (Dutch physician 2).
In their process of decision making, Dutch physicians reported placing a high value on patient quality of life and used that information as a key determinant as to whether a patient was treated aggressively. Dutch nursing home physicians often cited the ways in which they acquired their close knowledge of patients and their families, which was helpful when an acute illness arose.
"Because I look after patients during months usually, and during years often, I know them very well. Not only the patients, but also the relatives. So when there is a crisis, we have been through quite a bit before we arrived at this point where we are going to have this ultimate talk" (Dutch physician 4).
Although American physicians also acknowledged that previous and ongoing care discussions would be ideal, they often broached them only during an acute illness.
"You’ll improve the odds of not being inappropriately aggressive if you talk with the family ahead of time. If you wait until the patient is acutely ill and then ask them to consider just letting the patient die peacefully, generally they can not think straight at that time and will opt for the more aggressive treatment" (US physician 4).
Where Dutch physicians used quality-of-life assessment, American physicians cited the patient’s code status as a major consideration in the process of making treatment decisions, expressing frustration at the obligation to transport patients from the nursing home to the hospital if the patient did not have a "no code" or "do not resuscitate" order.
"The ‘full code’ ones are a little more difficult, because we probably already failed them at some point along the way in that they shouldn’t be a full code, so there’s been a problem some place. Either the family doesn’t really understand, or I haven’t really done an adequate job of explaining the difference between code and no code. But given that, if they’re a full code and they’re obviously becoming sick and something acute is happening, then occasionally we can keep them, but frequently we have to transport them out" (US physician 9).
In Dutch nursing homes, patients with dementia are not candidates for resuscitation, which is considered inappropriate and futile, and most Dutch physicians do not even discuss the possibility with families.
"I do not offer resuscitation when I talk to relatives or to a patient, because I think it’s a silly notion, when you talk about demented patients. The outcome is a much worse patient and the suffering will increase many fold. So we don’t offer that as an option" (Dutch physician 4).
There were differences within the 2 groups of physicians, as well as similarities between the US and Dutch physicians. US physicians also described cases for which treatment was withheld, and Dutch physicians were sometimes directive in recommending treatment.
"She was very demented and generally unhappy. We can’t cure her of dementia, and she is never going to get better. We could have saved her to die again in a few months or weeks. I look at it as the natural progression of the disease, and feeding tubes and antibiotics just are not appropriate. To me, helping someone pass away in a comfortable way is rewarding and you feel very protective. It is important to change gears from helping them to live to helping them to die nicely" (US physician 10).
"She was acutely ill with pneumonia. But she was, before she became ill, in a quite good condition, although the dementia was quite severe. I didn’t discuss it with the family. I told them she had pneumonia and that she has to be treated. I think I treat everyone unless there is a reason the treatment would not be successful" (Dutch physician 7).
DISCUSSION
Although physicians in the United States and in the Netherlands who care for demented elders in long-term care settings work in different social and cultural environments, both shared the belief that nonaggressive care was sometimes appropriate when demented nursing home patients became ill with pneumonia. These individual beliefs, however, were manifested differently for US and Dutch physicians in their role perceptions, in the process of their decision making, and in the way they responded to the patients’ family’s wishes.
The discordance between individual beliefs and social roles points to the importance of contextual elements within the physicians’ environment. To account graphically for these influences on physician decision making, we constructed conceptual models for US and Dutch physicians (Figures 1 and 2). Both models embed 3 contextual elements—societal values and constraints, technological medical training and values, and the policies and practices of the nursing home—as background factors that affect influences on physician decision making.
Figure 1 depicts contextual elements and influences on US physician decision making. The dominant contextual element in this model is technological medical training and values. American nursing homes are generally staffed by physicians trained in internal medicine and family medicine, where acute-care hospitals are primary training sites, and emphasis is placed on technology and diagnostics.14,15 The organization of nursing home care in the United States further constrains and shapes the physician’s role, as nursing home responsibilities are frequently a small part of a physician’s overall clinical practice, and busy physicians spend limited time there.16 In our study, American physicians frequently mentioned the lack of time for seeing patients at nursing homes, citing the poor financial reimbursement they receive for such work and their need to spend time at their primary site of practice, which is usually an office or hospital setting.
The organization of nursing home care also leads to a reduced sense of physician responsibility and a system in which medical decision making is often deferred to others, such as the family or hospital physicians. Larger societal values, such as personal autonomy, and constraints, such as litigation, play a part as well. Compared with their Dutch counterparts, US physicians perceived more threat from the family, most likely because they do not know the family well, and perhaps because they also work in a more uncertain legal and ethical climate.17 These contextual elements result in American physicians seeing their roles as more passive and neutral, diminishing their influence in the treatment decision and placing higher value on the perceived wishes of the family, and resulting in deferral to more-aggressive care along the treatment spectrum (Figure 1).
For Dutch physicians, the societal values and constraints include the wide public discussion regarding end-of-life care and the place of suffering in the Netherlands.17,18 Physician training of nursing home physicians, a second contextual element, places less emphasis on technology than in the United States. In the Netherlands, nursing home medicine is a specialty for which physicians are trained exclusively in nursing home settings and then employed there as their only site of practice.19 This organization of care provides the venue for physicians to get to know their patients and patients’ families; discussions can be facilitated and are more likely to occur, even before an acute illness. Although family input is important, Dutch physicians are more active in directing the family, embodying both societal and medical values that expect them to assume primary responsibility. As a result of their attitude in acting in the best interest of the patient, physician decision making favors the less-aggressive end of the treatment spectrum in our model (Figure 2). We included antibiotics for palliation in the model, however, as antibiotic treatment is a practice of Dutch physicians,4 even though evidence of the palliative effects of antibiotics is lacking.20
We triangulated our conceptual models with the perspective of society and the family, both of which play an important role in our model. Triangulation uses multiple data sources to support and enhance the understanding of the phenomenon under study.21,22 To begin, standards of care, although they are advanced by the health care profession, ultimately require the endorsement of society.23 Our model depicting the influence of Dutch society on physician decision making is supported by Dutch law and various Dutch medical professional organizations, which explicitly recognize that treatment may be withheld if the physician considers treatment futile, with the single Dutch guideline issued on the topic focusing on when to withhold antibiotics.24 In contrast, treatment guidelines for nursing home-acquired pneumonia in the United States focus on decisions related to hospitalization, choice of antibiotics, and when to switch from parenteral to oral treatment.25 Cure of the acute disease is often the primary focus, even with an underlying diagnosis of severe dementia.2
The Netherlands has even taken the controversial step of decriminalizing physician euthanasia, if certain procedures are followed and specific requirements are met, including the explicit request of a competent patient. The requirement for competency limits the practice of euthanasia in patients with dementia, and physician-assisted suicide in nursing home settings is rare, even in patients with an advance euthanasia directive.26,27 The Netherlands, however, has recently issued strict guidelines for the deliberate ending of life for newborns who live with severe and sustained suffering from incurable conditions, evidence that they do believe proxy decision makers can make end-of-life decisions for incompetent patients.28 Physician-assisted suicide, as embodied in the Oregon right-to-death movement, remains a contested ethical and legal issue in the United States, with many initiatives challenged in the court system. Although our study did not address euthanasia, this background highlights the societal differences between the United States and the Netherlands regarding attitudes toward death and dying. From an ethical point of view, active euthanasia is distinct from actions intended to hasten the end of life by withholding curative care and from administering medications primarily to manage pain or other symptoms but with the potential for hastening death.29
Families play an important role in our models, and physicians frequently mentioned their role in shared decision making. Family members in the United States continue to report dissatisfaction with the quality of end-of-life care delivered to their family member who died in a nursing home setting, citing high rates of unmet needs for symptom management, concerns about physician communication regarding medical decision making, a lack of emotional support for themselves, and a belief that their dying family member was not always treated with respect.30–32 Dutch physicians explicitly consider families’ feelings and preferences,33 but Dutch families’ attitudes and experiences need to be studied in greater detail.
Our findings suggest that Dutch physicians are more directive in their communications, exhibiting paternalism toward patients and their families. In contrast, physicians in the United States have moved away from this approach and toward a greater emphasis on patient autonomy.34 One risk of patient autonomy, however, is the withholding of physician clinical experience and recommendations regarding care. Beyond patient autonomy, physicians have the duty of beneficence to share their judgments about the futility or success of interventions or treatments.35 Quill and Brody have proposed an "enhanced autonomy" model that encourages patients, surrogate decision makers, and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient’s best interests; recommendations that arise from this process promote a collaboration among patient, families, and the physician so that choices are informed by both the medical facts and the physician’s experience.36 The current structure of nursing home care in the United States inhibits the implementation of this model, because it requires regular communication and a relationship with the patient and the family. In contrast, Dutch nursing home physicians have the structure to develop these relationships and utilize this model but would need to consider a less paternalistic approach to their care.
There are several limitations to our study. As an exploratory study, the conceptual model should be considered preliminary and open to modification. Qualitative studies are not intended to be statistically representative of any population but to provide an in-depth examination of complex phenomena. The frequency and validation of participating physicians’ experiences were not determined. There were many similarities between the US and Dutch physicians, as well as differences within the 2 groups, but the contextual influences were strong enough to emphasize the differences between the groups. Because we were interested in the physicians’ viewpoint, we did not quantify the degree of dementia or pneumonia in the patients. There are more nursing home beds per capita in the United States than in the Netherlands, so it could be that Dutch nursing home patients are sicker.37 Even so, the strength of this investigation lies in the in-depth examination and the emerging conceptual model, which depicts a complex interplay of medical and nursing home systems and societal phenomena. Finally, our results and model are based on the physician’s perspective and do not address the patient, family, or other nursing home employee view.
In summary, we found that physicians from the United States and the Netherlands described differences in their patient care roles, the family’s patient care wishes, and the process by which they make treatment decisions regarding care of demented nursing home patients who develop pneumonia. Efforts to improve the care of these patients must involve consideration of the context of societal values, the location of physician training, and the processes by which physicians determine and negotiate patient and family preferences regarding care.
FOOTNOTES
Conflicts of interest: none reported
Funding support: The US National Institute on Aging (Grant #AG01033), the Fetzer Institute, and the Donald W. Reynolds Foundation provided funding support. The authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Received for publication July 25, 2005. Revision received November 11, 2005. Accepted for publication November 21, 2005.
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Boockvar KS, Gruber-Baldini AL, Burton L, et al. Outcomes of infection in nursing home residents with and without early hospital transfer. J Am Geriatr Soc. 2005;53:590–596.
Forbes S, Bern-Klug M, Gessert C. End-of-life decision making for nursing home residents with dementia. J Nurs Scholarsh. 2000;32:251–258.
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Ribbe MW, Ljunggren G, Steel K, et al. Nursing homes in 10 nations: a comparison between countries and settings. Age Ageing. 1997;26 Suppl 2:3–12....查看详细 (34483字节)
☉ 11024498:Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol Misuse
ABSTRACT
PURPOSE Readiness to change drinking may influence the content or effectiveness of brief alcohol counseling. This study was designed to assess readiness to change and its relationship to alcohol misuse severity among primary care patients whose screening questionnaire was positive for alcohol misuse.
METHODS This study was a cross-sectional analysis of data collected from 2 consecutive mailed questionnaires. Male outpatients at 7 Veterans Affairs (VA) general medicine clinics were eligible if they returned both questionnaires, screened positive for alcohol misuse (augmented CAGE Questionnaire 1 point), responded to 3 readiness-to-change questions, and completed the Alcohol Use Disorders Identification Test (AUDIT). A validated algorithm based on 3 standardized questions categorized participants into 3 readiness groups (precontemplation, contemplation, action). Measures of alcohol misuse severity included AUDIT, CAGE, and the 3 consumption questions from the AUDIT (AUDIT-C). Analyses were descriptive; linear-by-linear associations between alcohol misuse severity and readiness were tested with 2 statistics.
RESULTS Response rates to the first and second surveys were 59% and 55%, respectively. Of the 6,419 eligible outpatients who screened positive for alcohol misuse, 4,797 (75%) reported any readiness to change (contemplation 24%, action 51%). Among patients with AUDIT scores >8, more than 90% indicated that they drank more than they should and/or had contemplated drinking less. Greater readiness was significantly associated with greater alcohol misuse severity (P 20). Similarly, higher severity of alcohol misuse was associated with increasing percentages of patients in the contemplation group reporting wanting but not having been able to reduce drinking: 3% in AUDIT zone 1; 10% in AUDIT zone 2; 27% in AUDIT zone 3; and 60% in AUDIT zone 4.
DISCUSSION
In this population of male VA primary care patients who screened positive for alcohol misuse in the past year, 75% indicated some readiness to change. Contrary to a stereotype that patients with alcohol misuse will deny concerns about their drinking, most patients whose tests were positive for alcohol misuse in this population indicated they drank more than they should or had considered or tried decreasing drinking. Moreover, readiness to change increased steadily as the severity of alcohol misuse increased. Among patients who scored 8 or more on the AUDIT, indicative of a high likelihood of active alcohol use disorders in this population,34,35 readiness to change was relatively stable, with more than 90% of patients indicating that they drank excessively or had considered change (Figure 2).
Findings of the present study were consistent with those of 2 previous primary care studies.11,17,18 Both required that patients provide written informed consent to participate in a study of their drinking. One study was small, and 56% of the 184 participating patients who had positive CAGE scores no longer drank alcohol.18 The other study used a sample of patients recruited for a randomized controlled trial of brief alcohol counseling interventions.11 In that study, 78% of patients who had positive test results did not participate in the trial, potentially limiting the generalizability of their findings. Our study is the first to describe readiness to change in a large sample of primary care patients who screened positive for alcohol misuse but were not being recruited into a study focusing exclusively on their drinking.
This study has several noteworthy limitations. First, our population consisted of male VA patients who were predominantly white and older, which may limit the generalizability of our findings to women and other primary care populations. Second, nonresponse bias could have influenced our findings. Forty-five percent of patients who screened positive for alcohol misuse on the initial ACQUIP survey were not included in these analyses. Nonparticipants were more likely to screen positive for a lifetime history of alcohol abuse or dependence on the CAGE, but were less likely to report high levels of current consumption on the AUDIT-C. Lower AUDIT-C scores among nonrespondents could reflect underreporting of alcohol use. Even in the unlikely event that all nonrespondents to the Drinking Practices Questionnaire were in the precontemplation group, however, almost one half of the resulting sample would still have been classified in contemplation or action. Social desirability could also have accounted for some of our findings. Patients who were not interested in changing might minimize their alcohol misuse and related problems or overreport recent decreases in their drinking so that their primary care clinicians would not bother them about their drinking. Finally, the algorithm used to measure readiness to change in this study has been validated only in a female VA population.28
The study also has several important strengths. First, the size of the sample is a strength, as is that more than 10% of the entire eligible study sample screened positive for alcohol misuse and returned the Drinking Practices Questionnaire. Additionally, the prevalences of self-reported alcohol misuse and related problems were high, decreasing the likelihood that high rates of readiness to change reflected social desirability bias and providing rich variation in alcohol misuse among participants. Finally, although the readiness-to-change questions have been validated in only women veterans, the brevity and clinical accessibility of this instrument makes it one of our study’s unique strengths.
This study indicates that most primary care patients who screened positive for alcohol misuse and who returned a questionnaire that assesses alcohol misuse had some recognition that they drink more than they should and/or have at least contemplated drinking less. Moreover, as screening scores increased, patients were more likely to report wanting but having been unable to decrease drinking. These findings have several implications for clinicians. First, primary care clinicians sometimes expect patients to deny their alcohol misuse when the issue is raised.13–16 Such denial is often thought to be especially common among patients with the most-severe problems, indicative of alcohol dependence.14
Our findings support findings of previous studies in more-select populations that suggest the opposite is true. The more a patient drinks and the more severe his problems caused by drinking, the more likely he will report recognition of or interest in changing his drinking. A recent study of clinicians’ attitudes and their association with smoking cessation counseling reported that clinicians’ perceptions that patients are not willing to quit smoking were associated with a lower counseling proclivity.40 Similar clinicians’ attitudes may be a barrier to conducting brief alcohol counseling interventions among patients with alcohol misuse. Our finding that most primary care patients with alcohol misuse report some level of readiness to change could help correct such attitudes. Second, these findings suggest that primary care clinicians could use scores obtained from brief alcohol-screening questionnaires as an indicator of readiness to change. Patients whose screening tests are positive but who have low scores are least likely to recognize they drink more than they should or to considered changing; brief advice aimed at assisting with problem recognition and building motivation may be most appropriate for these patients.
Maisto et al found that low levels of readiness to change at baseline were associated with improved drinking outcomes at follow-up for patients who received brief advice.11 Taken with our findings, we hypothesize that patients with the least severe alcohol misuse, who are least likely to recognize that they drink excessively or to have contemplated change, may benefit most from brief alcohol-related advice in primary care settings.11 This stance is consistent with current evidence-based guidelines that recommend screening for the entire spectrum of alcohol misuse in primary care settings.4,41 Appropriate and brief screening tests for this purpose include the AUDIT-C or single-item questions about binge drinking.34,42,43
That patients in this study with higher alcohol-screening scores were more likely to indicate recognition of their alcohol misuse or interest in changing should not be confused with readiness to enter specialized alcohol treatment. Many patients in this study’s contemplation group reported wanting but having been unable to decrease drinking, which was positively associated with the severity of alcohol misuse. Patients with more-severe alcohol misuse may need more-intense or repeated primary care interventions to support them toward specialized addictions treatment or abstinence.44,45 Similarly, it is unknown whether indication of readiness to change by primary care patients will result in subsequent changes in drinking, though patient readiness to change has been associated with decreased drinking in hospitalized patients.27 Further research is needed in both of these areas.
In conclusion, this study shows that most primary care patients who screen positive for alcohol misuse indicate concern about or are considering changing their drinking. Further, simple questions can elicit statements reflecting readiness to change, and patients with the highest alcohol-screening scores and greater alcohol misuse severity are most likely to indicate some readiness to change drinking. These findings should help counter clinician attitudes that patients with alcohol misuse deny excessive drinking or will not be interested in changing.
FOOTNOTES
Conflicts of interest: none reported
Funding support: The Ambulatory Care Quality Improvement Project (ACQUIP) was funded by Veterans Affairs Health Services Research and Development grants: SDR 96-002 and IIR 99-376. Dr Bradley is supported by a National Institute on Alcohol Abuse and Alcoholism award (K23AA00313) and was a Robert Wood Johnson Generalist Physician Faculty Scholar at the time this work was completed.
Disclaimer: Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, the National Institute on Alcohol Abuse and Alcoholism, or the Robert Wood Johnson Foundation.
Received for publication June 29, 2005. Revision received October 28, 2005. Accepted for publication November 28, 2005.
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☉ 11024499:Thoughts on Communication
ABSTRACT
Living without the ability to communicate is humbling. Time spent on a sabbatical in Florence, Italy, taught me that my outgoing manner, my interactional skills, and my ability to establish rapport, all personality traits and skills that I thought would overcome my inadequacies as a communicator in Italian are not immutable. I gained some understanding of what our nonnative English-speaking patients might feel. I learned the following lessons: (1) be cautious—what appears to be a lack of interest may be a lack of understanding; (2) our perceptions of aptitude may be mistaken if based on patients’ facial expressions and body language; (3) we should not adjust our words and speed of speech just because we think a patient cannot understand what we are saying; and (4) language is an amazingly powerful tool—the inability to communicate transforms us.
I just returned from Italy. My silence ends. I am able to communicate again. I spent the last 3 months on sabbatical at a medical school in Florence, Italy. Although I did not speak Italian, I was fluent in Spanish and hoped that would be enough; even my faculty sponsor in Florence was confident that because his colleagues were all able to speak English, I would have no major problems.
I did. I’m an educated professional, reasonably outgoing, with good interpersonal skills and language facility. I thought I would easily adapt. Survival would be no problem. It was. It was a problem with those I met at the supermarket, with Italians with whom I rode to work, with neighbors doing laundry at the laundromat. It was even a problem with the man who repaired my shoes. These Italians spoke no English, and at the end of the day I found myself staying at home alone to avoid any kind of personal contact.
On the bus ride to the hospital every morning, I found myself avoiding eye contact—the same eye contact I suggest my medical students use to improve their communication with patients. I was afraid to look at anyone fearing that I wouldn’t be able to answer simple questions, such as, "Which stop should I get off at to go to the St. Ambrosia market?" I feared, not just the inability to respond, but the embarrassment of appearing like a typical American tourist, arrogant and snobby, because he is unable to communicate in a foreign language.
In my nonprofessional life I’m a runner, and the runners I know are anything but snobs. We share friendly smiles, head nods, and slight waves of the hand, all universal signs of friendliness and camaraderie—a universal language. But one morning in Italy another runner about my age came along beside me. He made a comment—probably about the beautiful morning—and I failed to respond. In shame, I dropped my chin, speeding up to escape from him instead of running next to him. Having momentarily forgotten the universal running language I used at home, I found myself running with my head down, unable to share in the joy of a morning run with a potential running companion.
Living in this unanticipated silence gave me a newfound empathy for the nonnative English speaking patients in my practice. Do they have similar fears about their inability to communicate in a foreign environment? Do I draw conclusions about their character from their capacity or incapacity to communicate? Indeed, do these conclusions enter into my personal patient record of them as I provide them clinical care? What about our English-speaking patients who seek treatment in the foreign environment of the medical encounter, one in which words are not easily understood and cannot readily be found in standard dictionaries? Although our respiratory technologist patient may know about ABGs and hypoxemia, does he also know what we mean when we suggest his abdominal pain may be due to a mesenteric infarct?
As I reflect on my experience in Italy, knowing that this sabbatical has been both a rest and a reawakening, I find I learned the following lessons: (1) Experienced clinicians use nonverbal clues to better understand their patients. We need to be cautious—what appears to be a lack of interest may be a lack of understanding. (2) We often modify our treatment and approach in part based on perception rather than reality. Clinicians assume that patients who look puzzled or lost are unable to grasp the concepts, or that those who look unenthusiastic don’t like what we’re telling them. These same facial expressions and nonverbal behaviors may occur in patients who have limited English language skills; therefore, our perceptions of aptitude may be mistaken if solely based on patients’ facial expressions and body language. (3) We should not adjust our words and speed of speech just because we think a patient can’t understand what we are saying. For example, we might slow down our speech with wheelchair-bound patients who have suffered a stroke and now have expressive aphasia, when in fact their intelligence may be normal or above normal and their comprehension has not been impaired. (4) Most importantly, I learned that language is an amazingly powerful tool. The inability to communicate transforms us. Our lack of understanding and empathy may worsen our patients’ circumstances.
Now, when I teach my first-year medical students how to conduct a medical interview, I continue to remind them of the importance of nonverbal signs. I tell them that simply because a patient does not speak doesn’t mean he doesn’t want to or cannot. I tell them this based on lessons I learned on the bus rides and morning runs during my sabbatical in Italy.
FOOTNOTES
Conflicts of interest: none reported
Received for publication July 25, 2005. Revision received December 16, 2005. Accepted for publication December 26, 2005....查看详细 (5812字节)
☉ 11024500:Efficacy and Safety of Inhaled Corticosteroids in Patients With COPD: A Systematic Review and Meta-Analysis of Health Outcomes
ABSTRACT
PURPOSE We wanted to review systematically the efficacy, effectiveness, and safety of inhaled corticosteroids with respect to health outcomes in patients with chronic obstructive pulmonary disease (COPD).
METHODS We searched MEDLINE, EMBASE, The Cochrane Library, and the International Pharmaceutical Abstracts to identify relevant articles. We limited evidence to double-blinded randomized controlled trials (RCTs) for efficacy, but we also reviewed observational evidence for safety. Outcomes of interest were overall mortality, exacerbations, quality of life, functional capacity, and respiratory tract symptoms. When possible, we pooled data to estimate summary effects for each outcome.
RESULTS Thirteen double-blinded RCTs determined the efficacy of an inhaled corticosteroid compared with placebo; 11 additional studies assessed the safety of inhaled corticosteroid treatment in patients with asthma or COPD. Overall, COPD patients treated with inhaled corticosteroids experienced significantly fewer exacerbations than patients taking placebo (relative risk [RR] = 0.67; 95% CI, 0.59–0.77). No significant difference could be detected for overall mortality (RR = 0.81; 95% CI, 0.60–1.08). Evidence on quality of life, functional capacity, and respiratory tract symptoms is mixed. Adverse events were generally tolerable; pooled discontinuation rates did not differ significantly between inhaled corticosteroid and placebo treatment groups (RR = 0.92; 95% CI, 0.74–1.14). Observational evidence, however, indicates a dose-related risk of cataract and open-angle glaucoma. Severe adverse events, such as osteoporotic fractures, are rare; the clinical importance of the additional risk is questionable.
CONCLUSIONS Overall, the risk-benefit ratio appears to favor inhaled corticosteroid treatment in patients with moderate to severe COPD. Existing evidence does not indicate a treatment benefit for patients with mild COPD.
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is among the leading causes of morbidity and mortality worldwide.1 In 2000 COPD accounted for approximately 20.7 million outpatient visits, 3.4 million emergency department visits, 6.3 million hospitalizations, and 116,513 deaths in the United States.2 The World Health Organization estimates that by the year 2020, COPD will be the third-leading cause of death and the fifth-leading cause of disability worldwide.1
COPD is characterized by a progressive, irreversible limitation of airflow associated with an abnormal inflammatory response to noxious particles or gases. It is caused primarily by smoking.3,4
The beneficial effect of inhaled corticosteroid treatment for COPD remains controversial,3,5 in part because only smoking cessation is reliably shown to slow the rate of decline in lung function.4 Although the Food and Drug Administration (FDA) has not approved inhaled corticosteroids as monotherapy for the treatment of COPD, they are frequently prescribed to reduce or alleviate symptoms, increase exercise capacity, reduce the number and severity of exacerbations, and improve health status. The Global Initiative for Chronic Obstructive Lung Disease recommends inhaled corticosteroid treatment for patients with COPD who have a documented spirometric response to inhaled corticosteroids and for patients with moderate to severe COPD (forced expiratory volume in 1 second [FEV1] 100 patients) that lasted at least 1 year and reported an included outcome. For adverse events we also included evidence from mixed populations with asthma and/or COPD.
We assessed the internal validity (quality) of trials based on predefined criteria from the US Preventive Services Task Force (ratings: good-fair-poor)15 and the National Health Service Centre for Reviews and Dissemination.16 External validity (generalizability) was assessed but did not influence quality ratings. We rated trials with a fatal flaw in one or more categories as poor quality and excluded them from the analysis; we rated trials that met all criteria as good quality. The majority of trials received a quality rating of fair. We accepted the definitions of exacerbation as reported in each study because we did not have access to individual patient data. Although definitions of exacerbation varied across studies, most defined it as an episode requiring oral or parenteral corticosteroids, antibiotics, emergency department visits, or hospitalizations because of increased respiratory tract symptoms.
When possible, we pooled data to obtain summary effect estimates for a given outcome, using relative risks to measure effect sizes. We used fixed-effects models for all meta-analysis because the observed heterogeneity was low (<20%, assessed using the I2 statistic). We assessed publication bias using funnel plots and Kendall’s tests, although the validity of these methods is limited given the small number of component studies. All analyses were conducted using Stats-Direct 2.3.8 (StatsDirect Ltd, Sale, Cheshire, UK).
RESULTS
Overall we identified 880 citations. Figure 1 illustrates the disposition of citations and articles. Thirteen double-blinded RCTs determined the efficacy of an inhaled corticosteroid compared with placebo in patients with COPD. We excluded 1 study for quality reasons because of a high rate of postrandomization exclusions.17 We included 11 additional studies conducted in adult patients with COPD or asthma to assess the risk of adverse events of long-term inhaled corticosteroid use.
Tables 2 and 3 describe included studies.18–40 In efficacy studies, patients were generally smokers or former smokers with a clinical diagnosis of COPD. Only the Copenhagen City Lung Study enrolled smokers identified as having mild COPD during a random population survey and subsequent respiratory system screening.23 Severity of COPD varied from mild to severe across studies; inclusion criteria tended to exclude patients with asthma or good bronchodilator responsiveness. Patients with a history of asthma, allergic disease, or sudden onset of breathlessness were excluded from all studies. Further, FEV1 reversibility after bronchodilator use was frequently assessed before enrollment; cutoff criteria were between 10% and 15%. Nine trials (69%) were funded by pharmaceutical companies and 3 (23%) were supported primarily by governmental agencies or independent funds; 1 study (7%) did not report funding source.
Exacerbations
Two studies did not provide sufficient data on exacerbation rates and could not be included in the meta-analyses.20,21 Overall, pooled results of 4,300 patients from the 10 remaining trials showed a 33% reduction (95% CI, 23%–41%; RR = 0.67; 95% CI, 0.59–0.77) in COPD exacerbation rates over a mean follow-up period of 20.8 months (Figure 2A). Sensitivity analysis showed that this treatment effect derives largely from studies in populations suffering from moderate to severe COPD (respectively, FEV1 50% to <80% predicted and FEV1 <50% predicted according to American Thoracic Association criteria).41 Limiting the analysis to the 7 trials with populations with moderate to severe COPD (ie, excluding populations with mild COPD) produces an estimated benefit of inhaled corticosteroid treatment almost identical to the results of the overall meta-analysis (RR = 0.66; 95% CI, 0.57–0.75) (Figure 2B). The number needed to treat (NNT) in this population is 12 (95% CI, 9–18); ie, 12 patients with moderate to severe COPD need to be treated with an inhaled corticosteroid for 17.7 months to avoid 1 exacerbation. For the population with mild COPD (FEV1 80% predicted), we pooled results of 3 small studies (n = 191); no benefit of inhaled corticosteroid treatment emerged (RR = 0.92; 95% CI, 0.55–1.53). As noted, the sample size of this analysis is small, and point estimates of both subgroup analyses are within each other’s confidence intervals. Inferences about differences of treatment effects must be made cautiously.
In sensitivity analyses we compared pooled results of studies of newer inhaled corticosteroids (ie, fluticasone) that have a large degree of first-pass metabolism42,43 with those of older inhaled corticosteroids (ie, beclomethasone, budesonide, flunisolide, and triamcinolone). Relative benefits of both groups were almost identical (newer inhaled corticosteroids: RR = 0.69 [0.59–0.80]; older inhaled corticosteroids: RR = 0.65 [95% CI, 0.53–0.79]).
Mortality
The pooled relative risks (RR = 0.81; 95% CI, 0.60–1.08) for 4,370 patients resulted in no significant difference in all-cause mortality (Figure 3A). Overall, 2.9% of patients on placebo and 2.5% of patients on inhaled corticosteroids died (P = .27) during the mean follow-up period of 22.3 months. Limiting the analysis to studies of moderate to severe COPD (Figure 3B) yielded almost identical results (RR = 0.84; 95% CI, 0.61–1.15). No differences in mortality were apparent between groups taking newer and older inhaled corticosteroids.
Functional Capacity and Quality of Life
In the few studies that assessed functional capacity or quality of life, outcome measures were too heterogeneous to pool results in a meta-analysis; therefore, we analyzed findings qualitatively.
Five studies examined functional capacity and quality of life in patients with moderate to severe COPD.18,19,22,26,27 Two trials administered a 6-minute walking test after 6 months of inhaled corticosteroid treatment. In one, 6-minute walking distance was significantly greater for patients on fluticasone 1,000 mg/d than for patients on placebo (+27 m vs +9 m; P = .032).27 A smaller Canadian study did not detect any significant difference in walking distances for patients when comparing budesonide 1,600 mg/d with placebo (–15 m vs +13 m; P = NR).18 This trial also reported no significant differences in scores on the Chronic Respiratory Disease Questionnaire. Three studies of patients with severe COPD reported greater improvements in St. George’s Respiratory Questionnaire for patients on budesonide 800 mg/d or fluticasone 1,000 µg/d than for patients on placebo19,22,26; however, the clinical importance of the reported differences (range: –0.8 to –3.0) is uncertain.
Two Dutch studies originating from the DIMCA (Detection, Intervention, and Monitoring of COPD and Asthma) program, which recruited patients with mild COPD through population screening, did not find any differences in functional capacity for patients on fluticasone 500 mg/d and those on placebo after 2 years of treatment.24,28
Respiratory Symptoms
Most studies assessed respiratory system symptom scores, but the reported data were mixed and insufficient for meta-analysis. Four studies reported no significant differences in respiratory system symptoms when comparing inhaled corticosteroid with placebo.18,23,26,28 Three studies detected no overall differences in respiratory systems symptoms but did detect significant improvements in subscales, such as daily cough scores, sputum volume,27 night time awakenings,19 and dyspnea.29 In comparisons with placebo, 1 trial reported significantly lower symptom scores in patients during 2 years’ treatment with budesonide 1,600 mg/d21 and another during 3 years’ treatment with fluticasone 1,000mg/d.25
Adverse Events
Efficacy trials commonly reported rhinitis, oral candidiasis, sore throat, bruising, hoarseness, headache, cough, bronchitis, and upper respiratory infection. In most studies, incidence was below 10%. Pooled discontinuation rates because of adverse events did not differ significantly between inhaled corticosteroids and placebo (RR = 0.92; 95% CI, 0.74–1.14). Most studies combined patient-reported adverse events with a regular clinical examination by an investigator. Short study durations and small sample sizes limited the validity of adverse events assessment in many trials. Many studies excluded eligible participants that did not tolerate treatment during the run-in period, limiting the generalizability of adverse events assessment.
To take the limitations of RCTs into consideration and to assess rare but potentially serious adverse events, we also reviewed observational studies (Table 3). Specifically, we were interested in osteoporosis, posterior subcapsular cataracts, ocular hypertension, and open-angle glaucoma.
Bone Density and Osteoporotic Fractures
Overall, the evidence of an association between inhaled corticosteroid products and osteoporosis is mixed. A meta-analysis of randomized trials found no evidence of increased risk of loss of bone mineral density (BMD) or fractures,30 which is consistent with findings from an RCT not included in that meta-analysis.20,33
The strongest observational evidence comes from 2 case-control studies that measured fractures31,34; both reported a slight increase in the risk of fracture for inhaled corticosteroid-treated patients. In 1 study, only current high-dose users (700 µg/d) had an increased risk of nonvertebral fractures (OR = 1.68; 95% CI, 1.10–2.57).34 In the other, the risk of hip fracture was significantly higher in patients using an inhaled corticosteroid (OR = 1.19; 95% CI, 1.10–1.28). Additionally, evidence of an inhaled corticosteroid-associated reduction in BMD comes from a prospective cohort study in 109 premenopausal women32: an estimated bone loss of 0.00044 g/cm2 per puff per year of treatment. We view BMD as an intermediate outcome measure of osteoporosis; although a causal relationship exists between loss of BMD and risk of fractures from osteoporosis, the clinical importance of modest changes in BMD is often questionable.
Cataracts
The association between systemic corticosteroids and cataracts, especially at high doses administered for extended periods, is well documented in both children44 and adults.45 Systemic corticosteroid-induced cataracts typically are located on the posterior side of the lens and are referred to as posterior subcapsular cataracts.
Four observational studies evaluated the risk of adult patients developing cataracts, comparing nonspecific inhaled corticosteroid use with no inhaled corticosteroid use.35–38
A British case-control study of 15,479 patients with cataracts detected a modest but significant increase in risk for the overall use of inhaled corticosteroids (adjusted OR = 1.10; 95% CI, 1.00–1.20).38 A subgroup analysis of COPD patients, however, showed no significant increase in risk (adjusted OR = 1.03; 95% CI, 0.94–1.13). These results suggest a cumulative risk of inhaled corticosteroid use for the development of cataracts, because patients with asthma are generally exposed to inhaled corticosteroids for longer periods of their lives than are patients with COPD.
These findings are consistent with other observational evidence in patients with asthma or COPD. A retrospective cohort study with a nested case-control study,37 a case-control study,36 and a cross-sectional study35 reported increased dose- and duration-dependent risks of inhaled corticosteroids use for posterior cataract. These studies do not report on COPD patients alone.
Ocular Hypertension and Open-Angle Glaucoma
In 1 case-control study of 48,118 Canadians aged 66 years and older39 and 1 cross-sectional population-based eye study of 3,654 Australians aged 49 to 97 years,40 the risk of increased intraocular pressure or open-angle glaucoma was compared in patients using inhaled corticosteroids and patients not using inhaled corticosteroids. Both studies adjusted for age, sex, oral steroid use, history of diabetes, and history of hypertension but did not stratify by COPD patients. Both reported a dose-related increase in the risk of open-angle glaucoma for inhaled corticosteroid-treated patients compared with patients who had not used an inhaled corticosteroid.39,40 The case-control study observed this relationship only among current users of high doses of inhaled corticosteroids prescribed regularly for 3 or more months (adjusted OR = 1.44; 95% CI, 1.01–2.06)39; patients on low to medium doses did not have an increased risk (adjusted OR = 0.95; 95% CI, 0.77–1.19). In the cross-sectional study the association between ever using inhaled corticosteroids and elevated intraocular pressure or glaucoma occurred only in patients with a family history of glaucoma (OR = 2.8; 95% CI, 1.2–6.8).40
DISCUSSION
Our meta-analysis suggests that COPD patients treated with inhaled corticosteroids experience significantly fewer exacerbations than patients on placebo. The relative risk reduction is 33%; the NNT to prevent 1 exacerbation during 20.8 months is 12. This treatment effect is apparently stronger in patients with moderate to severe COPD. Pooled estimates for patients with mild COPD did not suggest a reduction of exacerbations. Sample sizes are too small, however, for clear inferences about the efficacy of inhaled corticosteroid treatment in patients with mild COPD.
We could not detect a significant benefit of inhaled corticosteroid treatment with respect to overall mortality, which in part may be attributable to short study durations (maximum 3 years) relative to the long natural course of disease and to the lack of power to detect such an outcome. We chose overall mortality as an outcome measure rather than COPD mortality, as it does not depend on a subjective judgment by outcome assessors and is therefore less prone to bias. The body of evidence concerning quality of life and functional capacity is mixed and yields no basis for clear conclusions. Empirical evidence suggests, however, that patient quality of life is related to the frequency of COPD exacerbation.46,47 Thus, fewer exacerbations resulting from inhaled corticosteroid treatment can provide indirect evidence for improved quality of life. In addition, inhaled corticosteroid treatment will spare some patients from dealing with systemic corticosteroids.
Efficacy data indicate that adverse events are usually mild and do not lead to significantly higher discontinuation rates for inhaled corticosteroid-treated than for placebo-treated patients. Osteoporotic fractures are rare; the clinical importance of the additional risk is questionable. Evidence from large observational studies consistently indicates a modest risk of cataracts and open-angle glaucoma; it is attributable largely to high dosage and long duration of inhaled corticosteroid use.
Our findings are partly consistent with earlier meta-analyses that assessed exacerbation rates.9,12 Van Grunsven et al9 reported no significant differences in exacerbation rates between the group on inhaled corticosteroids and the group on placebo. Results of a meta-analysis by Sin et al12 are consistent with our findings. Point estimates from our analyses, however, are more precise because of the greater number of component studies. Furthermore, neither of the 2 previous reviews included observational evidence for adverse events to assess the risk-benefit ratio of inhaled corticosteroid treatment. Results of long-term observational studies with respect to exacerbations and mortality are mixed.48–53 The COPE study, a double-blind discontinuation study of fluticasone (1,000 µg/d), reported that patients who discontinued inhaled corticosteroid therapy had a significantly higher recurrence risk of exacerbations than patients who remained on fluticasone treatment.49
We note several limitations in this literature and our work. Durations of efficacy studies are usually too short and sample sizes too small to assess reliably the effects on rare long-term outcomes (eg, mortality) and on rare but severe adverse events. Observational studies posed methodological concerns that precluded meta-analysis.
Because we did not have access to individual patient data, we assumed that definitions of exacerbations did not differ substantially across trials. Although this assumption could lead to some imprecision with respect to efficacy, it might also increase external validity because it synthesizes various definitions of exacerbation used in clinical practice. Moreover, we reviewed inhaled corticosteroids as a class, not taking differences in potency, delivery device, systemic exposure, and dosing into consideration. No treatment regimen appeared to be underdosed; however, because we could not conduct quantitative analyses on adverse events, we were unable to assess whether inhaled corticosteroids with low systemic absorption lead to fewer adverse events than inhaled corticosteroids with high systemic absorption. Our pooled efficacy results might underestimate treatment effects for patients with severe COPD who usually receive high-dose treatments. Differential loss to follow-up might also dilute treatment effects. Placebo groups consistently had a higher dropout rate than inhaled corticosteroid groups. The frequency of exacerbations and mortality might therefore be underestimated for placebo treatment.
None of the included studies can be viewed as an effectiveness trial with a high degree of generalizability. The patient populations often were highly selected and included exclusively current or former smokers. Patients with FEV1 reversibility of more than 10% to 15% were typically excluded. These factors further limit the generalizability of results for non-smoking patients with asthma who have chronic airways obstruction. Even so, good evidence exists from multiple trials that inhaled corticosteroid treatment is efficacious in patients with asthmatic features.13
Finally, we could not include unpublished studies; their absence may lead to an overestimation of treatment effects.
Additional large studies are needed that have the necessary power to address such health outcomes as mortality and quality of life. Results of the ongoing TORCH (Towards a Revolution in COPD Health) survival study may provide answers to some remaining questions.54 This 3-year, multicenter trial is randomizing approximately 6,200 patients with moderate to severe COPD to placebo, fluticasone, fluticasone/salmeterol, or salmeterol; it will end in 2006.
ACKNOWLEDGMENTS
We would like to thank Timothy Carey, MD, MPH, who provided insightful comments on various drafts of this paper.
FOOTNOTES
Conflicts of interest: none reported
Funding support: Funding for this research was provided to the Cecil G. Sheps Center for Health Services Research through a subcontract with the Center for Evidence-Based Policy; Oregon Health & Science University.
Received for publication June 9, 2005. Revision received September 27, 2005. Accepted for publication October 27, 2005.
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