Health-related quality of life in patients with idiopathic pulmonary fibrosis: a systematic review

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) profoundly affects the quality of patients' lives. A systematic review was performed to evaluate critically the published literature and to examine what is known about health-related quality of life (HRQL) in patients with IPF.

METHODS

The MEDLINE, EMBASE, Health and Psychosocial Instruments, and Cochrane Library databases were searched to 1 April 2004. Abstracts and bibliographies of published articles were scanned and contact was made with investigators. Included studies analysed HRQL (or quality of life) in at least 10 patients with IPF. Two reviewers independently selected studies, evaluated their quality according to predetermined criteria, and abstracted data on study design, patients' demographic and clinical characteristics, and quality of life outcome measures.

RESULTS

Seven studies met the inclusion criteria. The studies enrolled 512 patients with IPF and used three different instruments to measure HRQL. All studies had important limitations in methodological quality; none measured longitudinal changes in HRQL over time. Patients reported substantially impaired HRQL, especially in domains that measured physical health and level of independence. Patients with IPF appear to have similar impairments in HRQL to those with chronic obstructive pulmonary disease. Measures of dyspnoea were moderately correlated with scores from domains that measured physical health (R2 = 0.03-0.66) and energy/fatigue/pep (R2 = 0.19-0.55), but measures of pulmonary function and gas exchange did not correlate as strongly with these and other domains.

CONCLUSION

Studies of HRQL in patients with IPF suggest that, in addition to the obvious effect on physical health, general health, energy level, respiratory symptoms, and level of independence are also impaired. Variability in HRQL among patients is not fully explained by measures of dyspnoea or pulmonary function, suggesting that HRQL measures provide unique information. More research is needed to identify or design appropriate measurement instruments for patients with IPF and to examine changes in HRQL over time or in response to specific treatments.

Effect of diabetes on long-term mortality following contemporary percutaneous coronary intervention: analysis of 4,284 cases

OBJECTIVE

Diabetic patients are known to have reduced long-term survival following percutaneous transluminal coronary angioplasty compared with nondiabetic patients. However, it is unknown whether this survival disadvantage has persisted in the era of contemporary percutaneous coronary intervention (PCI) techniques, which include the widespread use of stents and the availability of platelet glycoprotein (GP) IIb/IIIa inhibitors.

RESEARCH DESIGN AND METHODS

Three hospitals in New York City contributed prospectively defined data on 4,284 patients undergoing PCI. The primary end point was all-cause mortality following hospital discharge for PCI.

RESULTS

Hypertension, renal insufficiency, and renal failure requiring dialysis were all more common in diabetic patients, whereas active smoking was less frequent. Congestive heart failure on admission was more common in diabetic than nondiabetic patients (7.7 vs. 4.0%, P < 0.001). Stents were placed in 78% of nondiabetic patients and 75% of diabetic patients (P = 0.045). Platelet GP IIb/IIIa antagonists were administered to 23% of nondiabetic and 24% of diabetic patients (P = NS). At a mean follow-up of 3 years, mortality was 8% among nondiabetic patients and 13% for diabetic patients (P < 0.001). After adjustment for differences in baseline characteristics between nondiabetic and diabetic patients, diabetes remained a significant independent hazard for late mortality (hazard ratio 1.462, 95% CI 1.169-1.828; P = 0.001).

CONCLUSIONS

Following contemporary PCI, diabetic patients continue to have worse survival than nondiabetic patients.

Squamous cell carcinoma of the anal sac in five dogs

Tumors of the perianal area of dogs are common and include multiple tumor types. Whereas perianal adenomas occur often, adenocarcinomas of the apocrine glands of the anal sac occur less frequently. A review of the literature revealed no reports of squamous cell carcinomas arising from the epithelial lining of the anal sac. Squamous cell carcinomas originating from the lining of the anal sac were diagnosed in five dogs. Microscopically, the tumors consisted of variably sized invasive nests and cords of epithelial cells displaying squamous differentiation. Four of the five dogs were euthanatized because of problems associated with local infiltration by the tumors. In the fifth dog, there was no evidence of tumor 7 months after surgical removal, but further follow up was not available.

CARD15/NOD2 risk alleles in the development of Crohn's disease in the Australian population

We have previously reported strong evidence for linkage between IBD1 and Crohn's disease (CD) in Australian Crohn's disease families. Three risk alleles for Crohn's disease, (Arg702Trp (C/T), Gly908Arg (G/C) and 980fs981 (-/C), were recently identified in the CARD15/NOD2 gene on chromosome 16, implicating this as the IBD1 locus. Using a novel diagnostic PCR-RFLP, we have examined the frequency of these alleles in 205 multiplex IBD families, 107 sporadic Crohn's disease cases and 409 normal individuals. We demonstrate that the three risk alleles are more frequent in Crohn's disease, than in controls, with allelic frequencies of 0.11, 0.02 and 0.07 respectively. Heterozygosity for individual variants conferred a three-fold increase in risk for Crohn's disease while substantially higher risks were associated with being homozygous or compound heterozygous. Despite a significantly lower population allele frequency for the frameshift mutation than reported by other groups, we see a similar contribution by this allele to the risk of developing Crohn's disease. While the three risk alleles influence susceptibility to Crohn's disease in Australia, we show that these alleles do not fully explain the linkage evidence and suggest that there are very likely additional IBD1 susceptibility alleles yet to be described in Australian CD at the NOD2 locus. We also show a second linkage peak in Australian CD that provides some support for a second disease susceptibility locus on chromosome 16.

The effect of pasture species on parasitism and performance of lambs grazing one of three grass-white clover pasture swards

Lamb parasitism and performance were compared on three pasture treatments: browntop/white clover, Yorkshire fog/white clover, and ryegrass/white clover swards maintained at a sward height of 5cm in each of two years by using continuous variable stocking management. In year 1, lamb performance (both suppressively drenched (SD) and trigger drenched (TD)) was similar on ryegrass and browntop swards but was poorer (P<0.05) on Yorkshire fog swards. In year 2, lamb performance (both SD and TD) was markedly better on ryegrass than on Yorkshire fog or browntop swards. This coincided with an increase in white clover content in the ryegrass/white clover swards and a decrease in white clover content in the browntop/white clover swards. Lamb performance was related to the white clover content of the swards (R2=85.4, P<0.001 and R2=77.5, P<0.001 for SD lambs and TD lambs, respectively). Differences among pasture treatments in faecal egg count (FEC) of TD lambs were greater in year 2 than in year 1 when no significant pasture effects were observed. In year 2, FEC was lowest in lambs which grazed ryegrass/white clover, intermediate in those which grazed Yorkshire fog/white clover and highest in lambs which grazed browntop/white clover, despite herbage allowance (kg herbage mass/kg lamb mass) being greater on the browntop/white clover and Yorkshire fog/white clover swards than the ryegrass/white clover swards. Circulating antibodies to gastrointestinal parasites were measured at the end of year 2. Antibody titres were highest (P<0.05) in the plasma of lambs which grazed ryegrass/white clover swards, and lowest in lambs which grazed browntop/white clover swards due to differences in levels of antibody to (P<0.05) Haemonchus contortus, Ostertagia circumcincta larvae and adults, but not Trichostrongylus colubriformis larvae or adults. These findings indicate that pasture composition, especially, the proportion of white clover, can help alleviate the production losses due to gastrointestinal parasitism. This information can provide a quick and readily adoptable practice for farmers who aim to reduce drench reliance and could become a key component of any integrated parasite control programme.

Synthetic and structural studies on [Fe2(SR)2(CN)x(CO)6-x](x-) as active site models for Fe-only hydrogenases

A series of models for the active site (H-cluster) of the iron-only hydrogenase enzymes (Fe-only H2-ases) were prepared. Treatment of MeCN solutions of Fe2(SR)2(CO)6 with 2 equiv of Et4NCN gave [Fe2(SR)2(CN)2(CO)4](2-) compounds. IR spectra of the dicyanides feature four nu(CO) bands between 1965 and 1870 cm(-1) and two nu(CN) bands at 2077 and 2033 cm(-1). For alkyl derivatives, both diequatorial and axial-equatorial isomers were observed by NMR analysis. Also prepared were a series of dithiolate derivatives (Et4N)2[Fe2(SR)2(CN)2(CO)4], where (SR)2 = S(CH2)2S, S(CH2)3S. Reaction of Et4NCN with Fe2(S-t-Bu)2(CO)6 gave initially [Fe2(S-t-Bu)2(CN)2(CO)4](2-), which comproportionated to give [Fe2(S-t-Bu)2(CN)(CO)5](-). The mechanism of the CN(-)-for-CO substitution was probed as follows: (i) excess CN(-) with a 1:1 mixture of Fe2(SMe)2(CO)6 and Fe2(SC6H4Me)2(CO)6 gave no mixed thiolates, (ii) treatment of Fe2(S2C3H6)(CO)6 with Me3NO followed by Et4NCN gave (Et4N)[Fe2(S2C3H6)(CN)(CO)5], which is a well-behaved salt, (iii) treatment of Fe2(S2C3H6)(CO)6 with Et4NCN in the presence of excess PMe3 gave (Et4N)[Fe2(S2C3H6)(CN)(CO)4(PMe3)] much more rapidly than the reaction of PMe3 with (Et4N)[Fe2(S2C3H6)(CN)(CO)5], and (iv) a competition experiment showed that Et4NCN reacts with Fe2(S2C3H6)(CO)6 more rapidly than with (Et4N)[Fe2(S2C3H6)(CN)(CO)5]. Salts of [Fe2(SR)2(CN)2(CO)4](2-) (for (SR)2 = (SMe)2 and S2C2H4) and the monocyanides [Fe2(S2C3H6)(CN)(CO)5](-) and [Fe2(S-t-Bu)2(CN)(CO)5](-) were characterized crystallographically; in each case, the Fe-CO distances were approximately 10% shorter than the Fe-CN distances. The oxidation potentials for Fe2(S2C3H6)(CO)4L2 become milder for L = CO, followed by MeNC, PMe3, and CN(-); the range is approximately 1.3 V. In water,oxidation of [Fe2(S2C3H6)(CN)2(CO)4](2-) occurs irreversibly at -0.12 V (Ag/AgCl) and is coupled to a second oxidation.

A controlled trial of an environmental tobacco smoke reduction intervention in low-income children with asthma

STUDY OBJECTIVES

To determine the effectiveness of a cotinine-feedback, behaviorally based education intervention in reducing environmental tobacco smoke (ETS) exposure and health-care utilization of children with asthma.

DESIGN

Randomized controlled trial of educational intervention vs usual care.

SETTING

The pediatric pulmonary service of a regional pediatric hospital.

PARTICIPANTS

ETS-exposed, Medicaid/Medi-Cal-eligible, predominantly minority children who were 3 to 12 years old and who were seen for asthma in the hospital's emergency, inpatient, and outpatient services departments (n = 87).

INTERVENTION

Three nurse-led sessions employing behavior-changing strategies and basic asthma education and that incorporated repeated feedback on the child's urinary cotinine level.

MEASUREMENTS

The primary measurements were the urinary cotinine/creatinine ratio (CCR) and the number of acute asthma medical visits. The secondary measurements were number of hospitalizations, smoking restrictions in home, amount smoked, reported exposures of children, and asthma control.

RESULTS

The intervention was associated with a significantly lower odds ratio (OR) for more than one acute asthma medical visit in the follow-up year, after adjusting for baseline visits (total visits, 87; OR, 0.32; p = 0.03), and a comparably sized but nonsignificant OR for one or more hospitalization (OR, 0.34; p = 0.14). The follow-up CCR measurement and the determination of whether smoking was prohibited inside the home strongly favored the intervention group (n = 51) (mean difference in CCR adjusted for baseline, -0.38; p = 0.26; n = 51) (60; OR [for proportion of subjects prohibiting smoking], 0.24; p = 0.11; n = 60).

CONCLUSIONS

This intervention significantly reduced asthma health-care utilization in ETS-exposed, low-income, minority children. Effects sizes for urine cotinine and proportion prohibiting smoking were moderate to large but not statistically significant, possibly the result of reduced precision due to the loss of patients to active follow-up. Improving ETS reduction interventions and understanding their mechanism of action on asthma outcomes requires further controlled trials that measure ETS exposure and behavioral and disease outcomes concurrently.

Epistasis and its possible effects on transmission disequilibrium tests

Most approaches to analysing complex genetic disorders are based on an underlying model that assumes that the probability of being affected is mainly due to the effect of a major, single disease locus. Where the penetrance (the conditional probability of being affected) is hypothesised to be influenced by known covariates, methods have been developed to accommodate these covariates appropriately in the analysis. Unexplained variation in the incomplete penetrance is then attributed to either unspecified environmental effects or to other genes of small effect that might act epistatically with the 'disease gene'. Recently, there have been some proposals to incorporate two (or more) possibly epistatic identified loci as major effects in the analysis. However, the effect of two (or more) major epistatic disease genes on the analysis of data that assumes a single 'disease gene', and so ignores any other major gene, does not seem to have been explored. This investigation is undertaken here for triad data consisting of affected singletons and their parents. Following development of a quite general underlying genetic model, a global approach to analysing two marker loci for triad data is developed. This approach is the appropriate one for such data where two, possibly epistatic, loci have been identified a priori. The motivation for the development of this methodology is to evaluate the possible effect a second epistatic disease locus might be having on the results for triad data collected and analysed in different population studies, where the underlying analysis is based on an underlying major, single disease locus model. It is shown that, dependent on the population parameters associated with the other unidentified major disease gene, results concerning the single 'disease gene' can vary markedly. So, finding that conclusions differ from study to study may be indicative of the 'disease gene' under investigation acting epistatically with other major disease genes.

Transperineal and transvaginal sonography of perianal inflammatory disease

OBJECTIVE

Perianal infection arises in small intersphincteric anal glands predominantly located at the dentate line. Documentation of fluid collections and the relationship of inflammatory tracts to the sphincter mechanism is important for surgical treatment. Transanal sonography for assessment of perianal inflammatory disease is limited because placement of the rigid probe into the anal canal does not allow assessment of disease in the perineal region. The purpose of this study was to validate the use of transperineal sonography in men and both transvaginal and transperineal sonography in women for evaluation of perianal inflammatory disease.

SUBJECTS AND METHODS

Fifty-four patients, 28 men and 26 women, were imaged with transperineal and a combination of transperineal and transvaginal sonography, respectively. All patients were examined in the supine lithotomy and left lateral position with a transvaginal 8-to 4-MHz probe or a linear 12- to 7-MHz transducer. All fluid collections, sinus tracts, and fistulas were described by their location in relation to the sphincter mechanism and perineum.

RESULTS

Forty-six of 54 patients had perianal fistulas or sinus tracts: 33 transphincteric, seven intersphincteric, and six extrasphincteric. Fifteen patients had an associated abscess. In the eight remaining patients, there were two anovaginal fistulas, one rectovaginal fistula, one prolapsed internal hemorrhoid, two perianal complex masses, and two vascular perianal or perirectal inflammatory masses. Twenty-six patients underwent surgical procedures involving the anorectal canal or perirectal region, and of these, preoperative sonographic findings were confirmed in 22 (85%) of 26 patients. Three patients refused surgery, and six are awaiting surgery at this writing. Fifteen patients were treated conservatively.

CONCLUSION

Transperineal and transvaginal sonography are accurate, painless, and cost-effective methods for documenting perianal fluid collections and fistulas or sinus tracts or both.

On cloning and clone libraries for finite and infinite length genomes

This paper develops mathematical theory to determine the representativeness of clone libraries for various models, defined below in the text. In particular, the means and variances of fragment lengths and the mean of the length of a randomly selected fragment are determined, as well as the probability of the event that a particular base pair of a given double-stranded DNA sequence is clonable. Further, some results are given for partial digestion where the digest is stopped before all cuts are made. A summary is given comparing the main biological conclusions from assuming that the length of the genome is (effectively) infinite with the corresponding conclusions from the more realistic assumption that the genome is of finite length.

Synthetic approaches to a variety of covalently linked porphyrin--fullerene hybrids

There is substantial interest in dyads in which C(60) is covalently linked to electron donors, such as porphyrins, which absorb light strongly in the visible region. We present here the details of the syntheses of such compounds, which can be broadly organized into categories depending upon the nature of the linker joining the two chromophores. The structural aspects of intramolecular electronic interaction that we have sought to explore have dictated the synthetic strategies employed to generate these classes of molecules. Flexible glycol linkers were used to allow close approach between the fullerene and porphyrin, facilitating through-space interactions. These linkers also allowed studies of the effects of metal cation complexation. Naphthalene and alkyne linkers were used to examine the possible effects a conjugated or aromatic linker might have on photophysical properties. Finally, steroids were used as linkers in dyads expected to possess a large distance between the two chromophores, in which only through-bond interactions between the fullerene and porphyrin should be possible.

Synthesis and evaluation of hexahydrochrysene and tetrahydrobenzofluorene ligands for the estrogen receptor

To prepare novel estrogen receptor (ER) ligands, we have developed a facile approach to substituted hexahydrochrysene and tetrahydrobenzo[a]fluorene systems. Substituents, including basic side chains, were added to these systems, and their binding affinity to ERalpha and ERbeta, and in some cases their transcriptional activity were evaluated.

Liver mass evaluation with ultrasound: the impact of microbubble contrast agents and pulse inversion imaging

Liver mass evaluation includes two essential elements--lesion detection and lesion characterization. Both of these are greatly improved on sonography with the addition of contrast agents and the use of specialized imaging techniques, particularly pulse inversion imaging. Ultrasound contrast agents are comprised of tiny microbubbles of gas that interact with the ultrasound beam producing an enhancement of the Doppler signal from blood. Pulse inversion imaging allows preferential detection of the signal from the microbubble agents with suppression of the signal from background tissue. Two imaging techniques include a low mechanical index (MI) nondestructive method to show lesional vascularity and a high MI destructive mode that produces disruption of the bubbles in a single frame. The latter allows for quantitative assessment of the relative enhancement of a lesion as compared with the adjacent liver parenchyma, which is a reflection of the relative vascular volumes. Vascular imaging has shown characteristic and reproducible features of common liver masses, including hemangioma, focal nodular hyperplasia, hepatocellular carcinoma, and liver metastases. Delayed postvascular enhancement of the normal liver, a phenomenon that is unique to certain classes of microbubble contrast agents, allows detection of more and smaller malignant lesions than on baseline.

Ultrasound for the visualization and quantification of tumor microcirculation

Advances in ultrasound based methods for the non-invasive assessment of the tumor microcirculation are described. Two new ultrasound approaches are highlighted. The first method relies on commercially available ultrasound contrast agents in combination with specialized nonlinear imaging sequences. Nonlinear scattering by microbubble contrast agents provides a unique intravascular signature that can be distinguished from the echoes caused by surrounding tissues. Through destruction-reperfusion experiments it is possible to use microbubble contrast agents as a tracer revealing the kinetics of tumor blood flow. The second ultrasound method for examining the microcirculation involves the use of much higher frequencies. At frequencies on the order of 50 MHz, Doppler processing allows the direct assessment of flow dynamics in realtime in arterioles as small as 15 microm. Three dimensional Doppler maps of flow patterning are presented. The strengths and weaknesses of these new methods are discussed and the potential for their use in preclinical animal drug studies, clinical drug trials, and prognostic studies is described.

Redox properties of C6S8(n-) and C3S5(n-) (n = 0, 1, 2): stable radicals and unusual structural properties for C-S-S-C bonds

The new anionic carbon sulfides C6S10(2-) and C12S16(2-) are described and crystallographically characterized. The C12S16(2-) anion consists of two C6S8 units connected by an exceptionally long (2.157(12) A) S-S bond. In solution, C12S16(2-) exists in equilibrium with the radical C6S8(-*). The equilibrium constant for radical formation (293 K, THF) is 1.2 x 10(-4) M, as determined by optical spectroscopy at varying concentrations. Radical formation occurs through scission of the S-S bond. On the basis of variable temperature EPR spectra, the thermodynamic parameters of this process are DeltaH = +51.5 +/- 0.5 kJ x mol(-1) and DeltaS = +110 +/- 3 J x mol(-1) x K(-1). C6S10(2-) is an oxidation product of C3S5(2-) and consists of two C3S5 units connected by an S-S bond. The S-S bond length (2.135(4) A) is long, and the CS-SC torsion angle is unusually acute (52.1 degrees ), which is attributed to an attractive interaction between C3S2 rings. The oxidation of (Me4N)2C3S5 occurs at -0.90 V vs Fc+/Fc in MeCN, being further oxidized at -0.22 V. The similarity of the cyclic voltammogram of (Me4N)2C6S10 to that of (Me4N)2C3S5 indicates that C6S10(2-) is the initial oxidation product of C3S5(2-).

Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial

OBJECTIVE

To compare the effectiveness and safety of low-dose unfractionated heparin and a low-molecular-weight heparin as prophylaxis against venous thromboembolism after colorectal surgery.

METHODS

In a multicenter, double-blind trial, patients undergoing resection of part or all of the colon or rectum were randomized to receive, by subcutaneous injection, either calcium heparin 5,000 units every 8 hours or enoxaparin 40 mg once daily (plus two additional saline injections). Deep vein thrombosis was assessed by routine bilateral contrast venography performed between postoperative day 5 and 9, or earlier if clinically suspected.

RESULTS

Nine hundred thirty-six randomized patients completed the protocol and had an adequate outcome assessment. The venous thromboembolism rates were the same in both groups. There were no deaths from pulmonary embolism or bleeding complications. Although the proportion of all bleeding events in the enoxaparin group was significantly greater than in the low-dose heparin group, the rates of major bleeding and reoperation for bleeding were not significantly different.

CONCLUSIONS

Both heparin 5,000 units subcutaneously every 8 hours and enoxaparin 40 mg subcutaneously once daily provide highly effective and safe prophylaxis for patients undergoing colorectal surgery. However, given the current differences in cost, prophylaxis with low-dose heparin remains the preferred method at present.

Radiology reports: examining radiologist and clinician preferences regarding style and content

OBJECTIVE

The introduction of picture archiving and communication systems (PACS) frequently includes the option of computer-generated itemized reports. This motivated us to reassess the merits of traditional prose dictated reports. This study examines radiologist and clinician preferences regarding report style and content.

MATERIALS AND METHODS

The study was conducted in two parts. The first part was a retrospective audit of existing medical imaging prose reports to determine their content. The second part comprised a questionnaire containing three mock clinical scenarios. Three pairs of reports were provided for each scenario, with only essential information in the first pair, some optional information in the second, and the most complete report in the third. Each pair consisted of a prose and itemized report with identical content. Participants ranked reports by preference and were asked specific questions regarding report content. The questionnaires were mailed to referring clinicians and administered during an interactive forum to staff radiologists, radiology fellows, and radiology residents.

RESULTS

The audit of existing reports showed a wide variation in all fields with consistency limited to a given radiologist. Responses to the questionnaire showed that, in general, a majority of radiologists and referring clinicians preferred itemized reports. The itemized report with the most detailed content was ranked highest of all three scenarios.

CONCLUSION

Prose reports foster a lack of standardization of content among different radiologists. Itemized reports facilitate complete documentation of information and measurements and are more popular with both radiologists and referring clinicians.

Tissue harmonic imaging: is it a benefit for bile duct sonography?

OBJECTIVE

Our purpose was to compare tissue harmonic imaging with conventional sonography of the biliary tract.

SUBJECTS AND METHODS

Eighty patients with suspect biliary disease had conventional sonography and tissue harmonic imaging with an ATL 3000 or 5000 scanner in a 6-month interval. Final diagnoses included malignant biliary obstruction (n = 30), choledocholithiasis (n = 16), sclerosing cholangitis (n = 4), normal or nonobstructed ducts (n = 16), and miscellaneous conditions (n = 14). Similar images were taken with each technique in terms of projection, field of view, focal zone selection, and evidence of disease. Two separate observers blinded to patient data and technique reviewed and graded images individually for the appearance of the lumen of the bile ducts, the length of the visible duct, the appearance of the duct wall, the presence of any intraluminal masses, and the appearance of associated acoustic shadows. Images were graded from zero to 3, with 3 being the best.

RESULTS

The median of the 546 tissue harmonic images was one grade higher than the median for the corresponding conventional images (p < 0.0001). Improvements with tissue harmonic imaging included better sharpness of the duct walls (p < 0.01), a clearer lumen (p < 0.0001), identification of a longer length of the common bile duct (p < 0.0001), and improved detection of intraluminal masses (p < 0.006). Acoustic shadows were better defined and blacker with tissue harmonic imaging (p < 0.007).

CONCLUSION

Improvement in contrast and reduction of side lobe artifacts with tissue harmonic imaging enhance visualization of the biliary ducts. Tissue harmonic imaging is now our routine technique for bile duct examination.

The impact of practice setting on physician perceptions of the quality of practice and patient care in the managed care era

BACKGROUND

Managed care is practiced in both traditional institutional health maintenance organization (HMO) settings and in a variety of complex and decentralized office-based arrangements. This study examines how practice setting affects physician perceptions of the quality of professional practice and patient care in a managed care environment.

PARTICIPANTS AND METHODS

A survey was conducted in 1998 of 1081 physicians in San Mateo County, California, who practice in either a traditional staff group model HMO (SGM-HMO) (n = 113) or office-based independent practice (OBIP) (n = 250). Respondents were surveyed about current and past practice characteristics, income changes, current satisfaction with professional and patient care matters, utility of treatment guidelines and formularies, and general perceptions of managed care. Responses were compared between practice settings using bivariate comparisons and logistic regression analyses.

RESULTS

Physicians in the SGM-HMO and those in OBIP reported similar hours worked per week, time spent with patients during office visits, and total patient encounters per week. Declining income was more frequent in OBIP (61% vs 47%) and relatively more substantial (27% with income declines >25% vs 4% in SGM-HMO). Adjusting for income changes, practice setting, years in practice, and sex, SGM-HMO physicians were significantly more satisfied with a variety of professional and quality of care issues (P<.001), viewed more favorably the utility of treatment guidelines and drug formularies (P<.001), and held more positive general perceptions of managed care (P<.001) than OBIP physicians.

CONCLUSIONS

In a managed care environment, SGM-HMO physicians are significantly more satisfied with the quality of practice and patient care than physicians in OBIP. This study suggests that the myriad managed care contracts, formularies, and guidelines received by physicians in OBIPs may lead to more negative perceptions of the quality of professional practice and patient care.