Taking account of quality. Discussion

Another report from the Institute of Medicine in March 2001 has joined a large body of literature documenting serious quality and safety problems. Eight health care leaders discuss ways in which organizations can reduce medical errors and improve patient outcomes.

Successful aging. How increased life expectancy and medical advances are changing geriatric care

If the unprecedented increase in life expectancy has a downside, it is the exposure of risk to chronic age-related disorders. As clinicians work to foster healthy aging, we must also seek ways to prevent the disabling disorders that keep many older persons from enjoying their longevity. The high prevalence of chronic illness and functional limitation among older persons underscores the need for strategically directed health and social services. Successful patient management must extend beyond diagnosis and disease treatment and include promotion of function and prevention of decline. Achieving this goal requires a seamless continuum of management and interdisciplinary caregiving. There also must be a focus on improving the understanding of the science of aging. New treatment approaches for managing aging may one day include cognitive enhancers, designer hormones, telomerase, antioxidants, and gene therapy.

Physician firearm ownership as a predictor of firearm injury prevention practice

OBJECTIVES

This study explored the relation between physicians' gun ownership and their attitudes and practices regarding firearm injury prevention.

METHODS

Internists and surgeons were surveyed, and logistic regression models were developed with physicians' personal involvement with firearms (in the form of a gun score) as the primary independent variable.

RESULTS

Higher gun scores were associated with less agreement that firearm injury is a public health issue and that physicians should be involved in firearm injury prevention but with a greater likelihood of reporting the inclusion of firearm ownership and storage as part of patient safety counseling.

CONCLUSIONS

Despite being less likely to say that doctors should participate in firearm injury prevention, physician gun owners are more likely than nonowners to report counseling patients about firearm safety.

In defense of a department of geriatrics

Departmental status for geriatrics offers many advantages, all of which are related to strengthening academic and clinical programs in aging. The training programs and the content of medical school curriculum in geriatrics remain inadequate under the current structures. A department of geriatrics can provide a stronger faculty base and allow effective interaction with other departments (including but not limited to internal medicine) that need geriatric training. A department of geriatrics also focuses on a model of care that involves working closely with other disciplines, such as nursing and social work. This interdisciplinary model helps expert providers work efficiently throughout the spectrum of care, strengthening continuity. The department can include other medical specialists, such as family practitioners, psychiatrists, and physiatrists, who work with caregivers and patients throughout a course of treatment to manage chronic illness and help maintain and enhance function and independence as long as possible. Comprehensive care and proper care management also substantially benefit institutions by expanding the patient population, reducing length of stay, and avoiding unnecessary hospitalization of older patients through effective discharge planning and transitional care. This requires strong relationships with long-term care providers, a characteristic strength of geriatricians. Although not all research in aging needs to be housed in a department of geriatric medicine, the presence of a critical mass of basic and clinical researchers creates an environment that can stimulate new initiatives and attract external funding. Additional research bridging basic translational and clinical phases relevant to the elderly population is best encouraged by maintaining relationships with other basic science and clinical departments.

Geriatrics for the 3rd millennium

It is a common knowledge that the population around the world is growing old at an unprecedented rate. This is the success story of increasing life expectancy. The demographic breakthroughs occurred in the 20th century. The quality of life breakthrough is our challenge for the 21st century. The implications of the growing elderly population are many, including: rising total health care expenditures; the increasing needs for long-term care services; and the need for expert and focused health care services. Since health care costs increase with advancing age of populations, these costs will fall on older persons, families, and society generally. There is real value for everyone in meeting the needs of an aging society, especially if seen as part of a social contract. The ability to live independently improves with access to good care, but decreases dramatically for those with age-related disabling conditions. With the decreasing number of informal caregivers around the world, frail elderly will require more formal long-term care services. However, due to inadequate attention given to long-term care issues, numerous developed countries have recently started to struggle to develop long-term care service programs that will both meet the rising needs for this service and be cost-effective. Effective medical care requires expertise in functional assessment, interdisciplinary care, and advances in treating symptoms of aging. The field of geriatrics is essential to modern health care, and geriatricians need to have proper training that focuses diagnosing and treating this group of patients. Quality care will not only help the elderly to live productively and independently, but it will also tremendously benefit families and communities.

Restructuring Medicare for the next century: what will beneficiaries really need?

Medicare coverage falls short of its original mandate of access to modern medicine and protection against the high costs of medical care. These shortfalls destabilize both health outcomes and the economic viability of older adults and their families. Our proposed revisions would promote, rather than discourage, optimal care for beneficiaries. By replacing incentives for fragmented, episodic care with an orientation toward functional status, care management, and integration with long-term care, we can make an invaluable investment in a successfully aging society.

Poverty and ill health: physicians can, and should, make a difference

A growing body of research confirms the existence of a powerful connection between socioeconomic status and health. This research has implications for both clinical practice and public policy and deserves to be more widely understood by physicians. Absolute poverty, which implies a lack of resources deemed necessary for survival, is self-evidently associated with poor health, particularly in less developed countries. Over the past two decades, economic decline or stagnation has reduced the incomes of 1.6 billion people. Strong evidence now indicates that relative poverty, which is defined in relation to the average resources available in a society, is also a major determinant of health in industrialized countries. For example, persons in U.S. states with income distributions that are more equitable have longer life expectancies than persons in less egalitarian states. There are numerous possible approaches to improving the health of poor populations. The most essential task is to ensure the satisfaction of basic human needs: shelter, clean air, safe drinking water, and adequate nutrition. Other approaches include reducing barriers to the adoption of healthier modes of living and improving access to appropriate and effective health and social services. Physicians as clinicians, educators, research scientists, and advocates for policy change can contribute to all of these approaches. Physicians and other health professionals should understand poverty and its effects on health and should endeavor to influence policymakers nationally and internationally to reduce the burden of ill health that is a consequence of poverty.

Erectile dysfunction: a multifaceted disorder

The cause may be vascular, neurogenic, hormonal, drug-related, psychogenic, or a combination thereof. In older men in particular, underlying causes may include life-threatening disorders. Evaluation requires directed questioning, since men often fail to volunteer important related symptoms. Clinical findings guide laboratory testing and treatment is tailored to the etiology.

A national survey of physician-assisted suicide and euthanasia in the United States

BACKGROUND

Although there have been many studies of physician-assisted suicide and euthanasia in the United States, national data are lacking.

METHODS

In 1996, we mailed questionnaires to a stratified probability sample of 3102 physicians in the 10 specialties in which doctors are most likely to receive requests from patients for assistance with suicide or euthanasia. We weighted the results to obtain nationally representative data.

RESULTS

We received 1902 completed questionnaires (response rate, 61 percent). Eleven percent of the physicians said that under current legal constraints, there were circumstances in which they would be willing to hasten a patient's death by prescribing medication, and 7 percent said that they would provide a lethal injection; 36 percent and 24 percent, respectively, said that they would do so if it were legal. Since entering practice, 18.3 percent of the physicians (unweighted number, 320) reported having received a request from a patient for assistance with suicide and 11.1 percent (unweighted number, 196) had received a request for a lethal injection. Sixteen percent of the physicians receiving such requests (unweighted number, 42), or 3.3 percent of the entire sample, reported that they had written at least one prescription to be used to hasten death, and 4.7 percent (unweighted number, 59), said that they had administered at least one lethal injection.

CONCLUSIONS

A substantial proportion of physicians in the United States report that they receive requests for physician-assisted suicide and euthanasia, and about 7 percent of those who responded to our survey have complied with such requests at least once.

Internists' and surgeons' attitudes toward guns and firearm injury prevention

BACKGROUND

The high rates of death, injury, and long-term disability related to firearms in the United States have led to growing concern in the health care community. Medical organizations and journals are devoting increasing attention to firearm violence as a public health problem; however, few reports discuss physician attitudes toward guns and prevention of firearm-related injury.

OBJECTIVE

To determine internists' and surgeons' attitudes toward guns and firearm injury prevention.

DESIGN

Analysis of results of a structured telephone interview.

SETTING

Internal medicine and surgical offices.

PARTICIPANTS

457 internists and 458 surgeons.

MEASURES

55 questions that covered six domains: experience with firearms, knowledge about clinical sequelae of firearm injury, knowledge about public policies on firearm violence, attitudes toward public policies on firearm violence, clinical practice behavior, and education and training.

RESULTS

The interview response rate was 45.3%, with a compliance rate of 82.5% and a 95% probability (error rate, +/- 5%). Ninety-four percent of internists and 87% of surgeons believe firearm violence is a major public health issue. A majority of internists and surgeons also support community efforts to enact legislation to restrict the possession or sale of handguns (84% and 64%, respectively). Furthermore, although 84% of internists and 72% of surgeons believe that physicians should be involved with firearm injury prevention, less than 20% of respondents usually engage in some form of firearm injury prevention practice in patient care.

CONCLUSION

Many internists and surgeons think that firearm injuries are a public health issue of growing importance, that physicians should incorporate firearm safety screening and counseling into their practice, that physicians should join community efforts to regulate handguns, and that specific gun regulation measures should be adopted as public policy.

Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure

OBJECTIVE

To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.

DESIGN

Survey of a national systematic sample of physicians.

PARTICIPANTS

Five hundred family practitioners, 500 general internists, and 500 cardiologists.

MEASUREMENTS AND MAIN RESULTS

Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%).

CONCLUSIONS

Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.

Improving palliative care

Although most deaths in the United States occur in hospitals, data suggest that hospitals and physicians are not equipped to handle the medical and psychosocial problems of dying patients. In this article, we review the barriers to achieving a peaceful death, including inadequate medical professional education on palliative care, and public and professional uncertainty about the difference between foregoing life-sustaining treatment and active euthanasia, and health professionals' difficulty recognizing when patients are dying and the associated sense that death is a professional failure. Other barriers include fiscal constraints on the length of stay, the number of nurses available to care for dying patients, legal and regulatory constraints on obtaining opioid prescriptions, and a segregated system of hospice care that requires patients to be separated from familiar health care providers and settings in order to receive palliative care at the end of life. Identifying the opportunities that can improve the delivery of palliative care at the end of life is the first step toward developing corrective approaches. Strategies that enhance these opportunities are proposed.