(73/585) Improving physicians' knowledge of the costs of common medications and willingness to consider costs when prescribing.
OBJECTIVES: To determine the effectiveness of an educational intervention designed to improve physicians' knowledge of drug costs and foster willingness to consider costs when prescribing. DESIGN: Pre- and post-intervention evaluation, using physicians as their own controls. SETTING: Four teaching hospitals, affiliated with 2 residency programs, in New York City and northern New Jersey. PARTICIPANTS: One hundred forty-six internal medicine house officers and attendings evaluated the intervention (71% response rate). Of these, 109 had also participated in a pre-intervention survey. INTERVENTION: An interactive teaching conference and distribution of a pocket guide, which listed the average wholesale prices of over 100 medications commonly used in primary care MEASUREMENTS AND MAIN RESULTS: We administered a written survey, before and 6 months after the intervention. Changes in attitudes and knowledge were assessed, using physicians as their own controls, with Wilcoxon matched-pairs signed-rank tests. Eighty-five percent of respondents reported receiving the pocket guide and 46% reported attending 1 of the teaching conferences. Of those who received the pocket guide, nearly two thirds (62%) reported using it once a month or more, and more than half (54%) rated it as moderately or very useful. Compared to their baseline responses, physicians after the intervention were more likely to ask patients about their out-of-pocket drug costs (22% before vs 27% after; P <.01) and less likely to feel unaware of drug costs (78% before vs 72% after; P =.02). After the intervention, physicians also reported more concern about the cost of drugs when prescribing for patients with Medicare (58% before vs 72% after; P <.01) or no insurance (90% before vs 98% after; P <.01). Knowledge of the costs of 33 drugs was more accurate after the intervention than before (P <.05). CONCLUSION: Our brief educational intervention led to modest improvements in physicians' knowledge of medication costs and their willingness to consider costs when prescribing. Future research could incorporate more high-intensity strategies, such as outreach visits, and target specific prescribing behaviors. (+info)
(74/585) A propensity analysis of late versus early nephrologist referral and mortality on dialysis.
Previous studies have analyzed the association between late versus early nephrologist referral (LR, ER) and poor clinical outcomes in patients with end-stage renal disease. We sought to determine whether these poor outcomes were causally related to LR, or whether LR was a proxy for poorer access to health care in general. An inception cohort of incident dialysis patients enrolled in the New Jersey Medicare or Medicaid programs was identified. Using a large number of demographic, clinical, and health care utilization covariates, propensity scores (PS) were then calculated to predict whether a given patient had been seen by a nephrologist at 90 d before first dialysis. Cox proportional hazards models were then built to test the association between timing of nephrologist referral and mortality during the first year of dialysis, using PS adjustment and matching to determine whether this association was confounded by other measures of reduced healthcare utilization. Neither adjustment for PS (HR = 1.31; 95% CI, 1.17 to 1.47) nor matching (HR = 1.40; 95% CI, 1.23 to 1.59) materially changed the initial 36% excess mortality in LR compared with ER patients (HR = 1.36; 95% CI, 1.22 to 1.51). Excess mortality among LR was limited to the first 3 mo of dialysis (HR = 1.75; 95% CI, 1.48 to 2.08) but not present thereafter (HR = 1.03; 95% CI, 0.84 to 1.25). Late nephrologist referral is an independent risk factor for early death on dialysis, even after controlling for other indicators of healthcare utilization. Further research is needed to identify patients at particular risk so that interventions to prevent early deaths on dialysis in LR patients can be developed and tested. (+info)
(75/585) Silicosis and end-stage renal disease.
OBJECTIVES: The objective of this study was to determine the incidence of renal disease among workers with silicosis. METHODS: A population of 1,328 workers with definite silicosis and adequate work history information, drawn from three states with silicosis surveillance systems, was followed. Renal disease was ascertained via linkage of the cohort with a United States register (which has existed since 1977) of end-stage renal disease. RESULTS: In the first analysis, it was assumed that the risk of end-stage renal disease began upon exposure to silica. In this analysis 12 cases of end-stage renal disease were found versus 15.6 expected, for a rate ratio of 0.77. Four cases of glomerular end-stage renal disease were found (standardized incidence ratio 2.65, 95% confidence interval 0.56-5.25). It is possible that some persons with end-stage renal disease died before being entered into the silicosis registers. In a second analysis, person-time at risk was assumed to begin at the date of entry into the silicosis register. A rate ratio of 1.67 (95% confidence interval 0.76-3.17) was found for end-stage renal disease on the basis of nine observed cases. CONCLUSIONS: The results do not clearly show that patients with silicosis have an excess of end-state renal disease, although they do suggest an excess of glomerular end-stage renal disease. Analyses were limited by small numbers and possible selection biases. (+info)
(76/585) Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer.
PURPOSE: Although clinical trials have clearly demonstrated the benefits of tamoxifen in women with primary breast cancer, little is known about how this drug is actually used in the general population. We sought to estimate adherence and predictors of nonadherence in women starting tamoxifen as adjuvant breast cancer therapy. PATIENTS AND METHODS: Subjects were age 18 years or older initiating tamoxifen for primary breast cancer and enrolled in New Jersey's Medicaid or Pharmaceutical Assistance to the Aged and Disabled programs during the study period, from 1990 to 1996 (N = 2,378). Main outcome measures were number of days covered by filled prescriptions for tamoxifen in the first year of therapy with the 4 years after tamoxifen initiation for a subset; predictors of good versus poor adherence. RESULTS: Twenty-three percent of patients missed taking tamoxifen on more than one fifth of days studied, although on average, patients filled prescriptions for tamoxifen for 87% of their first year of treatment. The youngest, oldest, nonwhite, and mastectomy patients had significantly lower rates of adherence; patients who had seen an oncologist before taking tamoxifen had significantly higher rates of adherence. Overall adherence decreased to 50% by year 4 of therapy. CONCLUSION: The mean level of adherence to tamoxifen is high compared with other chronic medications. However, nearly one fourth of patients may be at risk for inadequate clinical response because of poor adherence. Because of the efficacy of tamoxifen therapy in preventing recurrence and death in women with early-stage breast cancer, further efforts are necessary to identify and prevent suboptimal adherence. (+info)
(77/585) Endemic babesiosis in another eastern state: New Jersey.
In the United States, most reported cases of babesiosis have been caused by Babesia microti and acquired in the northeast. Although three cases of babesiosis acquired in New Jersey were recently described by others, babesiosis has not been widely known to be endemic in New Jersey. We describe a case of babesiosis acquired in New Jersey in 1999 in an otherwise healthy 53-year-old woman who developed life-threatening disease. We also provide composite data on 40 cases of babesiosis acquired from 1993 through 2001 in New Jersey. The 40 cases include the one we describe, the three cases previously described, and 36 other cases reported to public health agencies. The 40 cases were acquired in eight (38.1%) of the 21 counties in the state. Babesiosis, a potentially serious zoonosis, is endemic in New Jersey and should be considered in the differential diagnosis of patients with fever and hemolytic anemia, particularly in the spring, summer, and early fall. (+info)
(78/585) Household exposure factors, asthma, and school absenteeism in a predominantly Hispanic community.
The Passaic Asthma Reduction Effort (PARE) used an asthma symptom and household exposure factor questionnaire to screen 4634 elementary school children over a 4-year period in Passaic, New Jersey. During the first year, an additional 240 preschool children were also screened. Overall, 16% of the school children were reported by their parents to have been diagnosed with asthma. In all, 30% of responding families claimed to have at least one family member diagnosed with asthma and this was five times more likely if the target child had asthma. Exposures consistently associated with childhood asthma diagnosis included environmental tobacco smoke (ETS), presence of dampness/mold, roaches, and furry pets in the home. Diagnosis of asthma was primarily associated with all six symptoms used in the PARE questionnaire, and secondarily with environmental factors. Puerto Rican and black children had the highest asthma prevalence (26% and 33%), while Mexican children had the lowest (7%). Use of medications and school absenteeism among asthmatic children were associated with wheeze and night cough, but not with any specific environmental exposure. Increased school absenteeism by children undiagnosed with asthma was associated with ETS and dampness/mold in the home. Differences in asthma diagnosis and absenteeism in response to environmental factors were found across ethnic subgroups. Getting asthmatic children on medical management protocols and providing families with education about environmental risk reduction should aid in reducing morbidity in this ethnically complex population. Such coordinated efforts offer the promise of reducing school absenteeism. (+info)
(79/585) Alumni perspectives on community-based and traditional curricula.
In 1994, the University of Medicine and Dentistry of New Jersey-New Jersey Dental School (UMDNJ-NJDS) launched the Community-Oriented Dental Education (CODE) program. The CODE program provides senior dental students the opportunity to spend four days per week providing dental care in a community-based clinic. A survey of graduates of CODE (n = 55) and randomly selected graduates of the traditional curriculum (n = 110) was conducted via mail to determine attitudes relating to community service (CS), community-based learning (CBL), reasons for participating in their clinical program, perceived levels of clinical preparedness at graduation, and practice choices. A total of 111 surveys (66.9 percent) were returned to NJDS, with 84.6 percent of CODE alumni responding and 59.0 percent of traditional alumni (TA) responding. Of the 111 surveys returned, sixty-five (58.6 percent) were completed by TA, and forty-six (41.4 percent) were completed by CODE alumni. There were no differences among CODE and TA regarding attitudes toward CS and tendency to practice in underserved areas or to accept Medicaid payments. There were, however, some differences in attitudes toward CBL, reasons for applying or not applying to the CODE program, perceived impact of clinical education on graduates' preparedness, views of the extent to which the programs encouraged students to choose public or private areas of practice, and perceptions of how the desire to help communities influenced career and practice decisions. Some of these findings may be useful to schools as they plan extramural education programs. (+info)
(80/585) Rethinking the socioeconomics and geography of tuberculosis among foreign-born residents of New Jersey, 1994-1999.
OBJECTIVES: This study investigated the socioeconomic profile of foreign-born tuberculosis patients in New Jersey. METHODS: Foreign- and US-born tuberculosis patients in 1994-1999 were compared using various measures of socioeconomic status. RESULTS: Out of 4295 tuberculosis patients, 2005 (47%) were foreign-born. Foreign-born patients resided in more affluent, more educated, and less crowded areas than did US-born patients (P <.005). They were also more likely to have been employed during the 2 years before diagnosis (62% vs 41%, P <.001). Private physicians treated the majority of South Asian-born patients. CONCLUSIONS: Substantial numbers of employed foreign-born tuberculosis patients now reside in affluent New Jersey locations. Changes in tuberculosis control programs may be required when the socioeconomic status and place of residence of foreign-born populations diverge from traditional assumptions linking poverty with tuberculosis. (+info)