CONCLUSION: The most important of subjects' concern were regarding post-surgical pain, low expectations of the eventual efficacy of surgery, and concern over the cost of TKR. In addition, despite the high WOMAC disability score of the group, less than 50% of patients were referred to a specialist. Efforts to address the current disparity in use of TKR should attend to these potentially modifiable factors. We conducted a randomized effectiveness trial in the General Internal Medicine clinics at 7 Veteran Affairs facilities that had discrete firms. All patients who were assigned a primary provider and who had an appointment in the prior year were eligible. Randomization, intervention and analysis were by firm. Respondents to a baseline health inventory were regularly mailed the SF-36 and, as relevant, validated questionnaires about 6 chronic conditions: coronary disease, COPD, depression, diabetes, alcohol use and hypertension. From the SF-36, we computed physical and mental component scales (PCS and MCS). We also sent surveys about satisfaction with humanistic and organizational aspects of care and retrieved clinical data from computerized records. The information collected was presented to primary care providers of eligible patients at every visit for 2 years in graphical format (e.g., blood pressure, HbA1C, SF-36 scale scores and anginal frequency) plus interpretations (e.g.,``Patient unable to climb stairs due to shortness of breath'') and``tips'' derived from national guidelines. Clinicians also received summary reports comparing their patient panels with local and national norms and highlighting patients with potentially serious problems. ). There were also no significant differences in satisfaction in the humanistic or organizational domains between intervention and control firms. Similar results were found using several analytic strategies including restriction to patients who completed all forms. CONCLUSION: Routine collection and feedback of measures of general and conditionspecific health and satisfaction did not improve outcomes. It is likely that such data must be linked to specific management suggestions if they are to influence patients' outcomes. in several studies appears to be an independent risk factor for developing incident coronary artery disease (CAD). The biological mechanism explaining the increased risk is not certain. We wanted to determine if C-reactive protein (CRP), a marker of increased risk for CAD, is associated with major depression. METHODS: Our analysis is based on data from the third National Health and Nutrition Examination survey conducted between 1988-1994. The Diagnostic Interview Survey (DIS) was administered to 8451 individuals between 17 ± 39 years of age to assess current and past episodes of major depression. The analysis is based on 7091 individuals (3849 females and 3242 males) with complete data on CRP and other important covariates. Analysis was stratified by gender because of the influence of estrogens on CRP levels. Logistic models were used with detectable CRP as the dependent variable. Unadjusted and adjusted estimates for current (last year) and past major depression compared to never lifetime depression were calculated. Estimates are adjusted for sampling design and nonresponse. RESULTS: Men with current major depression (OR=3.29 95% CI 1.56, 6.92) and past major depression (OR=2.05 95% CI 0.84, 5.04) had elevated levels of detectable CRP after adjustment for age, African-American race, BMI, total cholesterol, log triglycerides, diabetes, systolic blood pressure, tobacco smoking (self-reported current or past or cotinine level above 10 ppm), and alcohol intake compared to never depression. A similar trend was found for single episode of depression (OR=1.13 95% CI 0.26, 4.90) and multiple episodes of depression (OR=3.87 95% 1.67, 8.96) compared to never depression after adjustment. There was a significant linear trend between number of lifetime depressive symptoms and elevated CRP (p < 0.001). The relationship between depression and elevated CRP was present for smokers, nonsmokers, and those with low or high total cholesterol. For women, there were no associations between any of the measures of depression and elevated CRP. Adjusting for current use of estrogens or ever use of oral contraceptive agents and excluding those who were pregnant did not substantially change the results. CONCLUSION: In young men, current major depression is associated with elevated CRP levels that appear to return toward normal when the depression remits. CRP may be one mechanism by which depression leads to increased coronary heart disease in men. The same associations were not present in women but we may not have been able to adequately account for their hormonal status. This cross-sectional data needs to be confirmed with prospective studies. PURPOSE: Understanding why people drink alcohol is important for the health and safety of individuals and the public. The aim of this study was to examine from a cognitive point of view the hypothesized link between drinking and stress. METHODS: 25 scenarios were constructed by combining two items, either two life-change events or a social situation and an emotional state. In the initial three experiments, 159 male and 43 female alcoholics and 157 male and 93 female non-alcoholics in France judged the degree to which these scenarios were stressful and subsequently the degree to which they stimulated an urge to drink. In the final experiment, 126 of the male alcoholics were studied at the beginning and end of an in-patient alcohol rehabilitation program. RESULTS: The alcoholics and non-alcoholics, regardless of gender, assigned similar stress values to the scenarios and used the same cognitive rules for combining the stress associated with two items (disjunctive rules for two life-change events and additive ones for a personal emotion combined with a social situation). They differed, however, in how they judged the urge to drink. The non-alcoholics reported little stimulus to drink from any combination of items, whereas the alcoholics not only perceived the individual items as stimulating an urge to drink, but also used the same cognitive rule in judging the combined urge to drink of two items as they used in judging the combined stress. After completing rehabilitation, the alcoholics judged the combinations of life-change events as stimulating less stress and less urge to drink; nevertheless, they continued to use a disjunctive combination rule. CONCLUSION: Stress and drinking are linked at a fundamental cognitive level among alcoholics, though not among non-alcoholics. Alcoholics should be helped to recognize this link, to reduce their feelings of stress, and to respond to stress in ways other than drinking. documented. Yet, widely used systems of monitoring quality such as the NCQA's HEDIS measures do not require plans to report results separately by patient sociodemographic group. This AHRQ sponsored project is investigating the need for and feasibility of plans reporting selected HEDIS measures stratified by key social groupings. Our initial analysis examines plans' performance on advising smokers to quit, stratified by social group. METHODS: We obtained HEDIS 2000 data for 3,663 commercially-insured and 2,824 Medicaid-insured members enrolled in 7 UnitedHealthcare plans located in 3 regions. As specified by the NCQA, the Consumer Assessment of Health Plans Survey (CAHPS 2.0) was used to collect information on whether the enrollee was a current or recent smoker (denominator) and advised to quit smoking (numerator). We obtained information on patients' sociodemographic characteristics, visits, and health from the survey. Response rates were 55% and 38% for commercial and Medicaid patients, respectively. We analyzed rates of advising smokers to quit separately for commercially insured and Medicaid patients as is customary with HEDIS measures. For comparisons between patients in different sociodemographic groups, we pooled data from the different plans. We used Chi-Square tests to compare the proportion of smokers advised to quit by gender (female vs. male), race/ethnicity [nonHispanic White vs. (nonWhites and Hispanics)], and education (high school or less vs. some college or more). Pending multivariate analyses will assess independent effects of these factors adjusting for age, number of visits, and self-reported health. RESULTS: Of the respondents, 693 commercially insured and 973 Medicaid patients were smokers. The average rate of advising smokers to quit was the same for commercial (66%) and Medicaid (66%) patients. Among commercially insured patients, men were less likely to be advised to quit than women (61% vs. 70%, P=.01) and a lower proportion of less educated patients were advised to quit than among more educated patients (70% vs. 64%, P=.10), however, the latter difference was not significant. In contrast, among Medicaid patients, nonHispanic Whites were more likely than other patients to be advised to quit (69% vs. 61%, P=.01). The proportion of commercially insured patients advised to quit was also higher for nonHispanic Whites than for others (67% vs. 60%), but the difference was not significant (P=.32 The study population consisted of 1394 diabetics with a mean age of 69.2 (+/À 7.2 SD), 98.4% male, and 1.6% female. The old-old diabetic population (n=360) comprised 13% of the Louisville VAMC patient population 75 years old and older in 1997 (equivalent to the national rate of diabetes in persons aged 75 and older (13.2%)). The mean cholesterol was 200 mg/dL (+/À 42.8 SD) and the mean LDL was 120 mg/dL (+/À34.3 SD). The oldest-old were least likely to have their cholesterol checked (p= < 0.01). They were also least likely to be placed on cholesterol-lowering medications when their LDL Cholesterol was greater than or equal to 160 mg/dL. However, in 1998 and 1999, the oldest-old were more likely to be treated with medication than the middle old. CONCLUSION: The oldest old are less likely to have their cholesterol checked, but once it is checked, they are more likely than the middle old to be treated. Since diabetes and cardiovascular disease are common, cardiovascular disease is more common in the elderly, and morbidity and mortality from cardiovascular disease is great, physicians need to attempt to reduce morbidity and mortality by adhering to the practice guidelines for cholesterol management Ð even in the oldest diabetics. Practice patterns demonstrated in this study suggest increasing use of cholesterol-reducing medications in older adults. . As indicated by a c-statistic significantly greater than 0.5, the two existing classification schemes predicted stroke better than chance: 0.78 for the scheme developed by the Atrial Fibrillation Investigators (AFI) and 0.82 for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, the new CHADS2 index performed better with a c-statistic of 0.87. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3 ± 1.7) for each 1-point rise in the CHADS2 score (Table) . CONCLUSION: The two existing classification schemes and especially a new stroke-risk index, CHADS2, can quantify the risk of stroke for patients who have AF. Use of the CHADS2 index should aid in the selection of antithrombotic therapy for patients who have non-rheumatic AF. PURPOSE: Medication errors (MEs) and adverse drug events (ADEs) are common in the hospital setting. However, relatively little is known about the frequency of MEs and ADEs in outpatients. Therefore, we prospectively examined the frequency, type, severity, and preventability of MEs and ADEs in the ambulatory setting. METHODS: We studied 2 academic hospital practices and 2 community based clinics in the Boston area, and collected copies of prescriptions written by 24 primary care providers from Sept 1999 to March 2000 (6 weeks per clinic). Prescription copies were reviewed by a pharmacist to screen for MEs and potential ADEs. In addition, patients who received prescriptions were telephoned 2 weeks after their visit to ask about problems with their medications, with a response rate of 59%. Patient-reported problems were presented to 2 MD reviewers, who classified them as ADEs or not, and determined severity and preventability. Events were considered preventable if they persisted for an unnecessarily prolonged period (even if they could not have been completely prevented). RESULTS: Of 1173 prescriptions screened during this time period, 202 (17%) were rule violations (orders that violate strict standards but are generally understood and generate no additional work), 44 (4%) were MEs, 59 (5%) were potential ADEs. The most frequent rule violations were missing route, and the most frequent MEs were errors in route or dose. The most frequent potential ADEs were errors in frequency and dose. Of 661 patients surveyed, 178 (27%) reported a total of 206 ADEs. Of these, 29 (14%) were serious, 74 (36%) were preventable, and 13 (6%) were both. The most frequent types of ADEs and preventable ADEs were CNS-related (35%, 36%), gastrointestinal (21%, 9%), and cardiovascular (16%, 18%). The most frequent medications involved in preventable ADEs were antidepressants (22%), ACE-inhibitors (14%), beta-blockers (10%), and calcium-channel blockers (10%). Of preventable ADEs (n = 74), physicians were primarily responsible in 63% and patients in 33%. The main types of physician error were failure to act on results of monitoring or tests (50%) and inappropriate drug choice (24%). The main type of patient error was failure to inform their physician of problems (100% Unfortunately, educational brochures are often generalized, and do not address the different needs and barriers that impair the self-management required for care of this chronic disease. Few materials are available that cater to individuals of different ethnic backgrounds, especially those with low literacy or education backgrounds. This study evaluated a new multimedia software application for diabetic populations with these needs in mind. The target population of subjects included diabetic patients from an urban, minority community not accustomed to computer usage. METHODS: 22 diabetic African-American patients were consecutively interviewed and digitally videotaped in an urban general medicine clinic. These individuals provided testimonials regarding the barriers, fears, benefits, and myths surrounding the ophthalmologic eye examination including pupil dilation. Specific issues, such as faith, lack of insurance, and misconceptions about eye exams were addressed. The video clips were edited and integrated into a multimedia application that included simple activities to engage the user over 15 ± 20 minutes. The application was available near the waiting room of a clinic for patients to view when waiting for an appointment, or afterwards before leaving. The program uses a touch screen, so previous technological experience was not required. A separate sample of 26 patients viewed the multimedia program, and completed a brief questionnaire. RESULTS: 11 male and 15 female diabetic patients completed the multimedia program and survey, with 17 (65%) African-American, and 18 (69%) having elementary or high school education. 12 of 26 (46%) have never used a computer before, and 18 (69%) described the computer as``easy'' or``very easy'' to use. Preferences for medium of learning about diabetes were greatest for computers (11), followed by doctors and nurses (8), television (5), and brochures and articles (4) . CONCLUSION: A multimedia patient education program that addressed barriers related to literacy and culture was found to be acceptable by a convenience sample. Additional telephone surveys will provide data regarding knowledge and attitudes toward obtaining annual eye examinations, as well as actual compliance with visits. Given the growing interest in on-line consumer health information, the availability of similar applications for underserved populations may help to bridge the``digital divide'' (or, the gap between different communities in terms of access to technology). PURPOSE: While gender selection of physicians has been studied extensively, mostly by survey, selection of physicians by race has rarely been addressed. We used an experimental design and an actor-portrayed video doctor to investigate patients' preferences for physician gender and race. METHODS: Participants were asked which one of six video doctors (one male and female African American, Latino, and Caucasian) they would pick to be their physician after viewing each deliver a 45-second health prevention message. The videotapes were professionally produced and great care was taken to keep all variables constant, including the age, attractiveness, and clothing of the video doctors; the video setting; and the delivery of the prevention message (script, non-verbal behaviors, facial expressions, and interpersonal style Ð e.g., warm, empathic, collaborative). Each group of 20 ± 22 participants viewed one of 18 configurations of the presentation order of the six video doctors to control for any order effect. RESULTS: 400 participants were recruited in a shopping mall in the San Francisco Bay Area. The sample was diverse in gender (39% male, 61% female); race (29% Caucasian, 8% African American, 26% Latino, 30% Asian, and 7% Other); and age (18 years ± 87 years). When asked who they would choose to be their physician, both male and female participants were more likely to choose a female (82%) as their physician rather than a male (18%). Among female participants, 88% chose a physician of their own gender, while only 29% of males chose a male physician. When asked who they would choose to be their physician, 23% of participants chose an African-American physician, 32% chose a Latino physician, and 44% chose a Caucasian physician. Fifty-two percent of African-American participants chose an African-American physician; 44% of Latino participants chose a Latino physician; and 56% of Caucasian participants chose a Caucasian physician. Among Asian participants, 20% chose an African-American physician, 37% a Latino physician, and 43% a Caucasian physician. CONCLUSION: The vast majority of participants in our study chose a female video doctor as their physician, regardless of their own gender. Although approximately half of African-American, Latino, and Caucasian participants chose their own race, the other half were willing to choose a video doctor of a different race. Our data suggests that when selecting a physician, patients may strongly associate women, regardless of a standardized patient-centered delivery, with those qualities they want in their physician. Future studies may want to use video doctor technology to further investigate patients' preferences in selecting their physician, in particular the effect of physician race on patient choice. PURPOSE: Adolescent obesity continues as public health epidemic. Data from the National Health and Nutrition Examination Surveys (NHANES I, II, III) reveal that the percentage of youth above the 85th percentile for body mass index (BMI) increased to approximately 22% by the late 1980's. Further, since the beginning of these surveys, the prevalence of adolescent obesity has increased by 39%, with Hispanic, Native American, and African American children more affected than other populations. A 1997 survey conducted by the Allentown (PA) Health Bureau revealed a 31% obesity rate among adolescent students in the Allentown School District (ASD), where 57% of students are non-white and 62% are eligible for free or reduced lunches. Both decreased physical activity and poor eating behaviors contribute to obesity. General internists have a responsibility but limited opportunities to understand and influence teen nutrition, especially in minority populations. METHODS: To better understand students' attitudes toward nutrition and physical activity, as well as barriers to improving their choices, we conducted focus groups among representative students to determine their food preferences, and dietary and activity patterns. We developed a 57-question survey that we utilized in six focus group sessions with high school students in an alternative program within the ASD. Sessions were audiotaped, and responses to questions categorized into four areas: Food choices, Physical Activity, Self-Esteem/Identity, and Knowledge. RESULTS: In general, students expressed a willingness to eat healthier foods, if provided a variety including fresh fruits and vegetables, as well as culturally acceptable products. Adolescents desired daily gym class with a variety of activities, although admitted that much of their free time was spent engaged in sedentary activities. Groups also expressed indifference, although many had basic knowledge of the consequences of obesity.