CONCLUSION: There was substantial geographic variation in clinical care and outcomes among veterans with AMI. Outpatient follow-up was highly variable and associated with mortality. Further studies are needed to determine the most effective strategies for improving outcomes after AMI. METHODS: We recently described a new, valid, and reliable instrument called QUEST, which has 4 scales measuring patients' perceptions of quality and their satisfaction with care by physicians (MDs) and nurses (RNs). We administered QUEST and other standardized instruments to 84 medical inpatients (45 terminally ill and 39 comparison) at 2 hospitals. We used correlations, t-tests, and ANOVA to test associations between sociodemographic/clinical factors and QUEST scores. RESULTS: Mean patient age was 60, APACHE-III physiology score 16.6; 71% were white, 60% men, 54% Catholic, 28% Medicaid/uninsured, 38% had cancer or HIV, 41% moderate/ severe pain, 19% depressed, and 58% private (PVT). Age, APACHE, race, gender, religion, insurance, and diagnosis were unassociated with quality or satisfaction. Quality and satisfaction scores for MDs were lower among``service'' (SERV) than PVT patients and lower among terminal than non-terminal patients. Quality and satisfaction scores for RNs were lower among SERV patients and depressed patients. P-values for ANOVA models for QUEST were: MD Quality = .01, MD Satisfaction (adjusted for pain) = .007, RN Quality = .16, RN Satisfaction = .002. CONCLUSION: Terminally ill SERV patients rated MD quality and satisfaction lower than PVT patients and lower than SERV patients not terminally ill. RN satisfaction scores were high only among PVT patients who were not depressed. Understanding these apparent differences in end-of life care will require further investigation. PURPOSE: At the end of life, when cure is no longer possible, perhaps the most important medical intervention that can be offered is time. However, almost nothing is known about the time health professionals spend with dying inpatients. METHODS: We asked day-shift nurses to use a diary to record how much time they spent in various activities for 47 medical inpatients at 2 teaching hospitals (25 terminally ill patients with Do Not Resucitate (DNR) orders and 22 comparison patients). To minimize Hawthorne effects, nurses were told to record multiple categories of activities and were only informed that this was a``time-motion study for seriously ill patients.'' This method has been validated against video-recordings of actual time spent in the room (r = .70, p < .0001). Non-English speaking patients, those whose clinical condition prohibited interview, and those with a reduced set minimental status (MMS) score indicating dementia were excluded. Charts were reviewed and patients were interviewed using a battery of standardized instruments. Because nursing time was not normally distributed, we used log-transformed time as our dependent variable. We then used t-tests, correlations, and ANOVA to test associations between sociodemographic/clinical data and bedside nursing time. RESULTS: The mean patient age was 59, and the mean APACHE-III physiology score 16.3; 64% were white, 19% African-American, 11% Latino, and 6% Asian; 60% were men, 39% Protestant, 41% had cancer or HIV, and 23% were depressed. The mean amount of time nurses spent with patients per day shift was 27 minutes. In bivariate analyes, age (p = .23), APACHE-III physiology score (p = .78), gender (p = .81), religion (p = .27), diagnosis (p = .99), and DNR status (p = .26) were unassociated with nursing bedside time. Nurses spent more time at the bedsides of patients with lower reduced-set MMS scores (indicating worse mental function (r = .26, p = .08)), more time with white patients compared with non-white minorities (31 minutes vs. 22 minutes, p = .08), and more time with depressed compared with non-depressed patients (43 minutes vs. 23 minutes, p = .02). In an ANOVA model, lower reduced-set MMS scores (p = .02), white race (p = .02), depression (p = .15), and a race-depression interaction term (.045) were associated with more nursing bedside time. CONCLUSION: In this population, nurses spent more time with patients who had worse mental function (even after excluding those who were frankly demented), and more time with white patients who were depressed compared with both non-depressed white patients and minority patients regardless of depression score. DNR orders were not associated with less nursing contact. While some of these results appear to suggest unexpected differences in the time nurses give to patients, firm conclusions will require further study. Ryukyu University Hospital, Nakagami, Okinawa PURPOSE: General internal medicine (GIM) as an academic discipline was recently introduced to medical schools in Japan. Residency programs are still quite young and fully trained primary care physicians are in shortage. In May 1999, the Ryukyu University Hospital started a general medicine clinic to provide better care for its patients. However, since there were no staff trained in GIM, specialists from the Department of Medicine and Department of Psychiatry were assigned to the clinic. We conducted two surveys to assess the attitudes toward and perceptions of GIM practice among specialists at different academic disciplines in the hospital. METHODS: First a survey was carried out using a questionnaire that was distributed to all physicians who work at the Ryukyu University Hospital. We also conducted a 2nd survey which focused on the experience at the GIM clinic for specialty physicians who had ever practiced at the clinic. RESULTS: Overall response rates were 66.3% (n = 236) and 75% (n = 48), respectively. The clinic performance over the first year was evaluated and rated from À3 (extremely poor) to +3 (excellent). Respondents whose specialty was not in internal medicine perceived the GIM clinic more positively (average +1.0) compared to internists with and without GIM clinic experience(average À1.9 and À1.6, respectively), which reached statistical significance (p < 0.001). Among residents, fellows and faculties, there was no statistical difference regarding attitudes toward the competence of primary care physicians, encouragement and positive regard for GIM. Eighty percent of internists who had practiced at the GIM clinic agreed that their clinical competencies as a specialist were not sufficient to be a primary care physician. 92% of them disagreed with the hospital's continued operation of the GIM clinic under current administration, however, if GIM trained physicians were stationed at the clinic, the same number of internists agreed that the clinic would play an important role at their hospital. Psychiatrists were more willing to cooperate with GIM clinic compared to other specialties. CONCLUSION: Historically, the culture of academic health centers had not been hospitable toward primary care. However, our survey demonstrated that the chilly climate has been changing. Only very few physicians perceive primary care tasks as not requiring a high levels of expertise. In many schools, increased attention to education for primary care practice is evident in Japan. A more generalist workforce with competence and expertise in primary care is essential. PURPOSE: Previous work has demonstrated that African American elders experience higher functional and cognitive disability than White elders. The Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive community-based long-term care services for nursing home eligible elders who remain in the community. Once enrolled patients have equal access to all needed medical and long-term care services at no additional cost. We examined the impact of enrollment in the PACE system on mortality differences between African American and White patients. METHODS: 2002 White patients and 859 African American patients enrolled at 12 nationwide PACE sites from 1990 ± 1996. All patients were followed from enrollment through death, or 12/31/97. On enrollment, measures of demographic characteristics, functional status, and comorbid medical diagnoses were obtained by social workers, nurses, and physicians. We used the method of Kaplan-Meier to describe mortality rates in African American and White patients. We used the log-rank test and Cox-proportional hazards models for bivariate and multivariate comparisons of mortality rates for African American patients vs. White patients. RESULTS: On enrollment into PACE, African American patients were younger than White patients (77.4 v 79.6, P < .01). However, African American patients had worse functional status (mean score on 10 point ADL scale, 6.5 v 7.2, p < .01) and were more likely to be diagnosed with dementia (56% v. 45% p < .01). 74% of both African American and White patients were women. A survival advantage for African Americans emerged after 9 months of enrollment in PACE.