Emeritus Faculty - University Medical Line, Medicine
Chief, Division of General Internal Medicine (Dept. of Medicine) (1997 - 2008)
Director, Department of Medicine Quality Assurance and Quality Improvement Programs (1998 - 2008)
Member, Stanford Hospital & Clinics Care Review Committee (1998 - 2008)
Senator-At Large, Stanford University School of Medicine Faculty Senate (2002 - 2005)
Chair, Clinical Science Affinity Group; School of Medicine Curricular Reform Project (2002 - 2003)
Member, SHC Quality Improvement and Patient Safety Committee (2003 - 2008)
Honors & Awards
Kaiser Family Fdn Award for Outstanding and Innovative Contributions to Medical Education, Stanford University School of Medicine (2006)
Awardee, Office of the Dean; Stanford University School of Medicine (2004)
Fellowship, California Healthcare Foundation Leadership Training (2001-3)
Listee, Best Doctors in America (1997-99)
Fellowship, Andrew W. Mellon Foundation (1977-81)
Fellowship, W.K. Kellogg Foundation; Hospital Research and Education Trust (1977)
Diplomate, American Board of Internal Medicine (1975)
Diplomate, National Board of Medical Examiners (1971)
Phi Beta Kappa, Amherst College (1966)
BA, Amherst College, French (1966)
MD, Case Western Reserve University, Medicine (1970)
Internship, Stanford Univ. Affil. Hospitals, Internal Medicine (1971)
Residency, Stanford Univ. Affil. Hospitals, Internal Medicine (1975)
Fellowship, RWJ Clinical Scholars; McGill, Health care planning (1976)
Current Research and Scholarly Interests
Quality improvement (QI) efforts seek to make medical care the best it can be rather than merely good enough to avoid censure. Focus on improving the average performance usually produces more net benefit than eliminating outliers, often by simplification, standardization, and specification. We have worked with electronic medication monitors, clinical databases, and computerized physician order entry systems for better clinical outcomes. We have also developed training modules for students, house officers, and clinicians for enhanced professionalism and accountability.
Recent work has emphasized optimizing among cost, quality and access, using examples of common internal medicine problems (e.g., community acquired pneumonia, diabetes mellitus, blood product transfusion). QI project teams arose in both inpatient and outpatient settings. The optimal results occur from combining didactic training and practical applications via projects with plan-do-study-act rapid cycles of change. We have also examined the relative impact of patient versus physician behaviors as well as system factors in determining clinical outcomes for control of elevated cholesterol.
In prior work, we explored medication adherence. Medication-taking represents a complex behavior integral to optimal outcomes in much of ambulatory medical care. We have helped develop and test electronic medication monitors capable of dynamic tracking of medication dispensing events over time. The technology offers a time-based matrix by which to interpret, understand, and improve clinical outcomes that depend on patients' medication-taking behavior.
Using the electronic monitor technology, we have studied
a) Normative patterns of medication-taking among subgroups of patients on chronic cardiovascular medications
b) Dose-response relationships among established and investigational antihypertensive medications for misinterpretations of optimal dosing recommendations
c) Critical evaluation of reported adverse drug reactions, based on dosing errors that involve omission, commission, or misscheduling
d) Clinical protocols useful for assessing apparent secondary resistance to treatment after initial clinical responsiveness
e) Cost-effectiveness of the incremental information about precise medication-taking events, patterns, and distortions.
Graduate and Fellowship Programs
- Review: In primary prevention, BP-Iowering treatment reduces major CV events in patients with SBP >= 140 mm Hg ANNALS OF INTERNAL MEDICINE 2018; 168 (4): JC15
Placebo Adherence and Mortality in the Heart and Estrogen/Progestin Replacement Study
AMERICAN JOURNAL OF MEDICINE
2012; 125 (8): 804-810
Analyses from double-blind randomized trials have reported lower mortality among participants who were more adherent to placebo compared with those who were less adherent. We explored this phenomenon by analyzing data from the placebo arm of the Heart and Estrogen/Progestin Replacement Study (HERS), a randomized, double-blind, placebo-controlled trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Our primary aim was to measure and explain the association between adherence to placebo and total mortality among the placebo-allocated participants in the HERS. Secondary aims included assessment of the association between placebo adherence and cause-specific morbidity and mortality.Participants with "higher placebo adherence" were defined as having taken at least 75% of their placebo study medication during each individual's participation in the study, whereas those with "lower placebo adherence" took less than 75%. The primary outcome was in-study all-cause mortality.More adherent participants had significantly lower total mortality compared with less adherent participants (hazard ratio, 0.52; 95% confidence interval, 0.29-0.93). Adjusting for available confounders did not change the magnitude or significance of the estimates. Analyses revealed that the association of higher adherence and mortality might be explained, in part, by time-dependent confounding.Analyses of the HERS data support a strong association between adherence to placebo study medication and mortality. Although probably not due to simple confounding by healthy lifestyle factors, the underlying mechanism for the association remains unclear. Further analyses of this association are necessary to explain this observation.
View details for DOI 10.1016/j.amjmed.2012.02.014
View details for Web of Science ID 000306741300025
View details for PubMedID 22840666
Adherence to placebo and mortality in the Beta Blocker Evaluation of Survival Trial (BEST)
CONTEMPORARY CLINICAL TRIALS
2012; 33 (3): 492-498
Randomized controlled trials have reported lower mortality among patients who adhere to placebo compared with those who do not. We explored this phenomenon by reanalyzing data from the placebo arm of the Beta Blocker Evaluation of Survival Trial (BEST), a randomized, double-blind, placebo-controlled trial of bucindolol and mortality.Our primary aim was to measure and explain the association between adherence to placebo and total mortality among the placebo-allocated participants in the BEST trial. Secondary aims included assessment of the association between placebo adherence and cause-specific mortality.Participants with "higher placebo adherence" were defined as having taken at least 75% of their placebo study medication over the entire course of each individual's participation in the study, while those with "lower placebo adherence" took <75%. Primary outcome was in-study all-cause mortality. To account for confounding, we adjusted for all available modifiable, non-modifiable and psychosocial variables.Adherent participants had a significantly lower total mortality compared to less-adherent participants (HR=0.61, 95% Confidence Interval: 0.46-0.82). Adjusting for available confounders did not change the magnitude or significance of the estimates. When considering cause-specific mortality, CVD and pump failure showed similar associations.Analyses of the BEST trial data support a strong association between adherence to placebo study medication and total mortality. While probably not due to publication bias or simple confounding by healthy lifestyle factors, the underlying explanation for the association remains a mystery. Prospective examination of this association is necessary to better understand the underlying mechanism of this observation.
View details for DOI 10.1016/j.cct.2011.12.003
View details for Web of Science ID 000303178100007
View details for PubMedID 22265975
A Culturally Adapted Telecommunication System to Improve Physical Activity, Diet Quality, and Medication Adherence Among Hypertensive African-Americans: A Randomized Controlled Trial
ANNALS OF BEHAVIORAL MEDICINE
2012; 43 (1): 62-73
Hypertension is more prevalent and clinically severe among African-Americans than whites. Several health behaviors influence blood pressure (BP) control, but effective, accessible, culturally sensitive interventions that target multiple behaviors are lacking.We evaluated a culturally adapted, automated telephone system to help hypertensive, urban African-American adults improve their adherence to their antihypertensive medication regimen and to evidence-based guidelines for dietary behavior and physical activity.We randomized 337 hypertensive primary care patients to an 8-month automated, multi-behavior intervention or to an education-only control. Medication adherence, diet, physical activity, and BP were assessed at baseline and every 4 months for 1 year. Data were analyzed using longitudinal modeling.The intervention was associated with improvements in a measure of overall diet quality (+3.5 points, p < 0.03) and in energy expenditure (+80 kcal/day, p < 0.03). A decrease in systolic BP between groups was not statistically significant (-2.3 mmHg, p = 0.25).Given their convenience, scalability, and ability to deliver tailored messages, automated telecommunications systems can promote self-management of diet and energy balance in urban African-Americans.
View details for DOI 10.1007/s12160-011-9319-4
View details for Web of Science ID 000300280300007
View details for PubMedID 22246660
- How Personal Is the Personal Health Record? ARCHIVES OF INTERNAL MEDICINE 2011; 171 (6): 575-576
Placebo Adherence and Its Association with Morbidity and Mortality in the Studies of Left Ventricular Dysfunction
JOURNAL OF GENERAL INTERNAL MEDICINE
2010; 25 (12): 1275-1281
A provocative finding from several double-blind clinical trials has been the association between greater adherence to placebo study medication and better health outcomes. We used data from the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Trial (SOLVD-TT) and the SOLVD Prevention Trial (SOLVD-PT) to examine whether such associations could be validated and to examine several sources of bias and potential confounding.Survival analytic methods were used to estimate the association between placebo adherence and several health outcomes, employing a number of modeling techniques to test for the existence of alternative explanations for the association. Higher adherence was defined as having taken ≥75% of prescribed study medication.Higher placebo adherence was associated with improved overall survival in both SOLVD-TT and SOLVD-PT [hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.35 to 0.79 and HR = 0.52, 95%CI: 0.38 to 0.71, respectively]. Associations were similar for fatal or non-fatal cardiovascular or coronary heart disease events. Adjustment for both modifiable and non-modifiable cardiac risk factors (including age, gender, diabetes, blood pressure, smoking, weight, alcohol use, and levels of education) had minimal effect on the strength of the association. Little evidence of bias was found as an explanation for this relationship.In these two trials, better adherence to placebo was associated with markedly superior health outcomes, including total in-study mortality and incident cardiovascular events. No important confounders were identified. These data suggest there may exist strong but unrecognized determinants of health outcomes for which placebo adherence is a marker.
View details for DOI 10.1007/s11606-010-1477-8
View details for Web of Science ID 000284978700007
View details for PubMedID 20706875
- Placebo adherence and its association with morbidity and mortality in the studies of left ventricular dysfunction J Gen Intern Med 2010; 25 (12): 1275-81
Diuretics were superior to calcium-channel blockers and short-term ACE inhibitors for reducing heart failure in hypertension.
ACP journal club
2007; 146 (1): 16-?
View details for PubMedID 17203936
Review: Beta blockers are less effective than other antihypertensive drugs for reducing risk of stroke in primary hypertension.
2006; 11 (3): 85-?
View details for PubMedID 17213106
Review: beta-blockers are less effective than other antihypertensive drugs for reducing risk for stroke in primary hypertension.
ACP journal club
2006; 144 (3): 67-?
View details for PubMedID 16646611
- Nurse care management for hypertension: A systems approach American Journal of Hypertension 2004; 17 (10): 921-7
- The search for high-yield, low-risk antihypertensive treatment American Journal of Medicine 2000; 108 (5): 429-30
Compliance with antihypertensive therapy: Raising the bar of expectations
AMERICAN JOURNAL OF MANAGED CARE
1998; 4 (7): 957-966
Recent advances in the effectiveness of antihypertensive therapies and the measurement of medication-taking behavior have raised the bar of expectations, both for patients and prescribing clinicians. This article reviews the principal findings and makes recommendations to improve pill taking among patients with hypertension. It summarizes several studies related to hypertension epidemiology, component behaviors contributing to suboptimal compliance with prescribed antihypertensive medications, the direct and indirect costs of nonadherent behaviors, and measures of pill-taking behavior. Based on this analysis, current levels of hypertension detection, treatment, and control remain suboptimal. Heuristics for adjusting antihypertensive regimens may be misleading and too simplistic. More than half of those patients failing to achieve goal blood pressure display suboptimal compliance rather than an inadequate regimen. In conclusion, there is a need for enhanced sophistication about medication-taking behavior, especially for hypertension, so that more patients with this condition can fully benefit from effective treatments.
View details for Web of Science ID 000075205800001
View details for PubMedID 10181995
Drug therapy: the impact of managed care.
Advances in pharmacology (San Diego, Calif.)
1998; 44: 1-32
View details for PubMedID 9547883
- Hypertension: Mechanisms, diagnosis, therapy Topol E (ed). Textbook of Cardiovascular Medicine New York, Lippincott-Raven 1997: 09-43
CLINICIAN AND PATIENTS WITH HYPERTENSION - UNSETTLED ISSUES ABOUT COMPLIANCE
AMERICAN HEART JOURNAL
1995; 130 (3): 572-579
Ambulatory treatment of hypertension depends largely on long-term oral medications to lower blood pressure and delay or prevent cardiovascular morbidity and mortality. Failure to achieve the therapeutic goal may reflect biologic, pharmacologic, or behavioral factors. Ignoring behavioral factors may result in unnecessary or even dangerous regimen escalation. More than half of patients with insufficient reductions in blood pressure display suboptimal medication compliance as assessed by pill count or bioassay. Once-daily dosing may be an important part of enhancing compliance, patient convenience, and regimen simplification; however, drug concentrations may be subtherapeutic when dosing delays or omissions occur. Electronic monitoring data in hypertension, glaucoma, seizure disorders, and other diseases indicate that 50% to 60% of patients adhere well to prescribed regiments, that 5% to 10% adhere poorly, and that the 30% to 45% adhere to an intermediate but markedly variable degree. A growing body of literature offers empirical support for focused and personalized interventions.
View details for Web of Science ID A1995RR59900025
View details for PubMedID 7661077
A MULTICENTER COMPARISON OF ADVERSE REACTION PROFILES OF ISRADIPINE AND ENALAPRIL AT EQUIPOTENT DOSES IN PATIENTS WITH ESSENTIAL-HYPERTENSION
JOURNAL OF CLINICAL PHARMACOLOGY
1995; 35 (5): 484-492
A multicenter, randomized, double-blind trial compared the safety and efficacy of the dihydropyridine isradipine with the angiotensin-converting enzyme (ACE) inhibitor enalapril given twice daily for mild hypertension. 160 patients received either isradipine (starting at 1.25 mg twice daily) or enalapril (starting at 2.5 mg twice daily) for 10 weeks. The dosage was increased if the average sitting diastolic blood pressure was > 90 mm Hg. Significantly greater mean reductions in systolic blood pressure were seen after 2, 6, and 8 weeks of isradipine. However, by the end of the trial, 83% of patients receiving isradipine and 78% receiving enalapril showed a decrease of at least 5 mm Hg in sitting diastolic blood pressure to a level below 96 mm Hg. Possible or probable drug-related adverse effects were reported in 36% of patients showing a good antihypertensive response to isradipine, and in 30% of those who responded to enalapril. There was a trend for a lower frequency of adverse effects in isradipine non-responders (25%) and a higher frequency in enalapril non-responders (43%). Pruritus, dizziness, edema, and fatigue were reported more often with isradipine, and cough and changed bowel habits were more common with enalapril. The relationship between the pattern of adverse effects and the extent of blood pressure reduction may be dependent on the mechanism of action of a drug. In responders, isradipine and enalapril showed differing patterns, but a similar overall incidence of adverse effects.
View details for Web of Science ID A1995QY34200007
View details for PubMedID 7657848
- PHARMACOKINETICS AS AN AID TO OPTIMIZING COMPLIANCE WITH MEDICATIONS CLINICAL PHARMACOKINETICS 1995; 28 (1): 1-6
- A multicenter comparison of adverse reaction profiles of isradipine and enalapril at equipotent doses in patients with essential hypertension J Clin Pharmacol 1995; 35 (5): 484-92
- Compliance with antihypertensive therapy: A shifting paradigm. Cardiol Rev 1994; 2 (4): 230-40
GAPS IN CARDIOVASCULAR MEDICATION TAKING - THE TIP OF THE ICEBERG
JOURNAL OF GENERAL INTERNAL MEDICINE
1993; 8 (12): 659-666
To search for major gaps in medication-taking behavior predisposing patients to cardiovascular morbidity and mortality.Convenience sample; cohort prospectively followed for < or = 5 months.General internal medicine and cardiology clinics in a university medical center.From among 893 patients, the authors identified 132 eligible individuals and entered 33 subjects (25%) with chronic cardiovascular conditions, 1-3 chronic oral medications for these conditions, overall regimen of < or = 6 drugs, regular visits at 1-3-month intervals, literacy in English, willingness to use electronic monitors, and physician permission to participate.Medication compliance rates and patterns by patient self-report, physician estimates, pill count, and electronic monitoring of pill vial opening.Despite moderately complex regimens (5.4 +/- 0.5 pills daily; range 1-11), most subjects took most medications according to the prescription: median intervals between pill vial openings were 1.00, 0.50, and 0.43 days for once, twice, and three times daily dosing, respectively. Medication-taking gaps of > or = 2 times the prescribed interdosing interval occurred for 48% of the patients. Patients' dosing patterns often produced "uncovered" intervals (mean duration 3.7 days, range 0-25) with doubtful pharmacologic effectiveness. These lapses were underestimated by patients and poorly perceived by their treating physicians, despite familiarity with their care. Baseline sociodemographic, psychosocial, medical system, or clinical characteristics did not predict the patterns or degrees of medication noncompliance.Major treatment gaps occur frequently, even in carefully selected ambulatory populations, and generally escape detection. The compliance patterns and gaps may contribute to reported excesses of cardiovascular morbidity and mortality.
View details for Web of Science ID A1993ML89900003
View details for PubMedID 8120681
ANTIHYPERTENSIVE MEDICATION-TAKING - INVESTIGATION OF A SIMPLE REGIMEN
AMERICAN JOURNAL OF HYPERTENSION
1993; 6 (7): 586-592
In search of strategies to improve compliance, we assessed medication-taking behavior among 19 ambulatory hypertensives, using both pill counts and electronic monitoring. The regimen consisted of one pill each day for < or = 63 weeks with return visits at 1 to 4 week intervals. The study population was 79% male, 68% white, and 16% black with mean (+/- SEM) age 58.4 +/- 2.5 years. Only 51% of the intervisit intervals displayed > or = 80% of vial openings within the desirable range (24 +/- 6 h). Pill counts detected only 2% of suboptimal interdosing intervals identified by electronic monitoring. Early changes in compliance correlated well with later changes (r = 0.83, P = .002). A few of the subjects exhibited a large deviation from the prescription, uncorrectable with drugs having a long duration of action. We conclude that (a) pill counts tend to overestimate patients' compliance rates; (b) changes in medication-taking behavior early in therapy may predict subsequent compliance rates; and (c) prolonging drug action may compensate for some imperfect medication-taking behavior.
View details for Web of Science ID A1993LP44000006
View details for PubMedID 8397999
Partial compliance: implications for clinical practice.
Journal of cardiovascular pharmacology
1993; 22: S1-5
Modern therapeutics unavoidably requires integration of a patient's medication-taking behavior in assessing the clinical response to treatment. Automatic escalation of the drug regimen whenever the treatment goal is not achieved carries major risks and should be discouraged. Medication-taking behavior, when studied carefully by dynamic measures like electronic monitors, displays marked inter- and intra-subject variability over time. Most deviations from the prescription are underdosings and occur randomly, rather than consistently or systematically. Such deviations are frequent, difficult to detect by traditional measures, and hard to predict from common baseline characteristics. Compliance tends to fall as dosing frequency rises above once daily. Better measures of medication-taking behavior permit evaluation of both adverse drug reactions and secondary resistance to therapy as resulting from pill taking itself. Negative consequences of partial compliance among hypertensive patients include marked increases in rates of rehospitalization and rates of coronary events. One alternative strategy to labor-intensive interventions for improving compliance is to develop longer-acting medications, which compensate in part for lapses in dosing frequency. Such a strategy reflects a search for therapeutic sufficiency rather than a rigid concordance between the prescription and medication-taking behavior.
View details for PubMedID 7522281
- Maximizing compliance with antihypertensive therapy Drug Therapy 1992; 22: 25-32
ISSUES IN PATIENT COMPLIANCE - THE SEARCH FOR THERAPEUTIC SUFFICIENCY
SYMP ON CIRCADIAN VARIATION IN CARDIOVASCULAR DISEASE : THE NEED FOR COMPLIANCE, AT THE 12TH CONGRESS OF THE EUROPEAN SOC OF CARDIOLOGY
KARGER. 1992: 2–10
Distinguishing among biological, pharmacological, and behavioural variability is essential for proper interpretation of the therapeutic experiment at each return visit. Within the behavioural component, partial compliance refers to all suboptimal levels of concordance between the patient's behaviour and the clinical prescription. However, the assessment of compliance is limited largely by imperfect measures of medication taking which are frequently distant in time and space from the medication-taking event itself. Most studies indicate compliance levels of only 50-70% with antihypertensive regimens as well as considerable variance from day to day and person to person. Therapeutic outcome may be a misleading method to assess the sufficiency of a regimen because of the high prevalence of suboptimal medication-taking behaviour. In selected situations, prolongation of pharmacological effect may compensate for imperfect medication-taking behaviour, confirmed by electronic medication monitors. Such pharmacodynamic prolongation exemplifies therapeutic sufficiency, a new paradigm for therapeutics in the 1990s.
View details for Web of Science ID A1992HV67100002
View details for PubMedID 1600536
- Compliance with medication timing: Implications from a medication trial for drug development and clinical practice. J Clin Res Pharmacoepidemiol 1992; 6: 15-27
RESUSCITATION ATTITUDES AMONG MEDICAL PERSONNEL - HOW MUCH DO WE REALLY WANT TO BE DONE
1991; 22 (3): 229-235
Cardiopulmonary resuscitation (CPR) is attempted every day. Whereas medical professionals and personnel perform these resuscitation attempts, no previous studies have reported the attitudes of medical personnel towards resuscitation for themselves. We have attempted to assess the prevalent attitudes among various physicians at various levels in training and nurses. An eleven item questionnaire was sent to medical students, house officers, attending physicians and registered nurses at university medical centers. Each questionnaire consisted of respondent's sociodemographic information, their attitudes about CPR for themselves and their beliefs about outcome after CPR with particular disease states. The results were analyzed using chi-square analysis. Four hundred questionnaires were mailed and 240 were returned (60% response rate). All groups favored resuscitation in a university hospital over other sites (P less than 0.05). More nurses requested to be 'no code' compared with other professionals (P less than 0.005). Attending physicians requested that CPR attempts be terminated after less time than any other group (P less than 0.005). Medical students requested resuscitation significantly more than any other group in the presence of terminal conditions such as metastatic cancer, acquired immunodeficiency syndrome and severe chronic obstructive pulmonary disease (P less than 0.005). Medical personnel's beliefs about CPR may be influenced by their experiences with particular patients and events. As trainees acquire more experience they appear less inclined to desire resuscitation efforts for themselves.
View details for Web of Science ID A1991GV71500002
View details for PubMedID 1663263
- A multicenter comparison of the safety and efficacy of isradipine and enalapril in the treatment of hypertension Am J Hypertension 1991; 4: 154S-157S
IMPROVED COMPLIANCE MEASURES - APPLICATIONS IN AN AMBULATORY HYPERTENSIVE DRUG TRIAL
CLINICAL PHARMACOLOGY & THERAPEUTICS
1990; 48 (6): 676-685
To assess the value of improved monitoring of medication-taking behavior in a drug trial, we employed a modified pill vial with microcircuitry to record the precise times when the vials were opened. After a 3-week placebo washout period, 21 ambulatory subjects with mild hypertension (mean age, 57 years; 67% men; 76% white) randomly received isradipine or enalapril twice daily in a double-blind titration during 10 weeks. Both drugs achieved a 13% reduction in sitting diastolic blood pressure (p less than 0.01) with minimal symptomatic or laboratory toxicity. Although pill counts indicated near-perfect compliance (92% to 99% for both groups), the electronic monitor showed that fewer than half of all openings occurred at the prescribed interval of 12 +/- 2 hours. Modest overdispensing was documented in the 3 days before scheduled visits. The monitor confirmed that pill count misclassified compliance sufficiency in 22% of visits and permitted more discrete attribution for drug-associated adverse reactions and secondary resistance to treatment. We conclude that the electronic monitor reduces ambiguity about medication compliance and helps interpret both the biology and pharmacology of the trial.
View details for Web of Science ID A1990EP62500012
View details for PubMedID 2147405
THE NATURAL-HISTORY OF MEDICATION COMPLIANCE IN A DRUG TRIAL - LIMITATIONS OF PILL COUNTS
CLINICAL PHARMACOLOGY & THERAPEUTICS
1989; 46 (2): 169-176
To assess medication compliance over time, we prospectively performed pill counts among 121 ambulatory hypertensive subjects for less than or equal to 12 months. Prescribed regimens consisted of pinacidil or hydralazine administered four times a day and of secondary drugs administered up to twice daily. Surreptitious pill counts occurred every 1 to 12 weeks. Among a middle-aged subject group that had been selected for high rates of compliance, we observed mean compliance rates that approximated 100%. We noted marked intrasubject and intersubject variability for any one medication, between medications, and over time. From baseline blood pressures (+/- SE) of 155.5 +/- 1.9/97.3 +/- 1.0 mm Hg, subsequent mean blood pressures varied by compliance subgroup: "hypocompliers" (less than 80%), 151.3/91.0 mm Hg; "hypercompliers" (greater than or equal to 120%), 147.6/91.4 mm Hg; and "eucompliers" (80% to 119%), 143.3/88.5 mm Hg (systolic blood pressure: F1,52 = -220.9, NS; diastolic blood pressure: F1,52 = -121.4, NS). We concluded that weekly pill counts indicated marked intersubject and intrasubject variability, obscured by long-term averages; that compliance lapses appeared to be random; and that excessive medication-taking was the most consistent with "pill dumping."
View details for Web of Science ID A1989AM16100007
View details for PubMedID 2667837
PROBLEMS IN CONSULTATION MEDICINE - THE GENERALISTS REPLY
JOURNAL OF GENERAL INTERNAL MEDICINE
1988; 3 (6): 592-595
View details for Web of Science ID A1988Q972300013
PILL COUNT MEASURES OF COMPLIANCE IN A DRUG TRIAL - VARIABILITY AND SUITABILITY
AMERICAN JOURNAL OF HYPERTENSION
1988; 1 (3): 309-312
To evaluate pill counts as a compliance measure for drug trials, we followed 121 ambulatory hypertensives selected for good compliance over less than or equal to 12 months. The medication regimens consisted of either pinacidil or hydralazine as monotherapy or with propranolol and/or hydrochlorothiazide. Pill counts for the two primary drugs were obtained at each of the 20 return visits. The population was characterized by chronic uncomplicated hypertension and sociodemographic diversity; mean age was 53 years. Despite excellent average weekly pill counts (overall mean compliance rate [+/- SD] = 96.0 +/- 13.2%), we observed large intersubject and intrasubject variance in weekly pill count assessment: individuals' mean standard deviation = 13.7% (range = 0%-86%) and mean coefficient of variation = 0.138 (range = 0.001-0.410). By pill count, 35% of individuals exhibited greater than 110% compliance on at least 1 visit. We conclude that (a) pill count variability is large, even among highly selected subjects, (b) traditional reports of overall pill counts are suboptimal, and (c) pill counts may unreliably measure medication-taking behavior because "supranormal" compliance by this method is improbable but common.
View details for Web of Science ID A1988N862600018
View details for PubMedID 3291897
- Problems in consultation medicine: The generalist's reply. J Gen Intern Med 1988; 35: 592-595
CONSEQUENCES OF WORKSITE HYPERTENSION SCREENING - CHANGES IN ABSENTEEISM
1987; 10 (4): 425-436
To confirm reports of increased absenteeism after worksite hypertension screening, we performed a three-stage blood pressure screening among 5888 self-selected heterogeneous workers at 11 electronics plants using standardized screening and labeling procedures. A total of 296 subjects with mean systolic blood pressure of 140 mm Hg or greater or diastolic blood pressure of 90 mm Hg or greater on all three occasions were considered to have sustained hypertension. From the untreated normotensive subjects matched for eight sociodemographic and occupational variables, we prospectively selected one to three controls for each sustained hypertensive subject. Uncorrected absenteeism rates for sustained hypertensive subjects increased 22% from baseline in the postscreening year. Correction by logarithmic transformation for skewed distributions and by rates for matched controls for temporal trends reduced these changes to statistical insignificance with high statistical power. Several subgroups exhibited trends to increased absenteeism. At 12-month follow-up, the blood pressure of the sustained hypertensive subjects showed mean decreases of 12.6/6.7 mm Hg (p less than 0.0001) after the majority had received pharmacological antihypertensive treatment. These results suggest that worksite hypertension screening and labeling produce insignificant absenteeism change overall among self-selected heterogeneous work force populations.
View details for Web of Science ID A1987M462700008
View details for PubMedID 3653971
- Management pitfalls in malignant hypertension. J Crit Illness 1987; 22: 9-10
- Resolving problems of measuring compliance with medication monitors. J Compliance Health Care 1987; 22: 23-35
CUMULATIVE EXPERIENCE WITH TERAZOSIN ADMINISTERED IN COMBINATION WITH DIURETICS
AMERICAN JOURNAL OF MEDICINE
1986; 80 (5B): 49-54
The short-term antihypertensive efficacy and safety of terazosin when administered with a diuretic were assessed in three randomized, double-blind, placebo-controlled studies. In all studies, adding terazosin to an established diuretic regimen resulted in significant incremental decreases in blood pressure from baseline to the final visit, with an overall satisfactory response rate of 56 percent versus 29 percent for control subjects. Mean decreases in supine diastolic blood pressure in the terazosin-treated groups ranged from 4.5 to 8.9 mm Hg, compared with mean decreases of 0.4 to 5.8 mm Hg in the placebo-treated groups; these differences generally achieved statistical significance. There were no clinically or statistically significant changes in pulse rates, physical examinations, or electrocardiographic tracings. Results of clinical laboratory tests revealed no evidence of drug-induced toxicity. Patients receiving the terazosin plus diuretic combination had a slight tendency to gain weight. The most common adverse effects reported by this group were dizziness, headache, and asthenia. The results of these studies indicate that combination therapy with terazosin plus a diuretic is both safe and effective for the treatment of hypertension.
View details for Web of Science ID A1986C639800008
View details for PubMedID 2872807
CONSEQUENCES OF WORKSITE HYPERTENSION SCREENING - DIFFERENTIAL CHANGES IN PSYCHOSOCIAL FUNCTION
AMERICAN JOURNAL OF MEDICINE
1986; 80 (5): 853-860
To evaluate reports of psychosocial dysfunction after worksite screening, a three-stage blood pressure screening was performed using standardized screening and labeling procedures. Of a heterogeneous group of 5,888 workers, 296 with sustained hypertension were identified and randomly assigned to traditional arousal or reassurance debriefings, matching each hypertensive subject with one to three normotensive control subjects on eight sociodemographic and occupational variables. Subjects exhibiting absenteeism increases or persistent hypertension six months after screening were randomly assigned to worksite health education programs or no intervention. After adjustment for values among matched control subjects, previously unaware hypertensive subjects had significant post-screening decreases in anxiety that were significantly associated with specific worksites and with reassurance rather than traditional debriefing (p less than 0.05). The health education program did not significantly affect anxiety, blood pressure, or absenteeism. Increased absenteeism was associated with higher baseline anxiety levels (p less than 0.05). It is concluded that worksite hypertension screening produces minimal adverse psychosocial changes, reassurance debriefing may be beneficial, and unspecified worksite characteristics may determine consequences of similar preventive medicine efforts.
View details for Web of Science ID A1986C309100027
View details for PubMedID 3706373
- Cumulative experience with terazosin administered in combination with diuretics Am J Med 1986; 80 (suppl 5B): 853-860
- Consequences of worksite hypertension screening: Differential changes in psychosocial function Am J Med 1986; 80: 853-860
- Cardiovascular risks for very low calorie diets Compreh Ther 1985; 11: 3-6
10 COMMANDMENTS FOR EFFECTIVE CONSULTATIONS
ARCHIVES OF INTERNAL MEDICINE
1983; 143 (9): 1753-1755
If internists are not explicitly instructed in how to perform consultations, the outcome of their consultative efforts may be suboptimal. We suggest that consultations will be more helpful if the following principles are followed: the consultant should determine the question that is being asked, establish the urgency of the consultation, gather primary data, communicate as briefly as appropriate, make specific recommendations, provide contingency plans, understand his own role in the process, offer educational information, communicate recommendations directly to the requesting physician, and provide appropriate follow-up. If these ten "commandments" are followed, the consultation is more likely to be effective and satisfactory for all the participants.
View details for Web of Science ID A1983RF40100019
View details for PubMedID 6615097
- Ten commandments for effective consultations Arch Intern Med 1983; 143: 1753-1755
- Resistant hypertension: Differential diagnosis and management recommendations Hosp Formul 1982; 17: 1320-1326
RESISTANT HYPERTENSION - DIFFERENTIAL-DIAGNOSIS AND MANAGEMENT RECOMMENDATIONS
1982; 17 (10): 1320-1326
View details for Web of Science ID A1982PN75400004
- Teaching cost control in medical school Patient Care 1981; 15: 198-215
- MEDICATION NON-COMPLIANCE - A RANDOMIZED TRIAL FOR PRIMARY CARE SKILL INSTRUCTION JOURNAL OF MEDICAL EDUCATION 1981; 56 (1): 59-61
- Contrasts in academic consultation Ann Intern Med 1981; 93: 537-538
- Medication noncompliance: a randomized trial for primary care skill instruction J Med Educ 1981; 56: 59-61
- The utility of a commercial film in hypertensive patient education Urban Health 1980; 93: 46-48
DIAGNOSING PANCREATIC-CANCER - AN ANALYSIS OF SEVERAL STRATEGIES
WESTERN JOURNAL OF MEDICINE
1980; 133 (1): 19-25
The usefulness of a clinical examination was compared with several other procedures (ultrasonography, pancreatic function tests, endoscopic retrograde cholangiopancreatography and angiography) for diagnosing pancreatic cancer. We used a simplified form of decision analysis to show the effects of different strategies on direct diagnostic costs, missed diagnoses and false-positive diagnoses. Our analysis indicates that existing laboratory tests are either too non-specific or too invasive to be used successfully as screening tests for pancreatic cancer. To decrease the number of unnecessary laparotomies due to false-positive test findings, patients should have a high probability of pancreatic cancer, based on clinical criteria, before further testing is carried out. In fact, existing clinical criteria are both sensitive and specific for pancreatic cancer.
View details for Web of Science ID A1980KC23000004
View details for PubMedID 7222644
ONCE-DAILY REGIMEN FOR PROPRANOLOL ANTI-HYPERTENSIVE THERAPY
CURRENT THERAPEUTIC RESEARCH-CLINICAL AND EXPERIMENTAL
1980; 27 (1): 29-39
View details for Web of Science ID A1980JD72300005
- Once daily regimen for propranolol antihypertensive therapy Curr Therap Res 1980; 27: 29-39
- Diagnosing pancreatic cancer; An analysis of several strategies West J Med 1980; 33: 19-25
- The general medicine clinic: the dilemma and teaching implications J Med Educ 1979; 54: 766-774
GENERAL MEDICINE CLINIC - DILEMMA AND TEACHING IMPLICATIONS
JOURNAL OF MEDICAL EDUCATION
1979; 54 (10): 766-774
An academic general medicine clinic (GMC) was studied to determine current patterns, shortcomings, and potential solutions. Retrospective medical record review of 349 randomly selected GMC patients from 1975 permitted profile generation. Only 11.5% of the patients had first visits in the study year. Almost 75% of the study group used the university hospital as their major source of care. Over two years only 58% continued in active care, while 5% died, 8% needed no further follow-up, and 29% were lost from care. The prevalence of hypertensive cardiovascular disease was disproportionately high. Patients exhibited chronic disease exclusively in 91% of return visits. The authors conclude that the GMC offers insufficient variety of patient presentations for optimal postgraduate medical education and inadequate accessibility for comprehensive medical care. Potential improvements include expanding the patient base, extending availability, and employing nonphysician clinicians.
View details for Web of Science ID A1979HP41000003
View details for PubMedID 490593
- URINARY-TRACT INFECTIONS - AMBULATORY CARE PERSPECTIVE PRIMARY CARE 1979; 6 (1): 97-112
- Hypertension continuation adherence: natural history and role as indicator condition Arch Intern Med 1979; 139: 545-549
NONTRADITIONAL PROBLEMS OF ANTIHYPERTENSIVE MANAGEMENT
WESTERN JOURNAL OF MEDICINE
1979; 131 (3): 179-192
Problems with patient screening, disease labeling, diagnosis confirmation, patient compliance and physician adherence continue to undermine efforts to control hypertension and prevent its complications.Simple screening involves patient selection bias, limited new diagnosis, arterial pressure lability, ambiguous disease definition, complex measurement imprecision and deficient patient follow-through. Case finding may improve some of these deficiencies. Recent data suggest that labeling a person as hypertensive may produce impaired self-concept, marital dissatisfaction and absence from work. Newer series confirm the low prevalence of curable, secondary hypertension among unselected patients and strongly argue for restricting extensive hypertensive evaluations to selected subpopulations. Patient noncompliance is highly prevalent, poorly predicted and imprecisely measured. Based on successful trials, specific suggestions can be made to achieve maximum patient compliance and physician adherence to diagnostic and therapeutic guidelines.
View details for Web of Science ID A1979JE66100001
View details for PubMedID 18748465
- In search of a gold standard for compliance Arch Intern Med 1979; 139: 627-628
- Medication packaging: Simple solutions to nonadherence problems? Clin Pharm Therap 1979; 25: 257-265
- Urinary tract infections; An ambulatory care perspective Primary Care 1979; 6: 97-112
- Modifying house staff behavior: Physician versus patient oriented intervention Proc 17th Annu Res Med Educ 1978: 315-9
PERIOPERATIVE DIABETIC CONSULTATION - PLEA FOR IMPROVED TRAINING
JOURNAL OF MEDICAL EDUCATION
1978; 53 (7): 590-596
To determine the clinical and educational impact of an academic general internal medicine consultation service, the investigators selected as a model the perioperative management of diabetes mellitus. They analyzed 17 consultative episodes over two years by retrospective medical record review to identify patterns and shortcomings. Most patients were elderly black females with maturity-onset diabetes mellitus exhibiting numerous past diabetic complications and other active general medical problems. Major findings included common failure to define the consultation purpose or document adequately follow-up visits, incomplete professional adherence to published guidelines for perioperative diabetic management, and correlation between failure to document the consultant's own physical examination and failure to reach new conclusions. Median cost for consultant-recommended tests was $179 (range $82 to $552) without clear linkage between medical care process and outcome. Consultative skills must be taught more effectively if medical consultations are to have maximal impact.
View details for Web of Science ID A1978FG42700007
View details for PubMedID 671501
PATIENTS OF INTERNISTS IN HOSPITAL OUTPATIENT DEPARTMENTS AND IN PRIVATE-PRACTICE
CANADIAN MEDICAL ASSOCIATION JOURNAL
1978; 119 (8): 891-895
To test the contention that patients in outpatient departments and private practices differ, variables were assessed that might affect both the process and the outcome of medical care. Two groups of 60 patients consulting nine Montreal internists who worked in both private practice and in an outpatient department of a university teaching hospital were surveyed. The internists served as their own controls. The two groups of patients were compared for 57 demographic, socioeconomic, access, utilization, attitudinal and current medical status variables. Financial factors were minimized by the existence of universal health insurance. The outpatient group was found to be older, less fluent in English, less likely to be employed, less educated, less wealthy, more dependent on public transportation, more disabled, more likely to use ambulatory services, more anxious about health, and more sceptical about physicians, yet more dependent on them than the private practice group. The outpatient group tended to have more active, significant medical conditions and to receive more prescriptions for medication than the private practice group, in contrast to the national patterns in the practice of internal medicine in the United States. Medical educators, researchers, administrators and providers of health care who have assumed that these two groups of patients are comparable must re-evaluate their practices.
View details for Web of Science ID A1978FU02300021
View details for PubMedID 737639
- Patients of internists in hospital outpatient departments and private practice Canad Med Assoc J 1978; 119: 891-895
- Perioperative diabetic consultation: A plea for improved training J Med Educ 1978; 53: 590-596
- The United Farm Workers Clinic in Delano, California; A study of the rural poor Publ Health Rep 1975; 90: 331-339
- Irreversible bone marrow failure with chlorambucil J Rheumatol 1975; 25: 421-429
IRREVERSIBLE BONE-MARROW FAILURE WITH CHLORAMBUCIL
JOURNAL OF RHEUMATOLOGY
1975; 2 (4): 421-429
Two cases of irreversible bone marrow failure are described, one with rheumatoid disease and one with systemic lupus erythematosus. Each case was associated with prior chlorambucil administration, effective in controlling the clinical manifestations (total dosage 398 and 1,764 mg respectively). The irreversibility of the bone marrow depression in the two cases presented stands in contrast to published assurances that chlorambucil-associated leukopenia is dose-related and readily reversible. The cases illustrate that chlorambucil therapy should not be continued after initial leukopenia, until peripheral counts or marrow cellularity has returned to normal. Titration of drug dosage and leukocyte count, as frequently employed with cyclophosphamide and other alkylating agents, must be presumed hazardous. Additional studies are needed to determine if irreversible bone marrow depression is dose-related or idiosyncratic.
View details for Web of Science ID A1975BE40700010
View details for PubMedID 1206673