Journal of general internal medicine
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Multicenter Study
Quality of care for decompensated heart failure: comparable performance between academic hospitalists and non-hospitalists.
Hospitalists improve efficiency, but little information exists regarding whether they impact quality of care. ⋯ Academic hospitalists and non-hospitalists provide similar quality of care for heart failure patients, although hospitalists are paying more attention to longitudinal care. Future efforts to improve quality of care in decompensated heart failure may require attention towards system-level factors.
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Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. ⋯ Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient's dignity and individuality rather than his or her autonomy.
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Randomized Controlled Trial
The impact of perceived treatment assignment on smoking cessation outcomes among African-American smokers.
The double-blind placebo-controlled design is commonly considered the gold standard in research methodology; however, subject expectation bias could subvert blinding. ⋯ Results support previous research that expectation bias associated with judgment of treatment assignment is a strong predictor of outcome and confirms this relationship in a smoking cessation trial using bupropion SR among African-American smokers.
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Lower extremity peripheral arterial disease (PAD) is highly prevalent and strongly associated with cardiovascular morbidity and mortality. The ankle-brachial index used to screen for PAD is not routinely performed in primary care settings. ⋯ Self-reported PAD is an independent risk factor for future vascular events in this predominantly non-white cohort. The addition of two simple PAD questions to the routine medical history in general medicine settings could identify high-risk patients who would benefit from further vascular evaluation and risk factor modification.
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Percutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy. ⋯ The widespread use of PCI in patients with stable coronary artery disease--despite evidence of little benefit in outcomes over medical therapy--may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.