Annals of internal medicine
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The Institute of Medicine defines health care quality as increasing "the likelihood of desired health outcomes" using "services ... consistent with current professional knowledge." This definition implies that quality measures can be based on either achieving health care outcomes or completing processes that experts agree have been shown by scientific evidence to improve outcomes. Process-based measures are especially suitable when the user needs to know how to improve quality, when provider comparisons show equivalent outcomes but all providers should improve processes, when measures are needed to evaluate health care that is intended to improve long-term outcomes, or when the contribution of individual providers (especially providers who have a small number of cases) needs to be defined. However, many different process-based measures are needed to comprehensively assess quality, and many process-based measures require detailed clinical data currently found only in medical records. ⋯ The merging of existing inpatient and outpatient databases with pharmacy and laboratory databases is an important step toward obtaining data that link all patient admissions, appointments, diagnostic procedures, and prescriptions with diagnoses and test results. Other data that are valuable for process-based measures must still be obtained by abstracting data from records, including clinical findings, patient preferences, and medical and family history. In the future, such data may be added to large databases to create computerized medical records.
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Review Practice Guideline Guideline
Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians.
To review the literature on diagnostic testing in syncope and provide recommendations for a comprehensive, cost-effective approach to establishing its cause. ⋯ Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.
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The use of crude marijuana for herbal medicinal applications is now being widely discussed in both the medical and lay literature. Ballot initiatives in California and Arizona have recently made crude marijuana accessible to patients under certain circumstances. As medicinal applications of pure forms of delta-9-tetrahydrocannabinol (THC) and crude marijuana are being considered, the most promising uses of any form of THC are to counteract the nausea associated with cancer chemotherapy and to stimulate appetite. ⋯ Our review focused on the medical use of THC derivatives for nausea associated with cancer chemotherapy, glaucoma, stimulation of appetite, and spinal cord spasticity. Despite the toxicity of THC delivered in any form, evidence supports the selective use of pure THC preparations to treat nausea associated with cancer chemotherapy and to stimulate appetite. The evidence does not support the reclassification of crude marijuana as a prescribable medicine.
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Support for the participation of physicians in the suicides of terminally ill patients is increasing, and the concrete effects on physician practice of a policy change with regard to physician-assisted suicide must be carefully considered. If physician-assisted suicide is legalized, physicians will need to gain expertise in understanding patients' motivations for requesting physician-assisted suicide, assessing mental status, diagnosing and treating depression, maximizing palliative interventions, and evaluating the external pressures on the patient. They will be asked to prognosticate not only about life expectancy but also about the onset of functional and cognitive decline. ⋯ Protection of the patient's right to confidentiality must be balanced against the need of health care professionals and institutions to know about the patient's choice. Insurance coverage and managed care options may be affected. All of these issues need to be further explored through research, education, decision making by individual practitioners, and ongoing societal debate.