Professor Emeritus, Medicine - Immunology & Rheumatology
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There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.To improve training for residents who provide chronic illness care in teaching practice settings.US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure
View details for DOI 10.1007/s11606-010-1392-z
View details for Web of Science ID 000283101900004
View details for PubMedID 20737232
View details for DOI 10.1007/s11606-010-1392-z
View details for Web of Science ID 000283101900004
View details for PubMedID 20737232
View details for PubMedID 18083673
View details for PubMedID 17583149
View details for PubMedID 17152451
Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks--medical management, role management, and emotional management--and six self-management skills--problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.
View details for Web of Science ID 000184521900001
View details for PubMedID 12867348
Patients with chronic conditions make day-to-day decisions about--self-manage--their illnesses. This reality introduces a new chronic disease paradigm: the patient-professional partnership, involving collaborative care and self-management education. Self-management education complements traditional patient education in supporting patients to live the best possible quality of life with their chronic condition. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is self-efficacy--confidence to carry out a behavior necessary to reach a desired goal. Self-efficacy is enhanced when patients succeed in solving patient-identified problems. Evidence from controlled clinical trials suggests that (1) programs teaching self-management skills are more effective than information-only patient education in improving clinical outcomes; (2) in some circumstances, self-management education improves outcomes and can reduce costs for arthritis and probably for adult asthma patients; and (3) in initial studies, a self-management education program bringing together patients with a variety of chronic conditions may improve outcomes and reduce costs. Self-management education for chronic illness may soon become an integral part of high-quality primary care.
View details for Web of Science ID 000179292300031
View details for PubMedID 12435261
To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization.Longitudinal design as follow-up to a randomized trial.Community.Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data.Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured.Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes.A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.
View details for Web of Science ID 000171821000008
View details for PubMedID 11606875
Measurement of change in patients' health status is central to both clinical trials and clinical practice. Trials commonly use serial measurements by the patients at 2 points in time while clinicians use the patient's retrospective assessment of change made at 1 point in time. How well these measures correlate is not known.To compare the 2 methods in measurement of changes in pain and disability.Longitudinal survey of patients starting new therapy for chronic arthritis in 1994 and 1995. Surveys were completed at baseline (before intervention) and at 6 weeks and 4 months.Community health education program and university medical and orthopedic services.A total of 202 patients undertaking self-management education (n = 140), therapy with prednisone or methotrexate (n = 34), or arthroplasty of the knee or hip (n = 28).Concordance between serial (visual analog scale for pain and Health Assessment Questionnaire for disability) and retrospective (7-point Likert scale) measures, sensitivities of these measures, and their correlation with patients' satisfaction with the change (7-point Likert scale).When change was small (education group), serial measures correlated poorly with retrospective assessments (eg, r=0.13-0.21 at 6 weeks). With greater change, correlations improved (eg, r = 0.45-0.71 at 6 weeks). Average agreement between all pairs of assessments was 29%. Significant lack of concordance was confirmed in all 12 comparisons by McNemar tests (P = .02 to <.001) and by t tests (P = .03 to <.001). Retrospective measures were more sensitive to change than serial measures and correlated more strongly with patients' satisfaction with change.The 2 methods for measuring health status change did not give concordant results. Including patient retrospective assessments in clinical trials might increase the comprehensiveness of information gained and its accord with clinical practice.
View details for Web of Science ID 000082596200031
View details for PubMedID 10501119
This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities.The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured.Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being.An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.
View details for Web of Science ID 000077870400002
View details for PubMedID 10413387
View details for PubMedID 8997911
The contributions of MACs and RRTCs to the generation of arthritis-related biopsychosocial research over the last 15 years have been enormous. However, the assimilation of biopsychosocial concepts into mainstream clinical practice, professional education, and public awareness will require a sustained national effort.
View details for Web of Science ID A1993LM08000002
View details for PubMedID 8318036
To determine the effects of the Arthritis Self-Management Program 4 years after participation in it.Valid self-administered instruments were used to measure health status, psychological states, and health service utilization.Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient.Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.
View details for Web of Science ID A1993KW02600002
View details for PubMedID 8457219
To determine the views of leaders in academic medicine concerning the need for programs in preventive medicine (PM) and the prevailing barriers to program development.Structured interviews.Medical schools of the United States.90% of deans and chairpersons of departments of medicine and preventive medicine.None.91% considered academic PM underdeveloped and 100% considered their own programs average or worse. Identified barriers to development included funding constraints, academic partiality to biomedicine, inadequate quality of preventive medicine research and faculty, public preferences for technologic care, and organization of academic medical centers (AMCs). While 80% perceived a shortage of able PM faculty and 60% considered PM research quality to be inadequate, only 12% of PM units gave research training high priority. While 95% of respondents held that AMCs should develop community programs and 75% identified social problems as a cause of chronic diseases, 65% agreed that community programs are not considered scholarly. Only 23% of PM units gave community service high priority.A policy contradiction exists: academic leadership agreed on the problems and needed changes in PM, yet the problems were often attributed to nonacademic sources, particularly finding and public preferences, and current academic practices commonly fail to address recognized developmental barriers within academic institutions. A chain of barriers is apparent. Breaking the chain may require a change in our understanding of the role of prevention.
View details for Web of Science ID A1992JZ45200009
View details for PubMedID 1453247
The epidemiology of systemic lupus erythematosus suggests that the excess morbidity and mortality in blacks with the disease is related to lower socioeconomic status. Poverty and factors associated with poverty are powerful predictors of poor outcome in a variety of chronic diseases, and lupus appears to be no exception. A body of studies in other illnesses suggests ways to neutralize, at least partially, the disadvantages of lower socioeconomic status, even though the root causes of poverty may be insurmountable. These include improving access to quality health care; targeting educational programs to promote recognition and understanding of the disease and the comorbid conditions that affect outcome; implementing programs to improve self-monitoring and adherence to medical regimens; developing opportunities to facilitate homemaking, childrearing, and working outside the home; and applying psychosocial interventions to enhance self-confidence and social support. Improved access to quality health care may actually lead to a decrease in health care costs.
View details for Web of Science ID A1991GG33700017
View details for PubMedID 1930337
An underlying assumption of self-care interventions is that they are most effective when reinforced. To test this assumption, 8 months after baseline, 589 subjects who had taken a 6-week Arthritis Self-management Course (ASMC) were randomized to (1) receive a bi-monthly arthritis newsletter, (2) attend a new 6-week Arthritis Reinforcement Course (ARC) or (3) receive no reinforcement. Between 8 and 20 months there were no significant differences among the three randomized groups. The results were unaltered by inclusion of assumed data of no change for the 46 subjects who did not complete the full 20-month study. Between baseline and 20 months all participants reduced their pain by 20%, depression by 14%, and visits to physicians by 35% (P less than 0.01). There were no trends toward loss of these effects over time. These findings indicate that the effects of a self-care intervention were sustained over 20 months and that the tested forms of reinforcement did not alter those effects.
View details for Web of Science ID A1989AB72800012
View details for PubMedID 2665110
Evaluation of the Arthritis Self-Management Course revealed significant positive changes in the practice of behaviors that were taught and in health outcomes. However, utilizing a variety of statistical techniques, we were able to demonstrate only weak associations between changes in behavior and changes in health status. This suggests the need to examine the mechanisms by which health education affects health status.
View details for Web of Science ID A1989R917000015
View details for PubMedID 2912467
There is evidence that the psychological attribute of perceived self-efficacy plays a role in mediating health outcomes for persons with chronic arthritis who take the Arthritis Self-Management Course. An instrument to measure perceived self-efficacy was developed through consultation with patients and physicians and through study of 4 groups of patients. Tests of construct and concurrent validity and of reliability showed that the instrument met appropriate standards. Health outcomes and self-efficacy scores improved during the Arthritis Self-Management Course, and the improvements were correlated.
View details for Web of Science ID A1989R917000006
View details for PubMedID 2912463
View details for PubMedID 3269676
This experiment tested a cognitive-behavioral rheumatoid arthritis treatment designed to confer skills in managing stress, pain, and other symptoms of the disease. We hypothesized that a mediator of the magnitude of treatment effects might be enhancement of perceived self-efficacy to manage the disease. It was predicted that the treatment would reduce arthritis symptoms and possibly would improve both immunologic competence and psychological functioning. The treatment provided instruction in self-relaxation, cognitive pain management, and goal setting. A control group received a widely available arthritis helpbook containing useful information about arthritis self-management. We obtained suggestive evidence of an enhancement of perceived self-efficacy, reduced pain and joint inflammation, and improved psychosocial functioning in the treated group. No change was demonstrated in numbers or function of T-cell subsets. The magnitude of the improvements was correlated with degree of self-efficacy enhancement.
View details for Web of Science ID A1988R935000004
View details for PubMedID 3063517
We measured the impact of rheumatoid arthritis (RA) and osteoarthritis (OA) by comparing the activities of patients with these illnesses to controls matched for age, sex, and community of residence. Our results indicate that patients with RA experience more losses than controls in every domain of human activity and that patients with OA experience more losses in the performance of household chores, shopping and errands, and leisure activities. The methods described here provide a simple, reliable way to assess the impacts of illness in the same terms for all dimensions of human activity.
View details for Web of Science ID A1987K037600013
View details for PubMedID 3668977
One hundred subjects with arthritis were randomized into lay-taught, or professional-taught 12-h arthritis self-management courses, or a control group. Outcomes, knowledge, exercise, relaxation, disability, pain, and number of physician visits were measured aat baseline and 4 months. Professional-taught groups demonstrated greater knowledge gain while lay-taught groups had greater changes in relaxation (p less than .01) and a tendency toward less disability. Although it is impossible to draw definitive conclusions, this study suggests that lay leaders can teach arthritis self-management courses with results similar to those achieved by professionals.
View details for Web of Science ID A1986E027400017
View details for PubMedID 3772925
Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.
View details for Web of Science ID A1985AKL3600011
View details for PubMedID 4004977
Academic medical departments confront important changes in funding sources and consequent pressure to change faculty activities. Valid information has often been lacking concerning the existing relations of faculty activity to funding sources. We examined those relations in the Stanford Department of Medicine through a combination of randomized observations of faculty and faculty self-reports over a period of one year. For an average 62-hour workweek, there was approximate consonance between types of activities and sources of salary support. Sensitivity analyses indicated that even sizable errors in self-reports would not have changed the outcomes substantially. Over 60 per cent of the activity involved "joint products," representing two or more categories of activity. There was wide variation in activities and fund sources between divisions. Per full-time faculty equivalent, research generated far more income than the most lucrative specialty practice; thus, at least in this type of department, attempts to compensate for lost research revenue by intensifying clinical practice will probably fail and undermine present research activities. The method of analysis used here may be useful in improving prospective planning by departments and by larger medical-policy bodies, particularly in the public sector.
View details for Web of Science ID A1985AFK6200005
View details for PubMedID 3982454
Care of patients with osteoarthritis is compared for three different types of health service: fee-for-service, prepayment (Kaiser Health Plan), and an experimental service (Midpeninsula Health Service--MHS). While charging fees-for-service, MHS modifies medical practice in defined ways and seeks to involve patients through supervised self-care. Volunteer panels of patients provide the data at 6-month intervals through self-administered questionnaires. This report covers the first 18 months. Health status has not changed. Annualized utilization data, adjusted for age, income, education, pain, disability, disease duration, and prescription drug use, indicate that MHS members have fewer physician visits, fewer diagnostic tests, and lower antiinflammatory drug use than the other two services. MHS members express satisfaction equal to or greater than other participants. The results suggest that, in addition to modified financial incentives, there is another strategy that is relevant to achieving effective, efficient, and satisfying health care.
View details for Web of Science ID A1985AFC8400008
View details for PubMedID 3982107
This study reports the partial isolation and characterization of plasma DNA by phenol extraction and concentration of the extract. DNA, identified by immunologic and chemical methods, was found in plasma from both normal persons and patients with systemic lupus erythematosus in amounts varying from 0.004 to 0.4 micrograms/ml. The DNA was predominantly of low molecular weight, approximating 100 to 200 base pairs. Patients with lupus tended to have higher concentrations of plasma DNA than normal persons, with considerable overlap between the groups. Plasma DNA concentrations correlated inversely with titers of antibody to DNA but not strongly enough for prediction of either variable in individual cases. Many patients had high levels of plasma DNA and its antibody without clinical nephritis. These results indicate the ubiquity of plasma DNA and suggest the necessity of factors other than mere presence of DNA and its antibody for initiation of glomerular damage in systemic lupus erythematosus.
View details for Web of Science ID A1984TA62800005
View details for PubMedID 6741982
Antibodies to different components of the extractable nuclear antigen (ENA) have been thought to be serological markers for clinical subsets of rheumatic diseases. However, incomplete characterization and standardization of antigenic components such as ribonucleoprotein (RNP), Sm, and SS-B (Ha), and the multiplicity of autoantibodies produced by different patients have confounded correlations between autoantibody specificity and disease subsets. This study describes the preparative separation of the antigens Sm, RNP, and Ss-B (Ha) by electrofocusing and their use in a rocket electrophoretic assay that in one step identifies and quantifies the multiple reactivities of patient sera exhibiting the speckled FANA pattern. Preparative electrofocusing generates milligram quantities of these antigens with retention of their immunologic and biochemical characteristics, facilitating further study of their biological properties and relationships to disease subsets.
View details for Web of Science ID A1982NZ96900009
View details for PubMedID 6808026
A structure for representation of patient outcome is presented, together with a method for outcome measurement and validation of the technique in rheumatoid arthritis. The paradigm represents outcome by five separate dimensions: death, discomfort, disability, drug (therapeutic) toxicity, and dollar cost. Each dimension represents an outcome directly related to patient welfare. Quantitation of these outcome dimensions may be performed at interview or by patient questionnaire. With standardized, validated questions, similar scores are achieved by both methods. The questionnaire technique is preferred since it is inexpensive and does not require interobserver validation. These techniques appear extremely useful for evaluation of long term outcome of patients with rheumatic diseases.
View details for Web of Science ID A1980JF16100001
View details for PubMedID 7362664
Four methods to detect antibodies reactive with soluble nuclear antigens were compared-the fluorescent antibody technique, hemagglutination, complement fixation, and immunodiffusion. Centain advantages and disadvantages of each method are described. The first three methods have greater sensitivity than immunodiffusion, but immunodiffusion discriminates most reliably between different antibodies.
View details for Web of Science ID A1977DC79500009
View details for PubMedID 403922
A soluble nuclear antigen that reacts with sera obtained from patients with systemic lupus erythematosus and Sjögren's syndrome has been described. The antigen, tentatively named the Ha antigen after the prototype serum, was shown to react with specific antibodies by precipitin, complement fixation, and immunofluorescence techniques. The Ha antigen prepared from isolated nuclei of calf thymus glands, calf liver, and rat liver showed identical immunological reactivities; a wide distribution among different species and tissues is presumed. The Ha antigen was destroyed by trypsin and relatively mild heat or pH variation from neutrality, but was resistant to DNase or RNase. Many of these characteristics are similar to those of the "B" antigen to which antibodies have recently been described in Sjögren's syndrome. The nuclear origin of the Ha antigen was confirmed by the speckled nuclear immunofluorescence staining pattern given by purified antibody to Ha obtained from a specific immune precipitate. Preliminary results showed approximately 13% of patients with systemic lupus erythematosus and 30% of patients with Sjögren's syndrome had precipitating antibodies to the Ha antigen.
View details for Web of Science ID A1977CU60400010
View details for PubMedID 64473
Extractable nuclear antigen contains ribo-nuclease-sensitive (ribonucleoprotein) and ribonuclease-resistant (Sm) components. To determine the diagnostic usefulness of antibodies to these antigens, a multicenter study was undertaken in which serums were analyzed for these antibodies and the findings compared with clinical and other laboratory characteristics of the patients. Of 100 patients with hemagglutinating antibodies to ribonuclease-sensitive extractable nuclear antigen, and only the same antibodies by immunodiffusion, 74 per cent had typical features of mixed connective-tissue disease; 12 features of systemic lupus erythematosus, eight those of scleroderma and six an undifferentiated mild connective-tissue disease. Of 27 patients with hemagglutinating antibodies to ribonuclease-resistant extractable nuclear antigen (and Sm antibodies by immunodiffusion), 85 per cent had typical systemic lupus. Thus, antibodies to nuclear ribonucleoprotein and Sm are of diagnostic use; if the serum contains only ribonucleoprotein antibody in high titer, it is likely that the patient has mixed connective-tissue disease.
View details for Web of Science ID A1976CK75300001
View details for PubMedID 1086429
View details for Web of Science ID A1973Q635500016
View details for Web of Science ID A1972O372400006