Faculty Bibliography

The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.

Regular physical activity decreases the mortality rate in middle-aged men and probably in middle-aged women. It is unknown whether this is also true in the elderly. We studied 285 men and women aged 75 years or older who were free of cardiovascular disease. Subjects were ranked by baseline physical activity levels and grouped into quartiles. After adjustments were made for cardiac risk factors, chronic obstructive pulmonary disease, and cancer, women in the second most active quartile had a much lower risk of mortality at 10 years (relative risk 0.24, 95% confidence interval 0.12 to 0.51). There was no statistically significant difference in men. There appeared to be an excess of sudden cardiac deaths in the most active women, although this group still lived longer than the least active women. We conclude that women aged 75 years or older who are more active live longer. This benefit may be attenuated in those who are extremely active

Men who are more active live longer, but it is not clear if the same is true for women. We monitored 1404 women aged 50 to 74 who were free of cardiovascular disease. We assessed physical activity levels and ranked subjects into quartiles. After 16 years, 319 (23%) women had died. The relative risk of mortality, compared to the least active quartile, was as follows: second quartile, 0.95 (95% confidence interval [CI] 0.72 to 1.26); third quartile, 0.63 (95% CI 0.46 to 0.86); most active quartile, 0.67 (95% CI 0.48 to 0.92). The relative risks were not changed by adjustment for cardiac risk factors, chronic obstructive pulmonary disease, or cancer or by excluding all subjects who died in the first 6 years (to eliminate occult disease at baseline). There was no association between activity levels and cardiovascular morbidity or mortality. We conclude that women who were more active lived longer; this effect was not the result of decreased cardiovascular disease

OBJECTIVE: To assess how often physicians counsel patients about exercise and to identify which primary care internists infrequently counsel about it. DESIGN: Cross-sectional survey of a random sample of primary care internists in Massachusetts. Questions covered physicians' attitudes, beliefs, and practices with respect to counseling about exercise; physicians' perceived barriers to counseling about exercise; physicians' personal exercise frequency; and physician demographics. PARTICIPANTS: Of 1,000 physicians, 687 were eligible and 422 returned usable questionnaires (response rate 61%). RESULTS: Data describing physician demographics, practice setting, measures of personal fitness, and beliefs regarding exercise were entered into a logistic regression model. The characteristic that best identified physicians who infrequently counsel about exercise was their perceived lack of success at counseling (OR 22.83, 95% CI 8.36-62.31). Other independent predictors of infrequent counselling were physicians' lack of conviction that exercise is very important (OR 4.86, 95% CI 1.70-13.91), physician age < or = 40 years (OR 3.08, 95% CI 1.33-7.15), and higher physician resting heart rate (OR 3.45, 95% CI 1.46-8.18). CONCLUSIONS: Several factors were found to be independently associated with the likelihood of a physician's counseling about exercise. These included physician perceived success at counseling, physician belief that exercise is important, physician age, and physician resting heart rate. These results suggest possible strategies to improve physician's counseling efforts