Showing papers in "Journal of Family Practice in 1993"

Prevalence of depressive symptoms in primary care.

Abstract: Background Depression is one of the most common medical disorders seen in primary care practice. The purpose of this study was to estimate the prevalence of depressive symptoms in primary care patients across the United States, and to describe patient characteristics that may be associated with an increased likelihood of those symptoms. Methods Survey data were obtained from a sample of 75,858 patients who visited one of 765 participating primary care physicians for any reason from February 1991 to September 1991. The outcome measurement used was the index score for presence of depressive symptoms on the Zung Self-rating Depression Scale. Results The overall prevalence of clinically significant depressive symptoms was found to be 20.9%, but the percentage of patients citing depression as a reason for visit (1.2%) was markedly lower. Patients who perceived their health as poor were more likely to have severe depressive symptoms than patients who perceived their health as excellent. Women, those in older age groups, and those with lower levels of education were more likely to have clinically significant depressive symptoms than men, those in younger age groups, and those with higher levels of education. When classified by marital status within each sex, married men and women were the least likely to have clinically significant depressive symptoms. Conclusions Clinically significant depressive symptoms are highly prevalent in primary care patients; however, depression is an infrequent patient complaint. There are certain patient characteristics that may cue the physician to consider depression in the differential diagnosis, particularly the patient's self-perception of his or her overall health status. In addition, certain other subsets of patients are at increased risk of depression, such as women, those in older age groups, and those of lower socioeconomic status.

Self-reported medical problems of adult female survivors of childhood sexual abuse

Abstract: BACKGROUND. Childhood sexual abuse has been established as an antecedent to specific psychological disorders in adulthood. Only recently have researchers begun to consider the effects of this early trauma on subsequent physical health status. The current study sought to explore the relationship between a history of childhood sexual abuse in female adults and subsequent self-reported medical complaints. METHODS. This consecutive sample study used a questionnaire to distinguish subjects with a sexual abuse history and those without such a history. Subjects were female patients over 18 years of age at a primary care health center. RESULTS. Twenty-six percent of the 523 subjects who completed the entire questionnaire acknowledged a history of sexual abuse in childhood. This percentage is consistent with estimates for the population at large. The abused group reported more problems in respiratory, gastrointestinal, musculoskeletal, neurological, and gynecological functions. Statistically significant discriminating variables for those who had been abused were (1) total medical complaints reported, (2) previous mental health treatment, and (3) age of first sexual intercourse. Among the abused group, only 5.1% had ever disclosed information about their sexual abuse experiences to a physician. CONCLUSIONS. At least one in four women are survivors of childhood sexual abuse. These women rarely spontaneously reveal this history to a physician, yet they are more likely than nonabused patients to report multisystemic medical complaints. To avoid misdiagnosis and misuse of medical services, physicians should routinely obtain a thorough sexual history, particularly when the patient has multisystem complaints. Language: en

The effect of parental expectations on treatment of children with a cough: a report from ASPN.

Abstract: BACKGROUND A previous retrospective study of children with cough raised questions about how physicians diagnose acute bronchitis. We hypothesized that if the physician perceives a parental expectation that an antibiotic is needed, it is more likely that a child with a cough will be diagnosed as having bronchitis and treated with an antibiotic. METHODS Data were collected prospectively in 44 primary care practices in the Ambulatory Sentinel Practice Network. Variables examined included elements of the patient's history and physical examination, diagnoses made, and treatments prescribed. RESULTS Data regarding 1398 patients were collected. A parental expectation that a prescription for an antibiotic would be given was associated with an increased likelihood of a diagnosis of bronchitis (relative risk 2.04, 95% confidence limits, 1.76 to 2.35, P < .001), and was second only to the physical finding of rales in the magnitude of its association with that diagnosis. The only other diagnosis associated with parental expectation of an antibiotic was viral upper respiratory tract infection, where parental expectation of treatment with an antibiotic was associated with a 49% reduction in the probability of that diagnosis. CONCLUSIONS The expectations of parents of children with a cough appear to influence physician decision making.

Perspectives on patient-doctor communication.

Abstract: Until recently, the content, structure, and function of communication between doctors and patients has received little attention and has been excluded from the realm of scientific inquiry; as a result, most clinicians have had little formal training in communication skills In this paper leaders in doctor-patient communication present four approaches that are currently used as the basis for clinical training and research, summarize the progress made in forming a consensus, and outline the implications of these perceptions for practicing physicians

Randomized placebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature.

Abstract: Background Acute bronchitis is a common clinical problem that causes considerable morbidity and presents both diagnostic and treatment dilemmas for the physician. An evaluation of all published randomized controlled trials of antibiotics in the treatment of acute bronchitis was conducted to (1) quantitatively assess methodologic rigor, (2) determine if effectiveness of antimicrobial therapy is known, and (3) analyze strengths and weaknesses of randomized controlled trials in family practice settings. Methods A scoring system for the evaluation of randomized controlled trials was adapted for this study. Four raters, who were blinded to which journals published the studies and the type of antibiotic used in each study, assessed the six-randomized clinical trials for treatment of bronchitis identified through a literature search. The trials were rated according to criteria that measured internal validity. Results Scores for internal validity ranged from 65.5 to 102.5 points with a maximum possible score of 120 points (54.6% to 85.4%). The two trials with the highest scores assessed doxycycline and showed no benefit from use of this antibiotic. Single trials that studied erythromycin and trimethoprim-sulfamethoxazole showed improvement in outcome from use of these drugs; however, of the six trials, these two studies ranked fourth and fifth for internal validity. Low scores resulted from small sample size, possible contamination with other treatment measures, and poor assessment of subjects' compliance with antibiotic regimen. Conclusions An evaluation of the current literature does not support antibiotic treatment for acute bronchitis. Further studies of this common illness are indicated. It is hoped that this critical review of randomized control trials will prove useful in the planning of future studies, in placing greater emphasis on methodologic rigor, and in giving greater consideration to the practical constraints of research in the family practice setting.

Prevalence and severity of urinary incontinence in ambulatory adults: An UPRNet study

Abstract: BACKGROUND: Although urinary incontinence (UI) is a common and costly problem, its prevalence and severity in ambulatory patients is not well established. The main objectives of this study were to define the prevalence and severity of urinary incontinence in adult men and women who came to a primary care office for health care, to determine if these patients had ever told a health care provider about this problem, and to determine if they would be interested in treatment if it were available and effective. METHODS: Men and women aged 20 years and over who came to family physicians' offices seeking health care for any reason during an 11-week period were the subjects of a survey by an anonymous questionnaire. Five family practice offices in UPRNet (the Upper Peninsula Research Network), a research network in Michigan, participated. We defined "current urinary incontinence" as any degree of incontinence in the past 12 months. RESULTS: Of the 2830 study participants, 33% had current urinary incontinence (95% confidence interval [CI] 31% to 35%). Incontinence was experienced by 11% of the men and 43% of the women. Urinary incontinence constituting a social or hygienic problem was reported by 5% of the men and 23% of the women (17% overall). Of those with current UI, 72% had not told a health care provider. Of the patients who had not told a physician, 37% said they would seek care if they knew tests and effective treatment were available. CONCLUSIONS: Urinary incontinence is a common problem among those seen in primary care settings, and its presence is often not known to the health care provider.

Identifying and treating wife abuse.

Abstract: BACKGROUND. Wife abuse, acknowledged as a critical problem in our society, is often undetected by family physicians. The purpose of this study was to identify the problems and potential solutions encountered by family physicians in the identification and treatment of wife abuse in London, Ontario. METHODS. Family physicians in London were recruited to participate in four focus groups. The groups' discussions were audiotaped and transcribed. The transcripts were analyzed using qualitative methodology to determine relevant themes. RESULTS. Thirty-two physicians (16 male and 16 female) participated in the focus groups. The majority were in group practice (81%). The average number of years in practice was 11.75. An analysis of the focus group session identified two major clinical themes with subcategories: (1) physician issues (ie, identification, treatment); and (2) patient issues (ie, barriers to identification, symptom presentation). CONCLUSIONS. The focus groups served as an effective method to engage family physicians in isolating their own as well as their patients' difficulties in confronting this serious problem. Language: en

Association between epidural analgesia during labor and fever.

Abstract: Background Epidural analgesia has been associated in previous research with an increase in maternal temperature. Methods Three studies were done: a retrospective chart review of women in labor, a prospective cohort study of women in labor, and a case-control study of newborns with fever. The prospective study enrolled 28 women, 14 of whom received epidural analgesia. Maternal temperature was measured hourly with a tympanic membrane thermometer. Other variables examined included duration of labor, duration of ruptured membranes, and room temperature. To further explore the possible association between maternal epidural exposure and newborn fever, a case-control study of newborns with fever at birth was carried out. Results In both the retrospective and prospective studies of women in labor, the duration of epidural analgesia was correlated with maximum maternal temperature during labor, with an increase, in the prospective study, of 0.07 degrees C per hour of exposure to epidural analgesia (P = .002). Controlling for other variables did not change the magnitude of this effect or its statistical significance. Similar trends were seen in the newborn's first temperature in both the prospective study of women in labor and the case-control study of newborns, but the associations were not significant (P = .07 and .08, respectively). Conclusions Epidural analgesia is associated with an increase in maternal temperature during labor and possibly with an elevation of newborns' first temperatures.

Serum creatinine as an independent predictor of coronary heart disease mortality in normotensive survivors of myocardial infarction. POSCH Group.

Abstract: BACKGROUND: Serum creatinine has been reported in previous studies to be a prognostic indicator for overall mortality, in particular in a hypertensive population. METHODS: The Program on the Surgical Control of the Hyperlipidemias (POSCH) was a randomized, controlled clinical trial. All patients had survived a single myocardial infarction, were normotensive, were not obese, were not having heart failure, and were free of diabetes mellitus and renal disease at entry into the study. POSCH had followed its control group patients (N = 417) for a minimum of 7.0 years. In this group, a prospective post hoc analysis of the relationship of baseline serum creatinine with subsequent overall and atherosclerotic coronary heart disease mortality was performed. RESULTS: The baseline serum creatinine values in the control group patients ranged from 0.7 to 1.9 mg/dL (60 to 170 mumol/L), and were found to be independent predictors (P < .01) of both overall mortality and atherosclerotic coronary heart disease mortality. Each 0.1 mg/dL (9 mumol/L) increment in the baseline serum creatinine increased the relative risk for subsequent overall mortality by 36% and the relative risk for subsequent atherosclerotic coronary heart disease mortality by 47%. CONCLUSIONS: These results demonstrate that a serum creatinine value, obtained in normotensive, nonobese, normoglycemic survivors of a myocardial infarction without preexistent renal disease or heart failure, provides independent prognostic information regarding subsequent overall and atherosclerotic coronary heart disease mortality.

Artificial neural networks for predicting failure to survive following in-hospital cardiopulmonary resuscitation

Abstract: Background Neural networks are an artificial intelligence technique that uses a set of nonlinear equations to mimic the neuronal connections of biological systems. They have been shown to be useful for pattern recognition and outcome prediction applications, and have the potential to bring artificial intelligence techniques to the personal computers of practicing physicians, assisting them with a variety of medical decisions. It is proposed that such an artificial neural network can be trained, using information available at the time of admission to the hospital, to predict failure to survive following in-hospital cardiopulmonary resuscitation (CPR). Methods The age, sex, heart rate, and 21 other clinical variables were collected on a consecutive series of 218 adult patients undergoing CPR at a 295-bed public acute-care hospital. The data set was divided into two groups. A neural network was trained to predict failure to survive to discharge following CPR, using one group as the training set and the other as the testing set. The procedure was then reversed, and the results of the two networks were combined to form an aggregate network. Results The trained aggregate neural network had a sensitivity of 52.1% and a positive predictive value of 97% for the prediction of failure to survive following CPR. The relative risk of actually failing to survive to discharge following CPR for a patient predicted not to survive was 11.3 (95% CI 3.3 to 38.2). Conclusions Predicting failure to survive following CPR is but one possible application of neural network technology. It demonstrates how this technique can assist physicians in medical decision making. Future work should attempt to improve the positive predictive value of the neural network, to consider combining it with an expert system, and to compare it with other predictive tools. Once validated, the network can be distributed as a separate application for use by practicing physicians.

Women's satisfaction with birth control.

Abstract: Contraception is a major component of preventive health care for women. There are indications that women are not satisfied with the methods of birth control currently available. Dissatisfaction with contraceptive methods may lead to unplanned pregnancies. Adult women visiting the family health center over a 1-year period were invited to participate in a research interview. Questions were asked about demographic variables and the womens use of and their satisfaction with contraceptive methods. Many women were displeased with the present methods of birth control. This is reflected in the numerous methods used by each women and by frequent use of permanent sterilization as a contraceptive method. Women were as dissatisfied with oral contraceptives as they were with the less efficacious methods such as condoms foams gels and rhythm. The only methods that has a greater than 70% satisfaction rate were tubal ligations and partners vasectomies. There is significant dissatisfaction with the methods of contraception currently available. Increased patient-physician discussion and education may improve satisfaction with birth control methods now used. New methods of contraception may be needed to prevent unplanned pregnancies. (authors)

Analysis of data.

Abstract: Consider the microarray experiment in Golub et al. (1999) where ALL and AML subtypes of leukemia are compared. The data are available within package multtest. We can analyse those data in SAGx with the function samrocNboot. The ideas behind it are presented in Broberg (2003). Briefly, the method relies on a penalised t-test statistica d = (x̄1 − x̄2)/(S + a) with fudge factor a Efron et al. (2001). In this case the effect estimated consists of a difference in group means. In general the method can estimate and test one such effect in the presence of explanatory variables such as AGE or GENDER using a linear model. In such a case the function samrocN provides a solution. Example code now follows.

Professional satisfaction and dissatisfaction of family physicians.

Abstract: BACKGROUND Physicians' satisfaction with their professional life influences the quality of patient care they provide and helps to determine the number and type of students attracted to the various fields of medicine. In this study, we sought to delineate areas of satisfaction and dissatisfaction among family physicians. METHODS A self-administered questionnaire was sent to all physicians in the state of Pennsylvania who were included in the 1990 directory of the American Board of Family Practice (N = 1944). RESULTS Completed questionnaires were received from 1066 family physicians in full-time practice. Sixty-five percent were satisfied with their professional lives. Patient relationships, a sense of clinical competence, and their relationships with their partners were among the most satisfying aspects of practice for all family physicians. Problems identified included regulations by third-party payers and government agencies and the large amount of paperwork encountered in practice. There were significant (P < .001) differences in satisfaction between physicians in different practice arrangements. Significant differences between practice types were also found in the degree of dissatisfaction with third-party payers and government agencies, paperwork, isolation from other physicians, and the threat of a malpractice suit. CONCLUSIONS Almost two thirds of family physicians are satisfied with their general professional lives. Conversely, one third are not. Clear areas of satisfaction and dissatisfaction have been defined for family physicians in general as well as for family physicians in various practice environments. This information may be useful in the development of policy to structure a medical system that meets the needs of both patients and physicians.

Full-thickness leg ulcers: patient demographics and predictors of healing. Multi-Center Leg Ulcer Study Group.

Abstract: Background Despite increased knowledge about the immediate and underlying causes of chronic leg ulcers, their management remains a challenge. Some ulcers rapidly respond to treatment whereas others do not, and the decision to reassess the patient and treatment modality is usually based on the clinician's own experience. Methods Following diagnosis of the underlying cause of leg ulcers, 181 patients were screened. The use of a hydrocolloid dressing (DuoDERM) was evaluated in the treatment of 61 patients with 72 full-thickness ulcers. Patient characteristics associated with deep wounds as well as patient and wound characteristics predictive of the extent of healing and time required for healing were identified. Results Patients with full-thickness ulcers were more likely to be overweight (P 30% reduction in ulcer area after 2 weeks of treatment was a predictor of both treatment outcome (P = .016) and time required for healing (P = .004). Odor at baseline and advanced age also were associated with increased time required for healing (P = .005 and .017, respectively). Conclusions Noninvasive clinical assessments can aid the clinician in predicting treatment outcome and may facilitate the decision to change therapy and evaluate treatment compliance.

Follow-up of abnormal Papanicolaou smears among women of different races.

Abstract: BACKGROUND Current information about racial differences in the rate of cervical abnormalities is incomplete, and there are few data about racial differences in compliance with follow-up and treatment. The purpose of this study was to investigate the frequency and follow-up of abnormal Pap smear findings in white, black, and Southeast Asian women. METHODS The charts of women who attended a St Paul family practice residency clinic and who had abnormal Papanicolaou (Pap) smear results between January 1, 1989, and September 1, 1992, were reviewed, and information about age, race, insurance, Pap smear findings, diagnostic studies, and treatment procedures was recorded. RESULTS Of 1794 women who had Pap smears during this period, 190 (10.6%) had abnormal results, with a diagnosis of atypia, dysplasia, or carcinoma. The rate of abnormality was greater for black women (16.4%) than for Southeast Asian (6.1%) and white women (11.6%); however, the proportion of abnormal Pap smears that showed moderately severe or worse changes was greater for Southeast Asians than for whites (30.6% vs 14.3%, P < .05). Southeast Asian women with abnormal Pap smears were also less likely than whites and blacks to follow through with recommended diagnostic and treatment procedures. CONCLUSIONS Southeast Asian women in this study were less likely than white and black women to comply with recommended follow-up diagnostic and treatment procedures for cervical disease.

Effect of type II diabetes mellitus on cognitive function.

Abstract: Background As people with diabetes mellitus suffer from peripheral and autonomic neuropathy, we thought it possible that deficits in cognitive function might also be found. Our objective was to compare the cognitive function of elderly persons with non-insulin-dependent diabetes mellitus (NIDDM) with a matched sample of persons without NIDDM: Methods Ninety outpatients over 50 years of age with NIDDM and 90 matched nondiabetic patients were recruited for the study. The Modified Mini-Mental State (3MS) and the Delayed Word Recall (DWR) test were used to assess cognitive function. Results On the 3MS test, the mean score of persons with NIDDM was 75.6, and that of nondiabetic persons was 79.5 (two-tailed t = 3.04, P = .013). On the DWR, the mean score of persons with NIDDM was 3.9, and that of persons without NIDDM was 4.7 (two-tailed t = 3.52, P = .012). Conclusions Persons with NIDDM had significantly poorer scores on two tests of cognitive function. Physicians should be aware of this association between type II diabetes and a small but definite impairment of cognitive function.

Accuracy of expectant mothers' predictions of fathers' attitudes regarding breast-feeding.

Abstract: BACKGROUND: Breast-feeding plays a well-recognized role in lowering infant morbidity and mortality during the first year of life Previous research has demonstrated that fathers contribute to the decision of which infant feeding method will be used, and can be effective promoters of breast-feeding A woman's decision to breast-feed her infant may rest on her assumptions of the father's attitude regarding this feeding method As the perception of a negative paternal attitude toward breast-feeding may discourage some women from breast-feeding, this study was designed to determine whether a mother can accurately predict the father's attitude on this subject METHODS: Subjects were 268 pairs of expectant mothers and fathers enrolled in childbirth preparation classes at five private hospitals in Houston, Texas Participants individually completed pretested surveys assessing their attitudes regarding breast-feeding Mothers' surveys additionally assessed their partner's attitudes toward breast-feeding RESULTS: More mothers than fathers reported exclusive breast-feeding as their preferred feeding plan (69% vs 58%), whereas only 54% of partners both responded they preferred breast-feeding Overall, fathers had more favorable attitudes toward breast-feeding than their partners predicted, but large numbers of fathers harbored misconceptions and negative attitudes toward breast-feeding Mothers' predictions were little more accurate than random guessing in predicting their partner's response (range: 56% to 83%) CONCLUSIONS: A mother's perception of her partner's attitudes toward breast-feeding influences her choice of infant feeding method If she perceives that the father has a negative attitude about breast-feeding, she will probably not choose this method Additional efforts to dispel misconceptions about breast-feeding should be made during childbirth preparation classes and prenatal visits

Do antidepressant medications relieve chronic low back pain

Abstract: Background Antidepressant medications are commonly prescribed for patients with chronic low back pain. A literature synthesis was performed to determine whether antidepressants are more effective than placebos in decreasing pain, disability, depression, and analgesic medication use in such patients. Methods English-language journal articles were identified from MEDLINE and PsycLIT databases, bibliographies, and inquiries to researchers and drug companies. Articles were included if they reported data from placebo-controlled or drug comparison trials of antidepressants for patients with low back pain. Six articles met these criteria. Results Three studies compared the effects of antidepressants and placebos on pain; two found no difference and one found a trend toward superiority of imipramine for patient-rated symptoms but no difference in investigator ratings. Effects on functional disability were examined in three antidepressant-placebo comparisons; only one found the antidepressant to be more effective. Antidepressant effects of an antidepressant vs placebo were compared in three studies; none found a significant difference. Effects on analgesic medication use were compared in three studies; one found amitriptyline to be superior and the others found no difference. Serious methodologic flaws characterized all six studies, and insufficient reporting of data precluded meta-analysis. Conclusions The literature has not demonstrated that antidepressants are superior to placebos in improving low back pain or related problems. However, further randomized controlled trials are needed to determine whether antidepressants are useful for low back pain.

Use of CT scans for the investigation of headache: a report from ASPN, Part 1.

Abstract: BACKGROUND Clinicians in the Ambulatory Sentinel Practice Network (ASPN) order computed tomography (CT) scans for approximately 3% of patients with headache. This study was undertaken to provide information about the reasons for ordering CT scans and the results obtained. METHODS Weekly return cards were used to collect data on every patient for whom a CT scan was ordered to investigate a headache during a 19-month period. Copies of CT reports were reviewed, and a chart audit was performed to collect further clinical information whenever an intracranial tumor, subarachnoid hemorrhage (SAH), or subdural hematoma (SDH) was reported. RESULTS Clinicians in 58 practices ordered 349 CT scans. Only 52 patients (15%) had abnormalities noted on neurological examination. Most CT scans were ordered because the clinician believed that a tumor (49%) or an SAH (9%) might be present. Fifty-nine (17%) were ordered because of patient expectation or medicolegal concerns. Of the 293 reports reviewed, 14 indicated that a tumor, an SAH, or an SDH was present. Two of the 14 (14%) were false positives. Forty-four (15%) of the reports noted incidental findings of questionable significance. CONCLUSIONS Because there are no clear guidelines for the use of CT for the investigation of headache, physicians must exercise good clinical judgment in their attempts to identify treatable disease in a cost-effective manner. ASPN clinicians made selective use of CT scans based on a combination of factors that included physician and patient concerns. CT was an imperfect tool in this setting. Most of the positive results represented false positives or incidental findings that could have led to adverse effects and additional costs.

Adequacy of prenatal care among inner-city women.

Abstract: BACKGROUND Lack of prenatal care is a well-recognized risk factor for infant mortality and low birthweight This study was conducted to identify factors that facilitate or inhibit access to prenatal care among low-income inner-city women METHODS A case-control interview study was conducted with women during their postpartum hospitalization at a midwestern inner-city hospital Fifty-eight women who had received no prenatal care and 71 women who had received markedly inadequate prenatal care were compared with 123 controls who had received intermediate or adequate prenatal care RESULTS The majority of subjects were minorities, single, had low incomes, and were in the Medicaid program Subjects' median age was 23 years and median parity 2, and the majority had not completed high school Inadequate prenatal care was independently associated with the following variables (adjusted odds ratios): lack of any insurance, including Medicaid (53), being a smoker (38), being homeless (27), being black (25), not being worried what the physician or nurse might say (24), not using contraception (21), having a household income of less than $400 a month (18), being ashamed or afraid of the pregnancy or the physician (14), having transportation problems (13), and level of education (08) CONCLUSIONS Practical factors related to poverty are substantial barriers to obtaining prenatal care Comprehensive approaches to prenatal services that address these barriers may be more effective in facilitating adequate prenatal care among low-income women

Effectiveness of an ethics consultation service.

Abstract: Background Ethics consultation is a relatively new service in clinical medicine. Most such services have been developed in departments of internal medicine. Few studies have evaluated the results of such consultations, and none have examined whether a family practice perspective enhances the consultation process. Methods An ethics consultation service was established in the Department of Family Medicine at Loma Linda University School of Medicine in 1990. Data were collected from the consultations performed during the first year. A questionnaire was sent to the attending physicians for their evaluation of the service. Results Ethics consultations were provided to the health care teams of 46 patients in five clinical departments. The attending physicians found the consultations to be important in clarifying ethical issues, educating the team, increasing confidence in decisions, and in patient management in more than 90% of the cases; however, the consultations resulted in significant changes in patient management only 36% of the time. Conclusions It is feasible to establish an ethics consultation service within a department of family medicine in a university hospital and to provide consultations to physicians in other specialties.

Continuous quality improvement for continuity of care

Abstract: BACKGROUND Continuous quality improvement (CQI) techniques have been used most frequently in hospital operations such as pharmaceutical ordering, patient admitting, and billing of insurers, and less often to analyze and improve processes that are close to the clinical interaction of physicians and their patients. This paper describes a project in which CQI was implemented in a family practice setting to improve continuity of care. METHODS A CQI study team was assembled in response to patients' complaints about not being able to see their regular physician providers when they wanted. Following CQI methods, the performance of the practice in terms of provider continuity was measured. Two "customer" groups were surveyed: physician faculty members were surveyed to assess their attitudes about continuity, and patients were surveyed about their preferences for provider continuity and convenience factors. RESULTS Process improvements were selected in the critical pathways that influence provider continuity. One year after implementation of selected process improvements, repeat chart audit showed that provider continuity levels had improved from .45 to .74, a 64% increase from 1 year earlier. CONCLUSIONS The project's main accomplishment was to establish the practicality of using CQI methods in a primary care setting to identify a quality issue of value to both providers and patients, in this case, continuity of provider care, and to identify processes that linked the performance of health care delivery procedures with patient expectations.

The value of laboratory tests for the screening and recognition of alcohol abuse in primary care patients

Abstract: BACKGROUND: Although alcohol abuse is prevalent in family practice, the diagnosis is not easily established. Laboratory tests are usually heavily relied on in the diagnostic process. METHODS: The value of laboratory tests for the screening and recognition of problem drinking in family practice is summarized, based on a review of the literature. A distinction is made between studies in selected populations of drinkers and studies in nonselected populations, ie, family practice. RESULTS: The most sensitive laboratory tests associated with excessive alcohol intake include gamma-glutamyl transferase (GGT), mean corpuscular volume, and the ratio of alanine aminotransferase to aspartate aminotransferase. No single laboratory test or combination of tests is shown to be appropriate for screening. The positive predictive value for GGT is only about 25% in a population that has a 10% prevalence of problem drinking and increases to about 55% in a population that has a 30% prevalence of problem drinking. CONCLUSIONS: Guidelines for the recognition of problem drinking in family practice should include elevated laboratory test values as one of the "alerting factors" for problem drinking, and not as a confirmation of a suspicion of problem drinking. In monitoring treatment response, GGT may be a powerful patient-motivating factor. Language: en

Patients' reactions to physician use of a computerized medical record system during clinical encounters

Abstract: Background As physicians begin to use computer technology in front of patients during clinical encounters, concern has been raised that such computer use may exert a dehumanizing effect on the physician-patient relationship. To investigate this concern, we measured patient reactions to physician use of a computerized medical record system during clinical encounters. Methods Adult patients who presented for clinical care were randomized into three groups. With the first group, the physician used a standard paper-and-pencil charting system during the encounter. With the second group, the physician used a computerized medical record system with keyboard input. With the third group, the physician used the computerized medical record system with voice input. Patient reactions were measured with a questionnaire that the patients completed after the clinical encounter. Results For most components of the physician-patient relationship studied in this report, questionnaire scores did not differ significantly among the three study groups. Patients in the voice input group rated physician explanations of patient problems significantly higher than patients in the other two groups. There was a trend for patient confidence in the physician to be higher in the keyboard input group. Although measured encounter durations were significantly shorter in the computer groups, there were no differences in patient satisfaction with encounter duration among the three groups. Conclusions Physician use of computers during clinical encounters was not associated with a decline in the perceived quality of the physician-patient relationship.

Self-reported hearing difficulty and audiometric thresholds in nursing home residents.

Abstract: BACKGROUND Nursing home practitioners usually assess the general health and functional abilities of each resident at the time of admission. If audiometric screening is not routinely available, assessment of the resident's hearing status will probably consist only of asking questions about hearing difficulty. In this study we explored which questions, when answered positively, were most strongly associated with moderate or severe hearing impairment. METHODS A total of 198 newly admitted nursing home residents answered questions regarding their hearing in common listening situations, and then underwent audiometric assessment. RESULTS Fifty-four percent of the residents had a pure tone average hearing level of > 25 dB at 500, 1000, and 2000 Hz and were therefore considered impaired. A single general question regarding hearing had a sensitivity of 69% in determining the presence of such impairment. Three specific questions which assessed hearing--in a group, while watching television, and while on the telephone--had a collective sensitivity of 83%. Asking the three questions was significantly (P = .003) more effective than asking only the general question. CONCLUSIONS A set of specific questions significantly improved the identification of residents whose hearing loss affected their daily living activities compared with the use of a single hearing loss question.

Health care needs of Appalachian trail hikers.

Abstract: Background With a growing interest and participation in hiking, predictions indicate that over 45 million Americans will participate in backpacking and day hiking in 1993. There has been very little assessment of the health care needs of this group. The purpose of this study was to assess the health care needs of Appalachian Trail backpackers. Methods Backpackers who completed hiking the Appalachian Trail in 1987 or 1988 received a 3-page survey questionnaire. The survey contained questions to elicit demographic information, general health characteristics, and health care experiences during the hike. Information about injuries, medications carried and used during the backpacking activities, health care needs, and trail time lost because of health problems was also requested. Results Injuries and illnesses were reported by 82% of the respondents, incurring an average loss of 4.7 days of hiking. Musculoskeletal complaints, traumatic injuries, and gastrointestinal complaints were most often reported. The severity of these problems was such that medical attention was sought in 25% of these events. Conclusions Hikers need to anticipate that musculoskeletal, gastrointestinal, and skin problems may occur during hiking. It is prudent to carry medications such as analgesics in the form of aspirin or other nonsteroidal anti-inflammatory agents, topical antibiotics, and bandages. Methods to purify water need to be used regularly, and adequate preparation of food needs to be a priority.

Colposcopic accuracy in a residency training program: defining competency and proficiency.

Abstract: BACKGROUND The determination of proficiency in procedural skills has evoked keen interest, but meaningful guidelines are limited by the absence of pertinent clinical data. Colposcopic accuracy is defined as the clinical correlation between a colposcopic impression and a histologic report. The colposcopic accuracy of physicians in a university-based family practice residency colposcopy program was evaluated. METHODS Demographic information, clinical findings, and laboratory results of patients evaluated by colposcopy were prospectively recorded. Colposcopic accuracy was calculated based on the agreement of the colposcopic impression with the histologic interpretation within one histologic grade. RESULTS Colposcopic examinations were performed on 282 patients. Histologic evidence of premalignant cervical disease was identified in 115 patients as follows: mild dysplasia, 72; moderate dysplasia, 24; and severe dysplasia, 19. The colposcopic impression agreed within one histologic grade in 188 of 205 patients for a colposcopic accuracy rate of 91.7% (95% CI = 87.1% to 95.1%). CONCLUSIONS Given an acceptable latitude of clinical correlation between the colposcopic impression and histologic interpretation, the colposcopic accuracy of family physicians compared favorably with that reported by other colposcopists. The more common colposcopic errors were overestimation of low-grade disease and underestimation of high-grade disease. Colposcopic accuracy at an essential minimal proficiency level of 80% should form the basis for assessing specialized perceptual ability and therefore determining colposcopic competency.

Physician awareness of prescription drug costs: a missing element of drug advertising and promotion.

Abstract: BACKGROUND: Although the cost of prescription drugs is recognized as an important facet of health care expenditures, many physicians are purportedly unaware of actual drug costs. To test this hypothesis, we surveyed physician awareness of the cost of 20 actively marketed prescription drugs. METHODS: A questionnaire listing four possible cost categories for each drug was administered to 305 registrants of a 5-day family medicine continuing education course. RESULTS: Ninety-two physicians completed the questionnaire. Only one, a 40-year-old, board-certified physician who had been in practice for 3 years, answered 70% of questions correctly. The average score for the other participants was 37% (range 0% to 75%). CONCLUSIONS: The majority of physicians questioned could not accurately identify the price range of commonly prescribed drugs. We recommend drug cost disclosure in drug advertising to help address this problem.

Fluoxetine-induced SIADH: a geriatric occurrence?

Abstract: After major depression was diagnosed in a 83-year-old woman, fluoxetine was prescribed. Six days later she became delirious and weak, necessitating hospitalization. She was found to have hyponatremia secondary to fluoxetine-induced syndrome of inappropriate antidiuretic hormone secretion (SIADH). Recovery was complete after discontinuation of the medication.