Showing papers in "Journal of Family Practice in 2001"

Validating the Adult Primary Care Assessment Tool

Abstract: n BACKGROUND This paper reports on the validation of the Consumer/Client Primary Care Assessment Tool Adult Edition (PCAT-AE) by assessing the congruence between the theoretically derived measures and the empiric results in terms of the underlying structure of the principal primary care domains. n METHODS The study participants were randomly selected from patients in a health maintenance organization group and a low-income group in South Carolina. They were either surveyed or interviewed regarding the achievement of primary care. Reliability, validity, and scaling analyses were conducted to assess and validate the 9 scales representing core primary care subdomains and 3 derivative domains: first contact accessibility, first contactutilization (first contact domain), longitudinality interpersonal relationships (longitudinality domain), coordination of services (coordination domain), comprehensiveness services available, comprehensiveness services received (comprehensiveness domain), family centeredness, community orientation, and cultural competence (derivative domains). n RESUL TS The results indicate that the hypothesized scales for primary care have substantial reliability and validity, and the extracted factors explained 88.1% of the total variance in the item scores. All of the 5 scaling assumptions (item-convergent validity, item-discriminant validity, equal item variance, equal item scale correlation, and score reliability) were met, suggesting that these items may be used to represent the primary care scales and the scoring of these items may be summed without standardization or weighting. n CONCLUSIONS Psychometric assessment supported the integrity and general adequacy of the PCAT-AE for assessing the characteristics and quality of primary care for adults. The PCAT-AE can be used as a quality measurement tool that assesses the adequacy of primary care experience.

Physician behaviors that predict patient trust.

Abstract: OBJECTIVE The goal for this study was to assess the relative strength of the association between physician behaviors and patient trust. STUDY DESIGN AND POPULATION: Patients (N=414) enrolled from 20 community-based family practices rated 18 physician behaviors and completed the Trust in Physician Scale immediately after their visits. Trust was also measured at 1 and 6 months after the visit. The association between physician behaviors and trust was examined in regard to patient sex, age, and length of relationship with the physician. RESULTS All behaviors were significantly associated with trust (P<.0001), with Pearson correlation coefficients (r) ranging from 0.46 to 0.64. Being comforting and caring, demonstrating competency, encouraging and answering questions, and explaining were associated with trust among all groups. However, referring to a specialist if needed was strongly associated with trust only among women (r=0.61), more established patients (r=0.62), and younger patients (r=0.63). The behaviors least important for trust were gentleness during the examination, discussing options/asking opinions, looking in the eye, and treating as an equal. CONCLUSIONS Caring and comfort, technical competency, and communication are the physician behaviors most strongly associated with patient trust. Further research is needed to test the hypothesis that changes in identified physician behaviors can lead to changes in the level of patient trust.

Switching doctors: predictors of voluntary disenrollment from a primary physician's practice.

Abstract: BACKGROUND Our objective was to evaluate 8 interpersonal and structural features of care as predictors of patients' voluntary disenrollment from their primary care physician's practice. METHODS We performed a longitudinal observational study in which participants completed a validated questionnaire at baseline (1996) and follow-up (1999). The questionnaire measured 4 elements of the quality of physician-patient relations (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust) and 4 structural features of care (access, visit-based continuity, relationship duration, and integration of care). Study participants were insured adults who reported having a regular personal physician at baseline and who completed both baseline and follow-up questionnaires (n=4108). The outcome measured was voluntary disenrollment from the primary physician's practice between baseline and follow-up. RESULTS One fifth of the patients voluntarily left their primary physician's practice during the study period. When tested independently, all 8 scales significantly predicted voluntary disenrollment (P <.001), with somewhat larger effects associated with the 4 relationship quality measures. In multivariable models, a composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio [OR]=1.6; P<.001), and the 2 continuity scales also significantly predicted disenrollment (OR=1.1; P<.05). Access and integration did not significantly predict disenrollment in the presence of these variables. CONCLUSIONS These findings highlight the importance of relationship quality in determining patients' loyalty to a physician's practice. They suggest that in the race to the bottom line medical practices and health plans cannot afford to ignore that the essence of medical care involves the interaction of one human being with another.

When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust.

Abstract: OBJECTIVE Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations. STUDY DESIGN Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit. POPULATION Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern. OUTCOMES MEASURED Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit. RESULTS Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit. CONCLUSIONS The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.

Three questions can detect hazardous drinkers.

Abstract: OBJECTIVE The researchers evaluated the Alcohol Use Disorders Identification Test (AUDIT), the first 3 questions of the AUDIT (AUDIT-C), the third AUDIT question (AUDIT-3), and quantity-frequency questions for identifying hazardous drinkers in a large primary care sample. STUDY DESIGN Cross-sectional survey. POPULATION Patients waiting for care at 12 primary care sites in western Pennsylvania from October 1995 to December 1997. OUTCOMES MEASURED Sensitivity, specificity, likelihood ratios, and predictive values for the AUDIT, AUDIT-C, and AUDIT-3. RESULTS A total of 13,438 patients were surveyed. Compared with a quantity-frequency definition of hazardous drinking (> or =16 drinks/week for men and > or =12 drinks/week for women), the AUDIT, AUDIT-C, and AUDIT-3 had areas under the receiver-operating characteristic curves (AUROC) of 0.940, 0.949, and 0.871, respectively. The AUROCs of the AUDIT and AUDIT-C were significantly different (P=.004). The AUROCs of the AUDIT-C (P or =3) and the AUDIT-3 (score > or =1) were 94.9% and 99.6% sensitive and 68.8% and 51.1% specific in detecting individuals as hazardous drinkers. CONCLUSIONS In a large primary care sample, a 3-question version of the AUDIT identified hazardous drinkers as well as the full AUDIT when such drinkers were defined by quantity-frequency criterion. This version of the AUDIT may be useful as an initial screen for assessing hazardous drinking behavior.

Weight management: what patients want from their primary care physicians.

Abstract: OBJECTIVE The researchers wanted to determine the weight management experiences of patients in primary care, and what those patients want from their physicians. STUDY DESIGN Patients completed a survey in a primary care waiting room. Afterward they were measured for body mass index (BMI). POPULATION A total of 410 consecutive adult patients in 2 primary care practices at the University of California, San Francisco, were approached, and 366 (89%) completed the survey. OUTCOMES MEASURED The primary outcomes were patient attitudes about weight loss, previous weight management experiences with their current physicians, and future preferences for weight management within the primary care relationship. RESULTS Ninety-seven percent of the obese patients (BMI > 30), 84% of the overweight patients (BMI=25-30), and 39% of the non-overweight patients (BMI < 25) thought they needed to lose weight. Forty-nine percent of the obese patients, 24% of the overweight patients, and 12% of the non-overweight patients had discussed weight with their current physicians. The types of weight management assistance that patients most wanted from their physicians were: (1) dietary advice, (2) help with setting realistic weight goals, and (3) exercise recommendations. CONCLUSIONS Although most patients believe they should lose weight, this is often not discussed during office visits. Most patients (especially those who are overweight or obese) want more help with weight management than they are getting from their primary care physicians.

Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years.

Abstract: Objective The researchers evaluated the effectiveness of paroxetine and Problem-Solving Treatment for Primary Care (PST-PC) for patients with minor depression or dysthymia. Study design This was an 11-week randomized placebo-controlled trial conducted in primary care practices in 2 communities (Lebanon, NH, and Seattle, Wash). Paroxetine (n=80) or placebo (n=81) therapy was started at 10 mg per day and increased to a maximum 40 mg per day, or PST-PC was provided (n=80). There were 6 scheduled visits for all treatment conditions. Population A total of 241 primary care patients with minor depression (n=114) or dysthymia (n=127) were included. Of these, 191 patients (79.3%) completed all treatment visits. Outcomes Depressive symptoms were measured using the 20-item Hopkins Depression Scale (HSCL-D-20). Remission was scored on the Hamilton Depression Rating Scale (HDRS) as less than or equal to 6 at 11 weeks. Functional status was measured with the physical health component (PHC) and mental health component (MHC) of the 36-item Medical Outcomes Study Short Form. Results All treatment conditions showed a significant decline in depressive symptoms over the 11-week period. There were no significant differences between the interventions or by diagnosis. For dysthymia the remission rate for paroxetine (80%) and PST-PC (57%) was significantly higher than for placebo (44%, P=.008). The remission rate was high for minor depression (64%) and similar for each treatment group. For the MHC there were significant outcome differences related to baseline level for paroxetine compared with placebo. For the PHC there were no significant differences between the treatment groups. Conclusions For dysthymia, paroxetine and PST-PC improved remission compared with placebo plus nonspecific clinical management. Results varied for the other outcomes measured. For minor depression, the 3 interventions were equally effective; general clinical management (watchful waiting) is an appropriate treatment option.

Communication about prostate cancer between men and their wives

Abstract: Objectives Metastatic prostate cancer is a serious disease that affects both men and their intimate partners. We explored the perceptions of men who have been treated for metastatic prostate cancer and the views of their wives regarding the changes that were caused by prostate cancer and its treatment. Study design We conducted retrospective focus group interviews with married men and separate focus groups with their wives. Population Twenty married men (11 white and 9 African American) with an average age of 69 years (range=60-82 years) and 7 of the wives (5 white and 2 African American) participated in our study. Thirteen of the men were treated with orchiectomy, and 7 received monthly hormone ablation therapy. Outcomes measured We compared the accounts of husbands and wives concerning the diagnosis and treatment of prostate cancer. Results The participants' accounts indicate little spousal communication about the implications of prostate cancer on their lives. In particular, couples appear to talk little about their emotions, worries, and fears. Conclusions Although wives have a profound interest in their husbands' prostate cancer, actual communication about the disease, its treatment, and the feelings it evokes may be less than we believe. Noncommunication in marriages might indicate that these couples are at increased risk for poor adjustment to prostrate cancer.

Routine screening for postpartum depression

Abstract: BACKGROUND: Postpartum depression (PPD) is a common and often overlooked condition. Validated screening tools for PPD exist but are not commonly used. We present the 1-year outcome of a project to implement universal PPD screening at the 6-week postpartum visit. METHODS: Universal screening with the Edinburgh Postnatal Depression Scale (EPDS) was implemented in all community postnatal care sites. One-year outcome assessments (diagnosis and treatment of PPD) were completed for a sample of the women screened using medical record review of all care they received during the first year postpartum. RESULTS: Sixty-eight (20%) of the 342 women whose medical records were reviewed had been given a documented diagnosis of postpartum depression, resulting in an estimated population rate of 10.7%. Depression was diagnosed in 35% of the women with elevated EPDS scores (> or =10) compared with 5% of the women with low EPDS scores ( Language: en

Understanding practice from the ground up.

Abstract: Background Our objective was to understand family practices from the ground up through intensive direct observation of the practice environment and patient care. Methods Eighteen practices were purposefully drawn from a random sample of Nebraska family practices that had earlier participated in a study of preventive service delivery. Each practice was studied intensely over a 4- to 12-week period using a comparative case study design that included extended direct observation of the practice environment and clinical encounters, formal and informal interviews of clinicians and staff, and medical record review. Design This multimethod assessment process (MAP) provided insights into a wide range of practice activities ranging from descriptions of the organization and patient care activities to quantitative documentation of physician- and practice-level delivery of a wide range of evidence-based preventive services. Initial insights guided subsequent data collection and analysis and led to the integration of complexity science concepts into the design. In response to the needs and wishes of the participants, practice meetings were initiated to provide feedback, resulting in a more collaborative model of practice-based research. Conclusions Our multimethod assessment process provided rich data for describing multiple aspects of primary care practice, testing a priori hypotheses, discovering new insights grounded in the actual experience of practice participants, and fostering collaborative practice change.

The factors associated with disclosure of intimate partner abuse to clinicians.

Abstract: OBJECTIVE: Our goal was to identify the prevalence, determinants of, and barriers to clinician-patient communication about intimate partner abuse. STUDY DESIGN: We conducted telephone interviews with a random sample of ethnically diverse abused women. POPULATION: We included a total of 375 African American, Latina, and non-Latina white women aged 18 to 46 years with histories of intimate partner abuse who attended 1 of 3 primary care clinics in San Francisco, California, in 1997. OUTCOMES MEASURED: We measured the relevance and determinants of past communication with clinicians about abuse and barriers to communication. RESULTS: Forty-two percent (159) of the patients reported having communicated with a clinician about abuse. Significant independent predictors of communication were direct clinician questioning about abuse (odds ratio [OR]=4.6; 95% confidence interval [CI] 3.2-6.6), and African American ethnicity (OR=1.8; 95% CI, 1.1-2.9). Factors associated with lack of communication about abuse included immigrant status (OR=0.6; 95% CI, 0.3-1.0) and patient concerns about confidentiality (OR=0.7; 95% CI, 0.5-0.9). Barriers significantly associated with lack of communication were patients' perceptions that clinicians did not ask directly about abuse, beliefs that clinicians lack time and interest in discussing abuse, fears about involving police and courts, and concerns about confidentiality. CONCLUSIONS: Clinician inquiry appears to be one of the strongest determinants of communication with patients about partner abuse. Other factors that need to be addressed include patient perceptions regarding clinicians' time and interest in discussing abuse, fear of police or court involvement, and patient concerns about confidentiality. Language: en

Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco.

Abstract: Background We hoped to determine the attitudes and practices of primary care physicians regarding the use of opioids to treat chronic nonmalignant pain (CNMP). We also examined the factors associated with the willingness to prescribe opioids for CNMP. Methods A survey was mailed to primary care physicians in the University of California, San Francisco/Stanford Collaborative Research Network. This survey contained questions regarding treatment in response to 3 case vignettes, the use of opioids for CNMP in general, and the demographic characteristics of the physicians. Results Among 230 physicians surveyed, 161 (70%) responded. Two percent of the respondents were never willing to prescribe schedule III opioids (eg, acetaminophen with codeine) as needed for patients with CNMP that persisted unchanged after exhaustive evaluation and attempts at treatment. Thirty-five percent were never willing to prescribe schedule II opioids (eg, sustained-release morphine) on an around-the-clock schedule for these patients. The most significant predictor of willingness to prescribe opioids for patients with CNMP was a lower level of concern about physical dependence, tolerance, and addiction. Conclusions Primary care physicians are willing to prescribe schedule III opioids as needed, but many are unwilling to use schedule II opioids around the clock for CNMP. Individual prescribing practices vary widely among primary care physicians. Concerns about physical dependence, tolerance, and addiction are barriers to the prescription of opioids by primary care physicians for patients with CNMP.

Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription

Abstract: Objective We identified those aspects of physician-patient communication that influence physicians to prescribe antibiotics for respiratory infections. Study design A multimethod comparative case study was performed including descriptive field notes of outpatient visits. Population We included patients (children and adults) and clinicians in 18 purposefully selected family practices in a midwestern state. A total of 298 outpatient visits for acute respiratory tract (ART) infections were selected for analysis from more than 1600 encounters observed. Outcomes measured Unnecessary antibiotic use and patterns of physician-patient communication were measured. Results Antibiotics were prescribed in 68% of the ART infection visits, and of those, 79% were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines. Patients were observed to pressure physicians for medication. The types of patterns identified were direct request, candidate diagnosis (a diagnosis suggested by the patient), implied candidate diagnosis (a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness, appealing to life-world circumstances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptable reasons and diagnoses to patients. Conclusions Patients strongly influence the antibiotic prescribing of physicians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limited benefits of such use, and clinicians should consider appropriate responses to these different patient pressures to prescribe antibiotics.

Randomized placebo-controlled trial of long-term treatment with sibutramine in mild to moderate obesity.

Abstract: OBJECTIVE The researchers assessed the long-term weight reduction efficacy, tolerability, and safety of sibutramine used once daily in conjunction with behavior modification to treat mild to moderate obesity. STUDY DESIGN This was a double-blind randomized placebo-controlled parallel-group comparative study of sibutramine 10 mg or 15 mg (or placebo) once daily for 1 year, given with dietary advice. POPULATION A total of 485 obese men and women with uncomplicated obesity were included (mean age=42 years, mean body mass index=32.7 kg/m2). OUTCOMES MEASURED The outcomes were mean weight loss, percentage losing more than 5% or 10% of their body weight, and adverse drug effects. RESULTS Among patients completing the study, those taking sibutramine 10 mg or 15 mg had greater mean weight loss compared with placebo at 12-month assessment (P or =5% and > or =10%). CONCLUSIONS Sibutramine 10 mg or 15 mg once daily given with dietary advice produces and maintains statistically and clinically significantly greater weight loss than dietary advice alone (placebo) throughout a 12-month treatment period, and is safe and well tolerated.

The patient's perspective of irritable bowel syndrome.

Abstract: Objective The researchers wanted to understand how irritable bowel syndrome (IBS) affects patients' lives and their interactions with physicians and the health care system. Study design A qualitative study was performed using focus groups of people with physician-diagnosed IBS. Immersion/crystallization was used to identify overriding themes. Population Adult volunteers with a previous physician diagnosis of IBS were included. Outcomes measured The outcomes were patient-reported symptoms, episode triggers, treatments, lifestyle changes, and interactions with their physicians that were related to IBS, and overriding themes identified from the focus groups. Results The subjects described IBS as a chronic episodic illness that affects their daily lives. Interaction with the medical community seldom clarified understanding of the condition or improved its management. Three overriding themes emerged from the groups: a sense of frustration, a sense of isolation, and a search for a niche in the health/sick role continuum. Frustration was evident in the perceived inability to control symptoms, prevent episodes, identify episode triggers, and obtain medical validation of the condition. The constant anticipation of the next IBS episode, the need for immediate access to toilet facilities, and the nature of the bowel symptoms often required withdrawal from social activities and resultant isolation. Conclusions IBS is perceived as a chronic condition resulting in frustration and social isolation, and physicians are perceived to be providing inadequate medical information or support to patients with IBS.

The quality of physician-patient relationships. Patients' experiences 1996-1999.

Abstract: Background Our objective was to examine how patients of primary care physicians are responding to a changing health care environment. The quality of their relationship with their primary care physicians and their experience with organizational features of care were monitored over a 3-year period. Methods This was a longitudinal observational study (1996-1999). Participants completed a self-administered questionnaire at baseline and at follow-up. The questionnaires included measures of primary care quality from the Primary Care Assessment Survey (PCAS). We included insured adults employed by the Commonwealth of Massachusetts who remained with one primary care physician throughout the study period (n=2383). The outcomes were unadjusted mean scale score changes in each of the 8 PCAS over the 3 years and associated standardized difference scores (effect sizes). The 8 PCAS scales measured relationship quality (4 scales: communication, interpersonal treatment, physician's knowledge of the patient, patient trust) and organizational features of care (4 scales: financial access, organizational access, visit-based continuity, integration of care). Results There were significant declines in 3 of the 4 relationship scales: communication (effect size [ES] = -0.095), interpersonal treatment (ES = -0.115), and trust (ES = -0.046). Improvement was observed in physician's knowledge of the patient (ES = 0.051). There was a significant decline in organizational access (ES = -0.165) and an increase in visit-based continuity (ES = 0.060). There were no significant changes in financial access and integration of care indexes. Conclusions The declines in access and 3 of the 4 indexes of physician-patient relationship quality are of concern, especially if they signify a trend.

Validation of a single screening question for problem drinking.

Abstract: OBJECTIVE: The researchers hoped to confirm the sensitivity and specificity of a single screening question for problem drinking: "When was the last time you had more than X drinks in 1 day?", where X=4 for women and X=5 for men. STUDY DESIGN: Cross-sectional study. POPULATION: Adult patients presenting to 3 emergency departments in Boone County, Missouri, for care within 48 hours of an injury. OUTCOMES MEASURED: The answers to the question were coded as never, more than 12 months ago, 3 to 12 months ago, and within the past 3 months. Problematic drinking was defined as either hazardous drinking (identified by a 29-day retrospective interview) or a past-year alcohol use disorder (defined by questions from the Diagnostic Interview Schedule). RESULTS: There was a 70% participation rate. Of 2517 interviewed patients: 29% were hazardous drinkers; 20% had a past-year alcohol use disorder; and 35% had either or both. Considering "within the last 3 months" as positive, the sensitivity of the single question was 86%, and the specificity was 86%. In men (n=1432), sensitivity and specificity were 88% and 81%; in women, 83% and 91%. Using the 4 answer options for the question, the area under the receiver-operating characteristic curve was 0.90. Controlling for age, sex, tobacco use, injury severity, and breath alcohol level in logistic regression models changed the findings minimally. CONCLUSIONS: A single question about the last episode of heavy drinking has clinically useful sensitivity and specificity in detecting hazardous drinking and alcohol use disorders.

Sexual problems of male patients in family practice.

Abstract: Objectives Little is known about men's expectations of their family physicians regarding sexual disorders. Our goal was to evaluate the frequency of sexual problems among male patients in family practice and to assess their need for help. Study design We performed a cross-sectional survey based on structured questionnaires answered by patients and physicians in German family practices. Population We approached 43 family physicians; 20 (43%) participated. On a single day all men 18 years and older visiting the participating practices were approached, and 307 (84%) took part in the survey. Outcomes measured Patients were asked about their frequency and type of sexual problems, their need for help, and their expectations of their physicians. The physicians described their perceptions and management of sexual problems in family practice. Results Nearly all patients (93%) reported at least 1 sexual problem from which they suffered seldom or more often. The most common problems were low sexual desire (73%) and premature ejaculation (66%). Occupational stress was considered causative by more than half of the men (107/201). Forty-eight percent considered it important to talk with their physicians about sexual concerns. However, most physicians initiated a discussion about sexual concerns only seldom or occasionally. There was a nonsignificant correlation between the physicians' assumed knowledge and the patients' wish to contact them in case of sexual problems (rho=0.26). Conclusions The high frequency of self-reported sexual disorders and the hesitancy of family physicians to deal with this topic signals a neglected area in primary health care. Certain conditions, such as occupational stress, which may be associated with sexual concerns, should encourage the physician to initiate discussions about sexuality.

Addressing multiple problems in the family practice office visit.

Abstract: OBJECTIVES The purpose of the study was to describe the number of problems addressed during family practice outpatient visits, the nature of additional problems raised, how they affect the duration of the visit, and how well they are reflected in the billing record. STUDY DESIGN Cross-sectional. POPULATION We studied a total 266 randomly selected adult patient encounters representing 37 physicians. OUTCOMES MEASURED A problem was defined as an issue requiring physician action in the form of a decision, diagnosis, treatment, or monitoring. Visit duration and the number of billing diagnoses were also assessed. RESULTS On average, 2.7 problems and 8 physician actions were observed during an encounter. More than one problem was addressed during 73% of the encounters; 36% of these additional problems were raised by the physician and 58% by the patient. On average, each additional problem increased the length of the visit by 2.5 minutes (P<.001). The concordance between the number of problems observed and the number of problems on the billing sheet indicated a trend toward underbilling the number of problems addressed. CONCLUSIONS Multiple problems are commonly addressed during family practice outpatient visits and are raised by both the physicians and the patients. Our findings suggest that current views of physician productivity and the billing record are poor indicators of the reality of providing primary care.

Why some cancer patients choose complementary and alternative medicine instead of conventional treatment.

Abstract: Objectives We examined cancer patients' reasons for declining all or part of recommended cancer treatment and choosing complementary and alternative medicine (CAM). Study design This was a qualitative interview study. Population Fourteen cancer survivors who reported having declined all or part of the recommended conventional treatment (surgery, chemotherapy, or radiation) were included. The participants were a subset from a multi-ethnic (Asian, Native Hawaiian, and white) group of 143 adults diagnosed with cancer in 1995 or 1996 who were recruited through a population-based tumor registry and interviewed about CAM. Outcomes measured We performed semistructured interviews regarding experience with conventional cancer treatment and providers, use of CAM, and beliefs about disease. Results All participants used 3 or more types of CAM, most commonly herbal or nutritional supplements. Across the board, participants stated that their reason for declining conventional treatment was to avoid damage or harm to the body. The majority of participants also felt that conventional treatment would not make a difference in disease outcome, and some but not all participants perceived an unsatisfactory or alienating relationship with health care providers. Some participants reported that their discovery of CAM contributed to their decision to decline conventional treatment, and participants generally perceived CAM as an effective and less harmful alternative to conventional treatment. Conclusions Cancer patients may benefit from interventions (eg, patient education, improvements in physician-patient communication, and psychologic therapy) to facilitate treatment decision making through increased understanding of conventional and CAM treatments and to identify barriers to treatment for individual patients.

Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population

Abstract: Objective Our goal was to compare the prevalence of mental illness and its impact on functional status in an indigent uninsured primary care population with a general primary care sample. We also hoped to assess patient preferences about mental health and medical service integration. Study design We compared a survey of consecutive primary care adults in April and May 1999 with a 1997-98 survey of 3000 general population primary care patients. Both studies used the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and the 20-question Medical Outcomes Study Short Form. Population The patients were from a private nonprofit primary care clinic in Grand Junction, Colorado, that served only low-income uninsured people. We approached a total of 589 consecutive patients and enrolled 500 of them. Main outcome measure The main outcomes were the prevalence of psychiatric illnesses and the relationship with functional impairment. We compared our findings with a more generalizable primary care population. Results This low-income uninsured population had a higher prevalence of 1 or more psychiatric disorders (51% vs 28%): mood disorders (33% vs 16%), anxiety disorders (36% vs 11%), probable alcohol abuse (17% vs 7%), and eating disorders (10% vs 7%). Having psychiatric disorders was associated with lower functional status and more disability days compared with not having mental illness. Patients indicated a preference for mental health providers and medical providers to communicate about their care. Conclusions This low-income uninsured primary care population has an extremely high prevalence of mental disorders with impaired function. It may be important in low-income primary care settings to include collaborative care designs to effectively treat common mental disorders, improve functional status, and enhance patient self-care.

Direct observation of smoking cessation activities in primary care practice.

Abstract: OBJECTIVE Our goals were to determine how often family physicians incorporate smoking cessation efforts into routine office visits and to examine the effect of patient, physician, and office characteristics on the frequency of these efforts. STUDY DESIGN Data was gathered using direct observation of physician-patient encounters, a survey of physicians, and an on-site examination of office systems for supporting smoking cessation. POPULATION We included patients seen for routine office visits in 38 primary care physician practices. OUTCOMES MEASURED The frequency of tobacco discussions among all patients, the extent of these discussions among smokers, and the presence of tobacco-related systems and policies in physicians' offices were measured. RESULTS Tobacco was discussed during 633 of 2963 encounters (21%; range among practices = 0%-90%). Discussion of tobacco was more common in the 58% of practices that had standard forms for recording smoking status (26% vs 16%; P=.01). Tobacco discussions were more common during new patient visits but occurred less often with older patients and among physicians in practice more than 10 years. Of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Although 68% of offices had smoking cessation materials for patients, few recorded tobacco use in the "vital signs" section of the patient history or assigned smoking-related tasks to nonphysician personnel. CONCLUSIONS Smoking cessation practices vary widely in primary care offices. Strategies are needed to assist physicians with incorporating systematic approaches to maximize smoking cessation rates.

Improving depression care: barriers, solutions, and research needs.

Abstract: Potential solutions for barriers to improved organization of care of depressive illness were identified. These included (1) aligning efforts to improve depression care with broader strategies for improving care of other chronic conditions; (2) increasing the availability of depression case management services in primary care; (3) developing registries and reminder systems to ensure active follow-up of depressed patients; (4) achieving agreement on how depression outcomes should be measured to provide outcomes-based performance standards; (5) providing greater support from mental health specialists for management of depressed patients by primary care providers; (6) campaigns to reduce the stigma associated with treatment of depressive illness; (7) increased dissemination of interventions that activate and empower patients managing a depressive illness; (8) redefining the lack of time of primary care providers for high-quality depression care as issues in organization of care and provider training; and (9) development of incentives (organizational or financial) for high-quality depression care. Research needs were identified according to what has been learned to date. Identified research needs included: studies of approaches to organization of case management, research in new populations (e.g., new diagnostic groups, rural populations, the disadvantaged, the elderly, and those with chronic medical illnesses), research on stepped care and relapse prevention strategies, evaluation of the societal benefits of improved depression care, and multisite trials and meta-analytic approaches that can provide adequate statistical power to assess societal benefits of improved care.

Introducing telemedicine technology to rural physicians and settings.

Abstract: Objective The researchers investigated rural health providers' perceptions of telemedicine, developed a framework for assessing their readiness to adopt this type of technology, and offered a guide for its implementation. Study design Qualitative data were collected from semistructured interviews with thematic analysis. Population The study population included physicians, nurses, and administrative personnel located in 10 health care practices in 4 communities in 3 rural Missouri counties. Outcomes measured The researchers measured how often health providers used telemedicine technology and their perceptions of the advantages, disadvantages, barriers, and facilitators involved in adopting it. Results Participants varied widely in their perceptions of telemedicine. Providers in practices affiliated with the university's tertiary center were more likely to use it than were those in private practice. Interviews and other data yielded 6 themes related to a provider's receptivity to technological change: These themes were turf, efficacy, practice context, apprehension, time to learn, and ownership. Each theme applies to the computer and videoconferencing components of telemedicine, and each may operate as a perceived barrier or facilitator of change. Conclusions Care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, when deciding whether and how fast to adopt telemedicine. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to health care providers, staff, and communities.

The Accuracy of Physical Diagnostic Tests for Assessing Meniscal Lesions of the Knee: A Meta­Analysis

Abstract: OBJECTIVE. Our systematic review summarizes the evidence about the accuracy of physical diagnostic tests for assessing meniscal lesions of the knee. SEARCH STRATEGY. We performed a literature search of MEDLINE (1966-1999) and EMBASE 1988- 1999) with additional reference tracking. SELECTION CRITERIA. Articles written in English, French, German, or Dutch that addressed the accuracy of at least one physical diagnostic test for meniscus injury with arthrotomy, arthroscopy, or magnetic resonance imaging as the gold standard were included. DATA COLLECTION AND ANALYSIS. Two reviewers independently selected studies, assessed the rnethodologic quality, and abstracted data using a standardized protocol. MAIN RESULTS. Thirteen studies (of 402) met the inclusion criteria. The results of the index and reference tests were assessed independently (blindly) of each other in only 2 studies, and in all studies verification bias seemed to be present. The study results were highly heterogeneous. The summary receiver operating characteristic curves of the assessment of joint effusion, the McMurray test, and joint line tenderness indicated little discriminative power for these tests. Only the predictive value of a positive McMurray test was favorable. CONCLUSIONS. The methodologic quality )f studies addressing the diagnostic accuracy of meniscal tests was poor, and the results were highly heterogeneous. The poor characteristics indicate that these tests are of little value for clinical practice.

A Randomized Controlled Trial of Telephone Management of Suspected Urinary Tract Infections in Women

Abstract: OBJECTIVE Although urinary tract infections (UTIs) in otherwise healthy ambulatory women are often managed over the telephone, there has been no systematic evaluation of this approach. Our objective was to compare the outcomes of uncomplicated UTIs in healthy women managed over the telephone with those managed in the office. STUDY DESIGN We randomly assigned women calling their usual provider with a suspected UTI to receive care over the telephone (n=36) or usual office-based care (n=36). All women had urinalyses and urine cultures. All were treated with 7 days of antibiotics. We compared symptom scores at baseline and at day 3 and day 10 after therapy. We also compared patient satisfaction at the end of the study. The settings were family practices in Michigan. POPULATION We included healthy nonpregnant women older than 18 years. RESULTS A total of 201 women with suspected UTIs called their physician. Of these, 99 were ineligible, and 30 declined to participate. The women were young (mean age=36.6 years) and predominantly white (86%). Sixty-four percent of the urine cultures had significant growth of a single organism. We observed no difference in symptom scores or satisfaction. Overall, satisfaction was high. CONCLUSIONS Short-term outcomes of managing suspected UTIs by telephone appear to be comparable with usual office care.

The economic impact of wasted prescription medication in an outpatient population of older adults.

Abstract: The causes and costs of outpatient medication waste are not known. We report the results of a cross-sectional pilot survey of medication waste in a convenience sample of 73 New Hampshire retirement community residents aged 65 years or older. We used questionnaires and in-home pill counts to determine the annual occurrence of medication waste, defined as no intention to take leftover medicines prescribed within the past year. Mean individual annual cost of wasted medication was $30.47 (range = $0-$131.56). Waste represented 2.3% of total medication costs. The main causes for waste included: resolution of the condition for which the medication was prescribed (37.4%), patient-perceived ineffectiveness (22.6%), prescription change by the physician (15.8%), and patient-perceived adverse effects (14.4%). Individual costs were modest, but if $30 per person represents a low estimate of average annual waste, the US national cost for adults older than 65 years would top $1 billion per year.

Does the family APGAR effectively measure family functioning

Abstract: Background The Family APGAR has been widely used to study the relationship of family function and health problems in family practice offices. Methods Data were collected from 401 pediatricians and family physicians from the Pediatric Research in Office Settings network and the Ambulatory Sentinel Practice Network. The physicians enrolled 22,059 consecutive office visits by children aged 4 to 15 years. Parents completed a survey that included the Family APGAR and the Pediatric Symptom Checklist. Clinicians completed a survey that described child psychosocial problems, treatments initiated or continued, and specialty care referrals. Results Family dysfunction on the index visit often differed from dysfunction at follow-up (kappa=0.24). Only 31% of the families with positive Family APGAR scores at baseline were positive at follow-up, and only 43% of those with positive scores at follow-up had a positive score at the initial visit. There were many disagreements between the Family APGAR and the clinician. The Family APGAR was negative for 73% of clinician-identified dysfunctional families, and clinicians did not identify dysfunction for 83% of Family APGAR-identified dysfunctions (kappa=0.06). Conclusions Our data do not support the use of the Family APGAR as a measure of family dysfunction in the primary care setting. Future research should clarify what it does measure.

Process evaluation of a tailored multifaceted approach to changing family physician practice patterns improving preventive care.

Abstract: Background We conducted a process evaluation of a multifaceted outreach facilitation intervention to document the extent to which the intervention was implemented with fidelity. We also hoped to gain insight into how facilitation worked to improve preventive performance. Methods We used 5 data collection tools to evaluate the implementation of the intervention, and a combination of descriptive, quantitative, and qualitative analyses. Triangulation was used to attain a complete understanding of the quality of implementation. Twenty-two intervention practices with a total of 54 physicians participated in a randomized controlled trial that took place in Southwestern Ontario, Canada. The key measures of process were the frequency and time involved to deliver intervention components, the scope of the delivery and the utility of the components, and physician satisfaction with the intervention. Results Of the 7 components in the intervention model, prevention facilitators (PFs) visited the practice most often to deliver the audit and feedback, consensus building, and reminder system components. All the study practices received preventive performance audit and feedback, achieved consensus on a plan for improvement, and implemented a reminder system. Ninety percent of the practices implemented a customized flow sheet, and 10% used a computerized reminder system. Ninety-five percent of the intervention practices wanted critically appraised evidence for prevention, 82% participated in a workshop with opinion leaders in preventive care, and 100% received patient education materials in a binder. Content analysis of the physician interviews and bivariate analysis of physician self-reported changes between intervention and control group physicians revealed that the audit and feedback, consensus building, and development of reminder systems were the key intervention components. Ninety-five percent of the physicians were either satisfied or very satisfied with the intervention, and 90% would have been willing to have the PF continue working with their practice. Conclusions Primary care practices in Ontario can implement significant changes in their practice environments that will improve preventive care activity with the assistance of a facilitator. The main components for creating change are audit and feedback of preventive performance, achieving consensus on a plan for improvement, and implementing a reminder system.