Relationship between patient race and survival following admission to intensive care among patients of primary care physicians.

This study investigated the existence of racial differences in the survival of patients admitted to intensive care by family physicians and general internists for circulatory illnesses. The study population consisted of 249 consecutive patients admitted by these specialists to an ICU in a tertiary care hospital in Pitt County, North Carolina, during the June 1985 to June 1986 period. Logistic regression was used to specify the unique effect of race on ICU patient survival in-hospital, controlling for potential confounding factors such as disease severity, type of health insurance, and case mix. Black patients were almost three times more likely than white patients to die in-hospital following admission to the ICU (RR = 2.9, 95 percent I = 1.5, 5.6). Most of this difference in survival was explained by racial differences in disease severity.

A classification of developmental activities of academic family medicine supported by federal grants.

Substantial funds have been awarded to academic departments of family medicine through the federal Establishment of Departments of Family Medicine grants program, initiated in 1980 under the Public Health Service Act. In 1989 the authors analyzed the successful grant applications in a sample of 61 institutions variously funded or re-funded for the grant cycles from 1980 through 1986 in order to classify the supported developmental activities. Three dimensions for explicating this activity emerged: (1) the functional area of the activity (e.g., curricular development); (2) the objectives of the activity (e.g., improving relevance of instruction); and (3) the strategies to be used to attain the objectives (e.g., addition of specialized faculty). This classification scheme provides a tentative but useful framework for characterizing departmental development.

Teaching clinical decision making in a family practice clerkship.

Limited health care resources and other social factors are making clinical decision making (CDM) a necessary subject of study for medical students. However, CDM material is technical and could be perceived by students as arcane. This study evaluated student attitudes toward a CDM module imbedded in a third-year medical student (MSIII) family medicine clerkship. A survey instrument was used for the evaluation and included a within-subject check for response consistency. The results show that MSIIIs feel that technical CDM material is within their grasp and that it is relevant to their day-to-day care of patients.

Absence of longitudinal changes in rheumatologic parameters after silicone breast implantation: a prospective 13-year study.

There have been numerous questions regarding the association of polysiloxane with connective tissue disease and alteration of host immune response. C-reactive protein, rheumatoid factor, and anti-streptolysin-O titers were measured in 218 patients. These studies are routinely used in the diagnosis of autoimmune disease and mixed connective tissue disease. This prospective study has been in progress since 1985. The first patients were seen in July of 1985, and those individuals willing to participate were followed from 1985 to 1998. The implants included saline-filled elastomer shells and polysiloxane gel-filled elastomer shells. These groups were examined separately and in combination for changes between preoperative and postoperative states. In each instance, there was no statistical increase or decrease. Each patient underwent a physical examination and completed a questionnaire focusing on signs and symptoms of autoimmune and connective tissue diseases. The laboratory data and subjective clinical results demonstrated no significant differences between a nonimplanted group versus the saline group alone, the gel group alone, or the combined groups. The data failed to suggest any causal relationship between implants and autoimmune or connective tissue diseases over the study period of 13 years (since 1985).

Assessment of the Federal Grant Program for the Establishment of Departments of Family Medicine.

As part of an evaluation of the Federal Establishment of Departments of Family Medicine Grant Program, nine departments of family medicine were visited from March to May 1988 to assess their development in the academic setting and to evaluate the role of the federal program in that developmental process. The study found that grant support has been useful in enhancing the status of family medicine by aiding research and curriculum development, supporting administrative infrastructure, and fostering other topics specific to individual departments. The flexibility with which departments can seek funds for specific needs makes broad measures of success impractical; however, it appears that funds from this grant program have been reasonably effective in advancing the academic stature of departments of family medicine. It is concluded from the study that the program should be continued and that its inherent flexibility should be preserved.

Circumcision: a decision analysis of its medical value.

Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions.

Process and outcome of critical care provided by community and academic primary care physicians.

Academic and community physicians traditionally have conducted their practices in separate settings. This study compared the process and outcome of critical care admissions of patients at one hospital by primary care physicians who were either in full-time academic positions or in community based practice. The comparison showed that community physicians treated an older patient population with a different diagnostic mix. Although the community physicians tended to serve older patients with Medicare coverage, the major difference between the two groups was that academic physicians requested 50% more consultations than community physicians (.86 and .56 consultations per admission, respectively). Analysis of outcome measures, such as survival time, readmission rate, and death rate, showed no differences. Survival analysis showed the risk of death to be significantly higher for patients of academic physicians (relative risk = 1.46, C1 = 1.07, 2.00). Other factors contributing significantly to the risk of death included severity of illness, patient age and race, and digestive diseases. The apparent differences in patient outcome between the two groups of physicians are more likely related to underlying differences in the patients than in the clinical approaches of their physicians.

Physician-related influences on use of health resources by primary care physicians.

With the increasing supply of physicians, speculation has focused on possible actions physicians might take to increase use of services (e.g., office visits, laboratory use, prescriptions, or referrals), thus adding to spiraling health care costs. A survey of primary care physicians--pediatricians, internists, and family physicians--was conducted to assess physician-related factors associated with health resource use. The most consistent factors found to explain the variance among physicians in use of these health resources were the number of years in practice, whether they graduated from a foreign medical school, government employment, self-assessed practice style, whether they were family physicians, and sex. There was no evidence that physician income, desire for income, or pace of practice had any effect on the amount of services physicians used in the "care" of the patients in the hypothetical cases. These findings suggest that if physicians induce demand for services in primary care, it is a minor factor in the increase of health care costs.

The effect of faculty private practice experience on appropriate charging for professional services.

Private practice experience is widely considered invaluable for academic family physicians, especially for clinical efficiency and for charging appropriately for professional services. This study tested the hypothesis that faculty members with private practice experience charged more appropriately for professional services. Patient-physician encounters were rated in terms of propriety of charges by consensus of two faculty physicians and compared to the actual level of service marked on the encounter form. Private practice experience for faculty resulted in less undercharging (21% of encounters undercharged versus 31% for faculty without that experience, P = .03). Physicians with private practice experience undercharged on average $.36 per encounter, versus $1.94 for providers without that experience (Kruskal-Wallis test, P = .27). Physicians with private practice experience also tended to perform more procedures but not to bill for more. Academic family physicians with private practice experience demonstrated more appropriate billing practices for professional services, but ideally preference for this type of academic physician should be based on other attributes, such as breadth of experience and efficiency in patient care.

Clinical use of decision analysis.

An introduction to the theory and practice of clinical decision analysis, including decision trees and rudimentary cost-effectiveness calculations. A brief review of several published articles is also included.

A glossary of medical decision-making terms.

Many of the terms used in medical decision making are foreign to clinicians. This problem creates a barrier that can prevent physicians from acquiring these new clinical tools. This glossary contains definitions of the most common terms as well as examples of their usage by using Down syndrome as the illustrative condition.

Chloride:phosphate ratio with hypercalcemia secondary to thiazide administration.

The chloride:phosphate ratio is of only limited value in aiding the clinician in the differential diagnosis of hypercalcemia. The use of thiazide diuretics may cause hypercalcemia with a chloride:phosphate ratio said to be consistent with a diagnosis of primary hyperparathyroidism. Parathormone assay remains the "gold standard" for definitive diagnosis of hyperparathyroidism.

Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines.

BACKGROUND: Managed care organizations are focusing on how physicians manage their patients with diabetes mellitus as an indicator of physician compliance with clinical practice guidelines. Assessment of physician compliance with published guidelines may reveal areas of disagreement between physicians and guidelines or between physicians and patients and may show areas for potential improvement of care. Compliance with the diabetes care guidelines was assessed in our clinics to determine physician beliefs and performance and patients' accommodation of recommended practices. METHODS: We interviewed 295 patients with diabetes and surveyed 47 providers at an academic family practice center to assess practices and beliefs regarding the care of patients with diabetes. We also reviewed a 1-year compilation of billing and referral records for physician use of glycosylated hemoglobin (hemoglobin A1c) testing and referral of patients for eye examinations. RESULTS: We found that physician beliefs and practices were divergent and that provider performance of these nationally recommended activities was low. More than 75% of providers said that they recommended hemoglobin A1c testing, but only about 50% of patients had a documented test in the billing system. When questioned, one third of the patients reported that their physicians recommended this test. Similarly, nearly all physicians stated that they recommended annual eye examinations, although only 43% of patients said that their primary care physician recommended this referral. CONCLUSIONS: Physicians can and must improve intervention and patient education in the care of diabetic patients. Patient knowledge, motivation, and practice must be augmented by physician efforts. Lack of compliance with guidelines may indicate deficiencies in physician knowledge, implementation problems, lack of belief in guidelines, or problems in patient compliance. Attention should be directed to all these areas.

Evaluation of standards of practice for primary care physicians using 12 hypothetical cases.

Concerns about the quality of medical care are increasing. As quality of medical care is difficult to measure, physicians have relied on standards based on research, consensus, or personal experience. The authors surveyed primary care physicians in Missouri to determine the presence and extent of standards of care for 12 hypothetical cases. The results demonstrate that within and between diagnoses there is both consensus and disagreement in case management. A standard of practice can be inferred for those management options achieving consensus. Further research is indicated for those options generating considerable disagreement to resolve the discrepancies in standards of care.

Outcomes of an insurance company-sponsored multichannel chemistry screening initiative.

BACKGROUND: The use of serum chemistry panels as screening tests has been studied in a variety of clinical and nonclinical settings. None of the studies, however, has attempted to carefully examine any potential harm done to participants, and none has measured the impact on health-related quality of life. METHODS: Consenting participants in an insurance company-sponsored screening initiative completed a questionnaire before and 6 months after having blood drawn for a 25-item chemistry panel and a lipid profile; for men older than 50, a prostate-specific antigen (PSA) test was also done. The prescreening questionnaire included demographic and health information. The postscreening questionnaire included questions about specific outcomes. Included in both questionnaires were single-item measures of self-rated health and self-rated worry about health, and the 17-item Duke Health Profile (DUKE), a measure of health-related quality of life. Various outcomes were examined, including the numbers of new diagnoses, numbers and types of new treatment recommendations, change in self-reported health and worry, and change in DUKE subscale scores. Participants who were potentially helped and those who were potentially harmed by the serum chemistry panels screening program were identified and further characterized. RESULTS: Of the 2249 subjects who satisfactorily completed both questionnaires, 2012 (89%) had at least one abnormal test result, but only 985 of these (49%) remembered having discussed their test results with a physician. A total of 342 individuals received new treatment advice. However, 29 (10%) of them indicated that they would be "somewhat unlikely" to "very unlikely" to follow it. Following the intervention questionnaire, there were statistically significant average decrements in the General Health, Physical Health, and Pain subscales of the DUKE for participants with abnormal results. Self-rated health status did not change but level of worry about health increased significantly. At least 250 (11%) subjects were potentially helped by the screening initiative, but at least 574 (26%) were potentially harmed by it. CONCLUSIONS: The use of serum chemistry panels as screening tests in nonclinical settings should probably be discouraged, since health-related quality of life is not improved and the intervention may harm more individuals than it benefits.

Accuracy of patient encounter and billing information in ambulatory care.

BACKGROUND: This study examined the degree of accuracy of billing data in an academically affiliated family practice. METHODS: The progress notes from 1253 consecutive visits were independently reviewed by two family physicians, and the diagnoses, use of procedures, and level of service were determined for each visit. Discrepancies between the reviewers were resolved by consensus. These data were compared with the data on the corresponding billing form that had been completed by the care providers (ie, physicians on the faculty, physicians in training, family nurse practitioners, and nurses). RESULTS: There was poor agreement between the billing form and progress note on level of service and number of diagnoses (kappa = 0.37 and kappa = 0.28, respectively). The progress note usually indicated that a higher level of service should have been billed for a visit than actually was billed. Underreporting of the number of diagnoses was substantial; the billing forms listed only 69% of the diagnoses identified in the progress notes. In 60% of visits, each diagnosis on the billing form had a matching diagnosis in the progress note. This could be improved to 78% of visits if broad categories of disease were used. Residents were similar to faculty in the accuracy of reported level of service and types of diagnoses, but were more likely to underreport the number of diagnoses. CONCLUSIONS: Ambulatory care data from computerized billing files may not be sufficiently accurate for proper reimbursement of physician services or for use in research.

Test of cure for genital Chlamydia trachomatis infection in women.

Convenient, reliable tests of cure for genital chlamydial infections have not been evaluated. Cervical appearance, endocervical Gram stain, enzyme immunoassay, and culture for Chlamydia trachomatis were evaluated during a pretreatment visit and at two subsequent randomized test-of-cure visits for 64 nongravid women with endocervical C trachomatis of 3544 patients screened. There were no useful correlations between C trachomatis resolution and cervical appearance. Endocervical Gram stain was determined to be unreliable for test-of-cure use. Both C trachomatis culture and enzyme-linked immunosorbent assay (ELISA) were shown to be effective for test-of-cure evaluation. The ELISA test became reliably negative 10 days after initiation of treatment and 1 to 5 days after the clearance of viable organisms detected by culture (P = .03). Convenience and cost considerations favor antigen detection methods. This study suggests that antigen detection methods can be used for situations in which test of cure is indicated, such as therapy noncompliance, circumstances supporting reinfection, pregnancy, complicated infections, requests for psychological reassurance, and evidence of persistent cervicitis.

The determination and interpretation of reference intervals for multichannel serum chemistry tests.

BACKGROUND: When interpreting the results of clinical chemistry tests, physicians rely heavily on the reference intervals provided by the laboratory. It is assumed that these reference intervals are calculated from the results of tests done on healthy individuals, and, except when noted, apply to people of both genders and any age, race, or body build. While analyzing data from a large screening project, we had reason to question these assumptions. METHODS: The results of 20 serum chemistry tests performed on 8818 members of a state health insurance plan were analyzed. Subgroups were defined according to age, race, sex, and body mass index. A very healthy subgroup (n = 270) was also defined using a written questionnaire and the Duke Health Profile. Reference intervals for the results of each test calculated from the entire group and each subgroup were compared with those recommended by the laboratory that performed the tests and with each other. Telephone calls were made to four different clinical laboratories to determine how reference intervals are set, and standard recommendations and the relevant literature were reviewed. RESULTS: The results from our study population differed significantly from laboratory recommendations on 29 of the 39 reference limits examined, at least seven of which appeared to be clinically important. In the subpopulation comparisons, "healthy" compared with everyone else, old (> or = 75 years) compared with young, high (> or = 27.1) compared with low body mass index (BMI), and white compared with nonwhite, 2, 11, 10, and 0 limits differed, respectively. None of the contacted laboratories were following published recommendations for setting reference intervals for clinical chemistries. The methods used by the laboratories included acceptance of the intervals recommended by manufacturers of test equipment, analyses of all test results from the laboratory over time, and testing of employee volunteers. CONCLUSIONS: Physicians should recognize when interpreting serum chemistry test results that the reference intervals provided may not have been determined properly. Clinical laboratories should more closely follow standard guidelines when setting reference intervals and provide more information to physicians regarding the population used to set them. Efforts should be made to provide appropriate intervals for patients of different body mass index and age.

Screening for microalbuminuria to prevent nephropathy in patients with diabetes: a systematic review of the evidence.

OBJECTIVE: Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is effective according to the criteria developed by Frame and Carlson and those of the US Preventive Services Task Force. STUDY DESIGN: We searched the MEDLINE database (1966-present) and bibliographies of relevant articles. OUTCOMES MEASURED: We evaluated the impact of MA screening using published criteria for periodic health screening tests. The effect of the correlation between repeated tests on the accuracy of a currently recommended testing strategy was analyzed. RESULTS: Quantitative tests have reported sensitivities from 56% to 100% and specificities from 81% to 98%. Semiquantitative tests for MA have reported sensitivities from 51% to 100% and specificities from 21% to 100%. First morning, morning, or random urine sampling appear feasible. Assuming an individual test sensitivity of 90%, a specificity of 90%, and a 10% prevalence of MA, the correlation between tests would have to be lower than 0.1 to achieve a positive predictive value for repeated testing of 75%. CONCLUSIONS: Screening for MA meets only 4 of 6 Frame and Carlson criteria for evaluating screening tests. The recommended strategies to overcome diagnostic uncertainty by using repeated testing are based on expert opinion, are difficult to follow in primary care settings, do not improve diagnostic accuracy sufficiently, and have not been tested in a controlled trial. Although not advocated by the American Diabetes Association, semiquantitative MA screening tests using random urine sampling have acceptable accuracy but may not be reliable in all settings.

Analysis of resident and attending physician interactions in family medicine.

Clinical teaching does not fit neatly into traditional teaching-learning models. The interaction between a resident and an attending physician is of particular interest because it has several functions including education, supervision, socialization, and quality control. The purpose of this study was to observe, classify, and record verbal teaching and learning behaviors in the resident-attending physician interaction. During a 12-month period, 125 observations of resident-attending physician interactions were recorded; the average length of the interactions was 4.27 minutes. The six most frequent resident verbal behaviors compared by postgraduate year level did not vary significantly. Only one of the six most frequent attending physician verbal behaviors varied significantly. In the average interaction of about 4 minutes, three fourths of the interaction was on patient care issues, leaving little time for teaching. There are many unanswered questions about the resident-attending physician interaction and its contribution to the training of a physician.