Costs associated with office visits for diarrhea in infants and toddlers.

We determined costs associated with diarrhea in a < 36-month-old ambulatory population. Children with acute diarrhea were enrolled during the rotavirus season at three centers. Questionnaires to assess costs of both medical and nonmedical factors were administered at the enrollment visit and 1 week later. Office computer records were reviewed to identify all visits by children with diarrhea during 1 year. Fifty-one patients were enrolled. The average cost per episode of diarrhea was $289, which included: $144, missed work; $57, office visits; $23, laboratory tests; $21, medications; $18, changed diet/oral rehydration solutions; $15, travel; $7, extra diapers; and $6, extra child care. During 1 year diarrhea accounted for 4% of all visits and 10% of visits among those < 36 months old. The annual cost at the three centers was $346,000, which extrapolates to $0.6 to $1.0 billion for the United States. Twenty-one percent of this cost was attributable to rotavirus diarrhea. We conclude that outpatient care for pediatric diarrhea is a major health care cost in the United States.

Integrating early clinical experience curricula at two medical schools: lessons learned from the Robert Wood Johnson Foundation's Generalist Physician Initiative.

The University of Texas Medical Branch and Eastern Virginia Medical School have created community-based generalist clinical experiences early in the first two years of medical school as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. This article describes these experiences and related curricula, outlining the common elements and differing approaches at the two institutions. It discusses the success of the new curriculum, presenting information from performance measures and surveys of students, clerkship directors, and faculty involved in the programs, and it describes further evaluative studies being planned. The authors discuss nine lessons learned and their conclusion that early clinical experience with generalist physicians is an important element of generalist curriculum reform. It improves student satisfaction with the first two years' experience and provides a structure for teaching patient-centered, integrated clinical medicine, which is important in the general professional education of all students. Whether or not the long-term goal of increasing students' interest in generalist careers is realized, incorporating early clinical experiences with generalists into a curriculum has positive effects on students, faculty, and the overall curriculum.

Giardia antigen detection in patients with chronic gastrointestinal disturbances.

BACKGROUND: Giardia lamblia, a protozoan parasite, is transmitted by cysts in contaminated water or food or by person-to-person contact. The standard in diagnosis has been the microscopic demonstration of fecal cysts, which yields many false negatives due to high variability in cyst excretion. A new method that detects infection even when few parasites are present is now available. This immunodiagnostic test is rapid, sensitive, and specific, and typically requires only a single stool specimen. In this study patients with gastrointestinal (GI) complaints were screened for Giardia antigens, and the test results were compared to conventional microscopy. Costs incurred by patients with chronic GI problems were documented. METHODS: Twelve patients with GI complaints were tested for Giardia by microscopy and 13 patients by the immunodiagnostic test. Patient charts were evaluated for pertinent history and the diagnostic tests ordered before giardiasis was considered. RESULTS: For all patients, microscopy was uniformly negative, but 6 of 13 patients were antigen positive. Patients with chronic complaints, later found to test positive for Giardia, typically underwent five diagnostic tests at a cost of $338. CONCLUSIONS: Giardiasis, an increasing problem in family practice, should be considered early in patients with GI disturbances. New, sensitive immunodiagnostic tests that usually require a single specimen are more useful than microscopy. Prompt diagnosis of giardiasis not only relieves patients of unpleasant symptoms, but can avoid unnecessary and costly evaluations.

Impact of the Americans with Disabilities Act on family physicians.

The Americans with Disabilities Act of 1990 prohibits discrimination against persons with disabilities in employment, government services, public accommodations, public transportation, and telecommunications. This article reviews the impact of the law on the practice of family physicians. Pre-employment medical evaluations are prohibited by law, but medical evaluations may be performed after an offer of employment and before job assignment has been made. Employment may be conditional on results only if medical confidentiality is protected, and exclusionary criteria are job related, applied universally, and do not discriminate against individuals with disabilities. The law provides that persons with disabilities will have equal access to medical care, through prohibiting discrimination based on disability and through the design and construction of medical offices. The law requires physicians who are covered by the law to make reasonable accommodations so that qualified employees and applicants can perform the essential functions of a job.

Preemployment evaluations: dilemmas for the family physician.

Preemployment evaluations present primary care physicians with numerous medical, ethical, and legal dilemmas. These examinations are especially problematic for community-based primary care providers unaccustomed to standards used by physicians in occupational settings. In response to a mailed questionnaire, 255 family physicians and general practitioners described their current methods of performing these examinations. Forty percent reported that employers routinely provide no information about the job for which the prospective employee is being evaluated. Respondents differed according to number and type of laboratory tests routinely included as part of a preemployment evaluation and in the proportion of prospective employees disqualified on the basis of the examination. Twenty-four percent reported no disqualifications, and 34 percent disqualified 5 percent or more. The percentage reporting medical and psychological information also varied. One-half routinely reported alcohol and drug abuse to employers, and of these, only one-half obtained a waiver for the release of such information. Five of every 6 physicians believed that it was more important to "tell the truth to the employer" than to "protect the interests of the employee." Our findings show that no consensus exists among the primary care physicians in our survey about the performance of preemployment evaluations. Because this can have serious consequences to workers, employers, and physicians, we propose guidelines for primary care physicians who perform preemployment evaluations.

Prevention of hepatitis B virus infection.

Hepatitis B virus infection is the most important cause of acute and chronic liver disease worldwide. The Immunization Practices Advisory Committee has proposed a comprehensive strategy to eliminate the transmission of hepatitis B virus in the United States. The three phases of this strategy are prevention of perinatal transmission of the hepatitis B virus, universal vaccination of all infants against hepatitis B virus infection and selected vaccination of high-risk adolescents and adults. Because family physicians provide obstetric, perinatal, adolescent and adult care, they can have a major influence on the success of this strategy.

Patient satisfaction and selected physician behaviors: does the type of practice make a difference?

This study was designed to show what specific physician characteristics lead to patient satisfaction and to compare satisfaction of patients using either prepaid or fee-for-service modes of payment within the same settings. We surveyed 1142 patients in five family practice clinics in rural and suburban areas of the North Central United States. Regression analysis of a seven-item satisfaction scale showed four significant factors that accounted for variance: sensitivity, is on time for appointments, follows up promptly, and provides personalized medical care. No meaningful differences were found between health-maintenance-organization and fee-for-service patients on these satisfactions. This study expands findings from previous research and raises more questions about reliable rating scales for complex physician/patient relations. Our methods can be used to investigate the effects of newer types of prepaid plans (including individual practice associations and preferred provider organizations) on patient satisfaction. The challenge for future investigations is to test and build reliable predictive models showing how physician characteristics, patient satisfaction, and quality of medical care affect each other in these more complex models of practice and reimbursement.

Improving prescription documentation in the ambulatory setting.

Use of a standard prescription pad, although it adequately meets the needs of drug delivery, requires the physician to document prescribed medications separately in the medical record. Failure to do so may lead to under-recognition of problems of potential drug interactions and adverse drug reactions, delays in prescription refills, and other areas of quality of care, especially in a setting where multiple physicians may be involved in the care of a patient. Of 83 prescriptions written in a primary care clinic, only 11 (13%) were noted on the chart medication form when physicians used prescription pads. Implementation of a "one-write" noncarbon prescription form that generated an instant copy increased prescription documentation to 83% (49 of 59 prescriptions) (x2 = 68.86; p < 0.005) over a one-week period. In a follow-up study conducted approximately 3.5 years after the initial intervention, use of the "one-write" form had maintained at 82% prescription documentation (32 of 39) prescriptions) (x2 = 52.05; p < 0.005). A "one-write" copy system could improve clinical care by improving medication documentation in the medical record.

Comparison of heterotypic protection against influenza A/Taiwan/86 (H1N1) by attenuated and inactivated vaccines to A/Chile/83-like viruses.

Children (n = 192) aged 3-19 years from 98 families completed this double-blind, placebo-controlled study comparing the efficacy of a bivalent attenuated (CR) vaccine with trivalent inactivated (TI) vaccine. Both vaccines contained A/Chile/83 (H1N1)-like antigens. After vaccination the geometric mean titer to A/Taiwan/86 (H1N1) was 1:36 in the CR group, 1:92 in the TI group, and 1:5 in the placebo group. During the influenza A/Taiwan/86 (H1N1) epidemic, 21.4% of CR recipients, 16.7% of TI recipients, and 43.9% of placebo recipients were infected with influenza A/Taiwan. TI vaccine provided better heterotypic protection than did CR vaccine for children aged 10-18 years (infection rate, 0 vs. 24%, respectively; P less than .025); in contrast, in the younger children (3-9 years), CR vaccine tended to be more protective (19% vs. 26% for TI).