Medical evaluation of psychiatric patients. I. Results in a state mental health system.

Thorough medical evaluation of 529 patients drawn from eight program categories in California's public mental health system revealed active, important physical disease in 200 patients who had 291 diseases. Fourteen percent of the patients had diseases known to themselves but not to the mental health system, and 12% of the patients had diseases newly detected by the study team. We estimate that of the more than 300,000 patients treated in the California public mental health system in fiscal year 1983 to 1984, 45% had an active, important physical disease. The mental health system had recognized only 47% of study patients' physical diseases, including 32 of 38 diseases causing a mental disorder and 23 of 51 diseases exacerbating a mental disorder. Patients treated in public sector mental health facilities should receive careful medical evaluations.

Screening women of childbearing age for human immunodeficiency virus. A cost-benefit analysis.

In light of the increasing problem of perinatal human immunodeficiency virus (HIV) transmission, the issue of screening women for HIV is receiving considerable attention. We analyzed the costs and benefits of screening women of childbearing age for HIV. The analysis was based on a dynamic model of the HIV epidemic that incorporated disease transmission and progression, behavioral changes, and effects of screening and counseling. We found that the primary benefit of screening programs targeted to women of childbearing age lies not in the prevention of HIV infection in their newborns but in the prevention of infection in their adult contacts. Because of this benefit, screening medium- and high-risk women is likely to be cost-beneficial over a wide range of assumptions about program cost and behavioral changes in response to screening.

The risks and benefits of childhood bacille Calmette-Guérin immunization among adults with AIDS. International MAC study groups.

OBJECTIVE: To define the risks of disseminated bacille Calmette-Guérin (BCG) or disseminated Mycobacterium tuberculosis in adults with AIDS who were immunized with BCG in childhood. DESIGN: HIV-infected patients with CD4 < 200 x 10(6)/l were enrolled from five study sites (New Hampshire, Boston, Finland, Trinidad and Kenya). Prior BCG immunization was determined and blood cultures for mycobacteria were obtained at study entry and at 6 months. Acid-fast bacilli were identified as Mycobacterium tuberculosis complex (MTBC) using DNA probes. MTBC isolates were then typed by both IS6110 restriction fragment length polymorphism and polymerase chain reaction/restriction enzyme analysis. SETTING: Most patients in New Hampshire and Finland were outpatients; most patients in Trinidad were inpatients with terminal illness; and most patients in Kenya were outpatients, although 44 were inpatients with terminal illness. PARTICIPANTS: A total of 566 patients were enrolled, including 155 with childhood BCG immunization; 318 patients had a single study visit and culture, and 248 patients had two study visits and cultures. MAIN OUTCOME MEASURES: Isolation and identification of mycobacteria from blood cultures. RESULTS: Blood cultures were positive for MTBC in 21 patients; none were positive for M. bovis BCG, and 21 were M. tuberculosis-positive. In Trinidad, seven (87%) out of eight isolates of M. tuberculosis were indistinguishable by IS6110 typing; BCG immunization was associated with a decreased risk of bacteremic infection with M. tuberculosis (P = 0.05). CONCLUSIONS: The risk of disseminated BCG among adult AIDS patients with childhood BCG immunization is very low. Childhood BCG immunization is associated with protection against bacteremia with M. tuberculosis among adults with advanced AIDS in Trinidad.

The international epidemiology of disseminated Mycobacterium avium complex infection in AIDS. International MAC Study Group.

OBJECTIVE: To determine rates of disseminated Mycobacterium avium complex (MAC) infection among AIDS patients in developed and developing countries, and to determine whether different rates reflect differences in exposure or immunity, or both. DESIGN: Prospective cohort study. SETTING: University hospitals and outpatient AIDS programs. METHODS: HIV-infected subjects with CD4 counts < 200 x 10(6)/l were interviewed and had CD4 lymphocyte counts, blood cultures for mycobacteria (baseline and at 6 months), and skin tests with purified protein derivative (PPD) and M. avium sensitin. RESULTS: Among 566 study patients rates of disseminated MAC were 10.5-21.6% in New Hampshire, Boston and Finland compared to 2.4-2.6% in Trinidad and Kenya (P < 0.001). PPD skin test reactions > or = 5 mm were present in 20% of patients from Kenya compared to 1% at other sites (P < 0.001). Among patients from the United States and Finland, multiple logistic regression indicated that occupational exposure to soil and water was associated with a decreased risk of disseminated MAC, whereas the following were associated with an increased risk of disseminated MAC: low CD4 count, swimming in an indoor pool, history of bronchoscopy, regular consumption of raw or partially cooked fish/shellfish and treatment with granulocyte colony-stimulating factor. CONCLUSIONS: Rates of disseminated MAC in AIDS are higher in developed than developing countries and are due to both differences in exposure and differences in immunity. These data provide a rationale for prevention of MAC through both active immunization and reduction in exposure to the organism.

Durability of improved physician early detection of cancer after conclusion of intervention support.

Physicians can potentially play an important role in the early detection of cancer. Interventions designed to encourage these activities have been shown to improve physician performance for up to 1 year. To assess their real value, improved physician performance must be judged over the longer term. The Cancer Prevention in Community Practice Project assisted a random subset of practices in implementing cancer early detection office systems. One year later, these practices were found to have provided more indicated breast and colorectal cancer early detection services than practices that did not receive assistance. This report addresses whether 12-month improvements in breast and colorectal cancer early detection were durable at 24 months despite no appreciable ongoing project support. A cross-sectional survey of 20-30 established patients/practice was conducted 24 months after the introduction of the intervention. These results were compared with base-line, 6-, and 12-month cross-sectional surveys to determine whether increases in indicated services and recommendations persisted. A longitudinal model for binomial data was used to quantitatively assess durability of effects. Ninety-nine practices participated, and 81 provided data at all 4 evaluation intervals. In office systems practices, improvements in stool occult blood testing and self breast examination recommendations to patients were maintained between 12 and 24 months while improvements in mammography recommendations and clinical breast examinations declined somewhat but remained superior to performance in control practices. Some improvements in physician early detection of cancer performance were maintained between 12 and 24 months. Future studies of physician behavior change should include follow-up beyond 12 months.

Using the patient's history to estimate the probability of coronary artery disease: a comparison of primary care and referral practices.

PURPOSE: According to probability theory, the interpretation of new information should depend on the prior probability of disease. We asked if this principle applies to interpreting the history in patients with chest pain. We compared the prevalence of coronary artery disease (CAD) in patients who had similar histories but who came from populations with different disease prevalence. PATIENTS AND METHODS: We studied two high-disease-prevalence populations (patients referred for coronary arteriography) and two low-disease-prevalence populations (patients from primary care practices). We used clinical characteristics of one arteriography population to develop a logistic rule for estimating the probability of coronary artery narrowing. The number of clinical findings determined the logistic score, which was proportional to the prevalence of CAD. RESULTS: The prevalence of CAD was much lower in the primary care population than in the arteriography population, even when patients with similar logistic scores, and thus similar clinical histories, were compared. CONCLUSION: A clinician must take account of the overall prevalence of disease in the clinical setting when using the patient's history to estimate the probability of disease. Failure to observe this caution may lead to errors in test selection and interpretation.

Using follow-up support with grand rounds CME in community hospitals.

PURPOSE: To determine the proportion of regional primary care physicians who would attend grand rounds on preventive services and their interest in and use of free follow-up enabling and reinforcing assistance to implement changes in their practice routines. METHOD: From January to July 1992 grand rounds on early detection of cancer were offered by Dartmouth Medical School at 38 acute care community hospitals in New Hampshire and Vermont. The target audience of 679 family physicians and general internists was identified through state medical society and hospital attending lists. The hour-long grand rounds program described preventive service guidelines and an office system that promoted their implementation. Follow-up practice support with planning, office staff training, and materials were offered to augment the effects of the grand rounds. Attendance was determined by sign-in documents. In addition, all attendees were asked to complete a survey regarding practice and personal characteristics and interest in follow-up assistance. Statistical comparisons were made using chi square and Fisher's exact tests. RESULTS: In all, 261 family medicine physicians and general internists (38.4%) attended. Certain categories of physicians were more likely to have attended: internists, those younger than 55 years, and physicians on the staffs of hospitals located in small towns. Assistance was requested by 70.1% of the attendees; many requested more than one type of assistance. Physicians from hospitals in smaller towns were more likely to show interest in follow-up assistance and use it when offered. CONCLUSION: Many of the grand rounds attendees were receptive to follow-up assistance that could improve the preventive services they provided. Most hospitals offer grand rounds, and many organizations have interest in and resources for helping physicians provide high-quality care. Future research should establish the best linkage to the actual care provided in practices and explore the relevance of similar approaches to clinical areas beyond prevention.

Physician preventive care philosophy and the five year durability of a preventive services office system.

A group of 30 community physicians who practiced in northeastern United States and who participated in the Cancer Prevention in Community Practice project in 1988 were interviewed five years later. The aim of the interviews was to assess the long-term impact of the preventive services office system which had been introduced by the project. The qualitative analysis of interviews revealed three distinct physician philosophies about the provision of preventive services: a Request Only focus, responding to specific patient inquiries about prevention but taking no initiative to recommend indicated services; a Health Maintenance Visit focus, providing indicated services only during visits specifically scheduled for preventive care; and an Opportunistic Prevention focus, providing indicated preventive services at every chance. Physicians demonstrated these philosophies in their overall view of disease prevention, perceived obstacles to delivery of preventive care, as well as in their continued use of flow sheets and their impression of the value of the Cancer Prevention in Community Practice project. The long-term impact of the office system was the most apparent in the Opportunistic Prevention group. We conclude that the durability of a preventive services office system is influenced by a physician's preventive care philosophy.

High rates of disseminated infection due to non-tuberculous mycobacteria among AIDS patients in Finland.

OBJECTIVE: to determine the rate of disseminated infection due to non-tuberculous mycobacteria (NTM) among Finnish AIDS patients, and to analyse the epidemiology of these infections. METHODS: in a prospective cohort study HIV-infected patients with CD4 counts < 200 x 10(6)/l were interviewed, and had mycobacterial blood cultures performed at baseline and at 6 months, then subsequently for clinical indications; autopsies were performed on patients who died. The cohort was followed at least for 24 months or to death. Water samples were collected from the homes of patients and from the environment and cultured for organisms of the Myobacterium avium complex (MAC). Environmental and clinical isolates were compared using pulsed field gel electrophoresis (PFGE). RESULTS: NTM infection occurred in 22 (43%) of 51, 19 isolates were Mycobacterium avium, two M. genavense and one M. intracellulare. Multivariate analysis identified urban residence (P=0.04) and eating raw fish (P=0.04) as independent risk factors. Molecular analysis revealed two clusters of related isolates (three M. avium, two M. genavense) among urban residents. CONCLUSION: AIDS patients in Finland have high rates of disseminated infection due to NTM. Clusters of identical organisms and association with urban residence suggests that these are newly acquired infections in advanced AIDS.

The diagnosis of abdominal pain in ambulatory male patients.

The purpose of this study was to identify clinical characteristics that could predict the diagnosis in ambulatory patients with abdominal pain. We studied 552 unselected ambulatory male patients whose average age was 47 years and whose median duration of pain was 3 weeks. Potentially serious disease occurred in 21% of the patients. Single abnormal findings had a low predictive value for serious disease. However, by using combinations of clinical findings, we could construct and test a decision rule to identify a group of patients who had a low prevalence of serious disease. This "low risk" group contained 36% of all patients with abdominal pain. Laboratory tests were almost always normal in these patients. Our findings suggest a diagnostic strategy for evaluating abdominal pain: When the initial examination shows that there is little chance of serious disease, laboratory tests should be deferred or omitted altogether. In patients who have a very low likelihood of potentially serious disease, it may be useful to regard "nonspecific abdominal pain" as a positive diagnosis, rather than a diagnosis of exclusion.

Promoting sun protection in elementary schools and child care settings: the SunSafe Project.

Elementary schools and child care settings in rural New Hampshire participated in a sun protection program that reached more than 4,200 children. The program was part of a successful multifaceted community intervention targeting children ages 2-9. Program components included curricular materials, training and support for school/child care staff, and parent outreach. Evaluation showed good uptake of the curriculum by teachers and child care providers, improvements in sun protection policy in participating schools and child care settings, and significant knowledge and attitude improvements in fourth grade children tested, as well as actual behavior change. The study highlighted the importance of flexible, developmentally appropriate curricular materials and active engagement of principals and directors in policy review. In addition, for parent outreach programs to be successful, children needed to participate.

Systematic bias in recording the history in patients with chest pain.

Because of its central importance in medical diagnosis, sources of bias in the patient history must be identified. We report here a study of interobserver agreement in chest pain histories. Histories were obtained by physicians, nurse practitioners, and self-administered questionnaires. We used a discriminant rule to classify the histories as being more or less typical of angina pectoris. A sub-group of the subjects underwent coronary arteriography after the histories were obtained. In subjects with positive coronary arteriograms, physicians consistently obtained histories typical of angina pectoris more often than a self-administered questionnaire. There was no significant systematic bias when comparing physician interviews to the questionnaire among subjects with negative arteriograms nor when comparing two physicians' interviews or a nurse practitioner interview to a questionnaire. When compared to physician interviews, nurse practitioner interviews produced histories less typical of angina pectoris. We conclude that there are systematic differences between the histories obtained by physicians, nurse practitioners, and self-administered questionnaires. Questionnaires can produce biased patient histories and should be carefully validated before being used in patient care activities or health care research.

Psychologically mediated effects of diagnostic tests.

Laboratory tests are purported to affect patients even if they have no diagnostic values. We tested this hypothesis by measuring clinical outcomes of 176 patients thought clinically to have nonspecific chest pain. They were randomly allocated either to have a routine electrocardiogram and serum creatine phosphokinase tests (test group) or to have all diagnostic tests withheld (no-test group). Fewer patients in the tests group (20%) reported short-term disability after the index visit than patients in the no-test group (46%) (p = 0.001). Logistic discriminant analysis confirmed that the use of diagnostic tests was an independent predictor of recovery. Patients in the test group felt that care was "better than usual" more often (57%) than patients in the no-test group (31%) (p = 0.001). After the index visit, the two groups were equally worried about serious disease and equally sparing in their use of other medial care for chest pain.

Improved access to women's health services for Alaska natives through community health aide training.

This project demonstrates the effect of increasing the skills of Community Health Aides (CHAs) on the use of specific preventive health services by women in remote Alaska villages. Eight CHAs were trained in specimen collection for Pap and sexually transmitted disease testing, and in clinical breast examination. Skill competency was monitored. Computerized medical records of all women between the ages of 18 and 75 in the four villages with trained CHAs and in four comparison villages (n = 1093) were checked for Pap status prior to CHA training and again 12 months later. All eight CHAs achieved competency and provided services in their village clinics with telephone support from an experienced clinician. The post-training year Pap test rate of women who were overdue for a Pap test was 0.44 in the villages with trained CHAs; the rate among the women in the comparison villages was 0.32 (p = .079).

Sun protection counseling for children: primary care practice patterns and effect of an intervention on clinicians.

OBJECTIVES: To describe current primary care sun protection advice for children and assess the effect on clinicians of an intervention to enhance their sun protection advocacy. SETTING: Primary care practices caring for children in New Hampshire with special attention to clinicians serving 10 towns that were involved in a randomized controlled trial of the multicomponent SunSafe intervention involving schools, recreation areas, and primary care practices. DESIGN/INTERVENTION: A statewide survey of all primary care clinicians serving children addressed their self-reported sun protection advocacy practices. Clinicians in 10 systematically selected rural towns were involved in the subsequent intervention study. The primary care intervention provided assistance to practices in establishing an office system that promoted sun protection advice to children and their parents during office visits. MAIN OUTCOME MEASURES: Sun protection promotion activities of primary care clinicians as determined by their self report, research assistant observation, and parent interviews. RESULTS: Of 261 eligible clinicians responding to the statewide survey, about half provide sun protection counseling "most of the time" or "almost always" during summer well care visits. Pediatricians do so more often than family physicians. Clinicians involved in the intervention increased their use of handouts, waiting room educational materials, and sunscreen samples. Compared with control town parents, parents in intervention towns reported an increase in clinician sun protection advice. CONCLUSIONS: The SunSafe primary care intervention increased sun protection counseling activities of participating clinicians. A single-focus preventive service office system is feasible to include in community interventions to promote sun protection.

Persistent increase in children's sun protection in a randomized controlled community trial.

BACKGROUND: Reducing sun exposure during childhood may prevent skin cancer later in life. Sun protection increased immediately following implementation of the SunSafe multicomponent, community-based intervention delivered in 1996 through schools, day care centers, primary care offices, and beach recreation areas. Whether sun protection levels would remain higher than preintervention levels the following summer was unknown. METHODS: A randomized controlled trial based in 10 New Hampshire towns addressed children's use of protective clothing, shade, and sunscreen at freshwater beach areas. The intervention was provided initially between March and May 1996. A brief project follow-up contact was provided to schools, day care centers, beaches, and primary care offices between March and May 1997 to restock intervention materials and to answer questions. Observations of 1490 children during June through August of 1997 were compared with observations made prior to any intervention between June and August of 1995. RESULTS: In intervention towns, the proportion of children using at least some sun protection increased by 0.15 from 0.58 in 1995 to 0.73 in 1997 while the proportion in control towns increased by 0.03 (P = 0.033). This increase was due to more use of sunscreen, but not more use of protective clothing or shade. In 1997, care-givers of children in intervention towns reported receiving more sun protection information from school and health care sources than control town caregivers (62% versus 33%, P < 0.006). CONCLUSIONS: In intervention communities, a higher proportion of children used sun protection in 1997 than at baseline. Increases from 1995 to 1997 were similar in magnitude to short-term increases between 1995 and 1996 that we have been previously reported.

An office systems approach to cancer prevention in primary care.

PURPOSE: The provision of preventive services holds a central place in primary care. Achievement of prevention standards offers a challenge. The authors address the efficacy of an office systems approach to improving cancer prevention and early detection services, provide a guide to assessing the appropriateness of office systems dissemination in practices targeted for improvement, and describe the range of dissemination strategies available. OVERVIEW: Preventive service office systems depend on establishing practice routines, using tools such as flow sheets, and sharing responsibilities among practice clinicians, staff, and patients. Systems have been shown to be efficacious in a variety of settings. Computers provide a significant enhancement to paper-based tools. Some practices develop office systems themselves, whereas others require external support. Before attempting to disseminate preventive services offices systems, disseminators should ensure that adequate assistance can be provided, that assistance follows a format that is acceptable to target practices, and that target practices are receptive to assistance and able to cooperate. Dissemination strategies include journal articles, continuing education programs, manuals and tool kits, facilitation, and academic detailing. The relative expense and efficacy of these approaches require further assessment. CLINICAL IMPLICATIONS: Office systems hold promise in enhancing provision of cancer prevention services in primary care. The practice should be approached as a team, and should include practice clinicians as well as nonclinical staff members. Current research should provide answers over the next few years about the cost-effectiveness of various approaches and the most feasible ways to promote dissemination to practices that need it.

Solar protection of children at the beach.

BACKGROUND: Excessive sun exposure during childhood has been associated with subsequent development of skin cancers. Children have been advised to avoid sun exposure, use protective clothing, and apply sunscreen lotions, but how completely these recommendations are followed has not been studied. OBJECTIVE: To determine the extent of sun protection among children visiting lake beaches, the methods used, and the characteristics associated with more protection. DESIGN: Direct observations of children were linked with concurrent care giver/parent interviews. SUBJECTS/SETTING: A total of 871 children 2 to 9 years of age and their parents/care givers at freshwater beaches in 10 small New Hampshire towns during July and August 1995. OUTCOME MEASURES: Protection of the head, torso, and legs according to method used (hats, shirts, pants, sunscreen, or shade). RESULTS: Fifty-four percent of children were protected by at least one method for all three body surface regions, although 17% had no protection for any region. Sunscreen was used either alone or in combination with clothing for at least one region in 79%. Hats were used by 3%, shirts by 22%, and pants to the knee by 49%. Only 12% of observed children were in the shade. The region that was protected most often was the legs for boys (due to swim suit styles) followed by the torso for both sexes. The region most often unprotected was the legs for girls followed closely by the face for both boys and girls. Girls were significantly more likely to have no protection (31.2% female vs 7% male, chi2 83.3) due to better leg protection from swim trunks to the knees popular with boys. Full protection of all three regions was more common for children younger than 5 (odds ratio [OR] = 1.8, 95% confidence interval, [CI] 1.3-2.5), for children perceived to usually or always burn (OR = 2.0, 95% CI 1.4-2.7), for children whose parents had more than a high school education (OR = 1.8, 95% CI 1.3-2.5), and if the parents indicated receiving sun protection information from a school or clinician during the previous year (OR = 1.7, 95% CI 1.2-2.3). Approximately 51.6% of parents recalled receiving childhood solar protection advice in the past year from either their physician, a nurse, or a school/day care setting. CONCLUSIONS: Sunscreen provided the most common form of solar protection. Hats and shade were used rarely, and shirts were also underused. Although the sun protection of these children visiting the beach was substantial, nearly half were still not fully protected. Clinician advice within the past year was associated with better protection. Clinicians could increase their influence by providing more specific counseling about how to achieve full protection. Use of multiple methods of protection rather than just sunscreen and full protection rather than protection for just one or two body regions should be emphasized. It is helpful to remind families to protect the regions most frequently omitted from protection: girls' legs and boys' and girls' faces. Advice can be enhanced with patient education materials such as included in the "Slip" (on a shirt), "Slop" (on sunscreen), and "Slap" (on a hat) program developed in Australia and available through the American Cancer Society.

Periodic health examinations and the provision of cancer prevention services.

OBJECTIVES: To learn about cancer prevention services in primary care practices and to understand physician factors that affect the provision of these services. DESIGN: Survey of physicians and their patients in 1992. SETTING: Cooperating physicians (n = 72) of a random selection of community general internist and family physician practices in New Hampshire and Vermont. PATIENTS: Patients (n = 2775) of the study physicians for at least 1 year, aged 42 years or older, with no life-threatening threatening illness, who recently visited the physician. MAIN OUTCOME MEASURES: Proportion of sample patients per practice provided age- and sex-appropriate cancer prevention services in the previous year. RESULTS: In this primary care population, a high proportion of patients received appropriate services in 1992. A periodic health examination within the past year was an important predictor for the receipt of many cancer prevention services. Female physicians provided more periodic health examinations than male physicians; internists provided more than family physicians. CONCLUSIONS: The strongest determinant of receiving preventive services is having a periodic health examination. If clinicians and policymakers decrease emphasis on the periodic health examination as a major opportunity to provide indicated preventive services, they should ensure that a satisfactory alternative strategy is in place.

A medical algorithm for detecting physical disease in psychiatric patients.

An algorithm for screening psychiatric patients for physical disease was empirically derived from a comprehensive assessment of 509 patients in California's mental health system. The first 343 patients were used to develop the algorithm, and the remaining 166 were used as a test group. Calculations were made for several versions of the algorithm, and the data were compared with the diagnoses listed in the patients' admission mental health record. The algorithmic procedure was more accurate and more cost-effective than the medical evaluation procedures used by the state mental health system. When applied to the test group, the algorithm detected up to 90 percent of patients who had an active, important physical disease at a cost of $156 per patient. The mental health system had detected 58 percent of test-group patients with a disease at a cost of $230 per patient.