Use of groups in well child care.

A controlled study was conducted to examine the use of groups for well child care in the office setting. Group visits were compared to traditional visits by assessing the efficiency, efficacy, content, and process of visits as well as patient satisfaction. The group method was efficient and required no more provider time per pair than individual visits. The group method effectively changed the process and content of the well child visits and was acceptable to the sample population. Few changes in health care utilization were found, but mothers in the experimental group completed more well child visits and sought less advice between visits than mothers in the control group. The group method offers an alternative method of care that is worthy of further investigation and implementation.

Maternal-fetal pH difference and fetal scalp pH as predictors of neonatal outcome.

The purpose of this study was to determine if interpretation of fetal scalp pH values would be enhanced by concurrent measurement of maternal venous pH. The last fetal capillary pH obtained before delivery was compared with simultaneous maternal-fetal pH difference as predictors of neonatal outcome assessed by five-minute Apgar scores. Fetal scalp pH and maternal-fetal pH difference were significantly correlated with r = -0.72 (P less than .0001). The acidotic fetuses born to acidotic mothers had low maternal-fetal pH differences, and all were nondepressed at birth. A 33% reduction in false negatives was found using maternal-fetal pH difference instead of scalp pH alone. Errors in interpretation of fetal scalp pH can be reduced by the use of maternal-fetal pH difference.

The role of the community-oriented primary care physician.

The role of community-oriented primary care is the subject of considerable debate and controversy, leading to confusion for both its practitioners and educators. This paper attempts to clarify this role by applying systems theory to the concept of community-oriented primary care as first-contact medical care for the patient, in the context of the community. Relationships between the primary care physician and the following entities are defined: the patient; the physician's and patient's community, culture, and society; the physician's office; the medical care system; and the physician's and patient's families. The educational implications of the resultant role are discussed.

Successful modification of medical students' cardiovascular risk factors.

Modifying identified risk factors for cardiovascular disease should change an individual's risk. Educational interventions might change behavior to modify some risk factors. To evaluate this possibility, we evaluated the health and fitness status of freshman medical students at the University of Utah (n = 89) in 1983 and determined their cardiovascular risk factors. During a preventive cardiology course later that year, students received their results. We reevaluated the students during their senior year using the same method. For both years, we obtained complete data on 77 (87%) of the eligible students. As freshmen 83% of these students had at least one modifiable risk factor, compared with 62% with a risk as seniors. The number of reevaluated students with low levels of high-density lipoprotein cholesterol, low estimations of aerobic capacity, or both, decreased significantly (P = .009 and P = .0008, respectively). The preventive cardiology educational intervention may have changed behavior and improved cardiovascular risk factors.

Research skills development in family medicine fellows.

This study was conducted to identify factors that contribute to the development of research skills among Robert Wood Johnson Foundation (RWJF) family medicine fellows, and to relate this process to their overall training. All 23 of the 1981-82 RWJF fellows were surveyed. Most fellows believe they are being well prepared to conduct research, and estimate they will spend approximately one-fourth of their future time in research activities.

A prevention armamentarium for aeromedical practitioners.

Recent advances in preventive medicine offer practitioners exceptional opportunities to help patients and their families have longer, healthier, and more enjoyable lives. Those involved in aerospace medicine are uniquely qualified by their training and experience to apply this enhanced prevention armamentarium. The discussion considers a number of activities and techniques which can provide important patient benefits at acceptable costs.

A comparison of family practice clinics and free-standing emergency centers: organizational characteristics, process of care, and patient satisfaction.

Because of the increasing popularity of free-standing emergency care centers as a source of primary care services, this cross-sectional study was conducted to compare four of them with two family practice centers that provided extended hours. A total of 2,339 patient encounters were examined with data obtained from both physicians and patients. The factors that were found to be a basis for discrimination between the two types of practice were the cost of care and the patient's satisfaction with convenience and personal attention from the physicians. The overall average costs were significantly higher for the free-standing centers ($45) as compared with the family practice clinics ($27). Convenience and time factors, including waiting time, time spent with the physician, time to get an appointment, clinic location, and out-of-pocket cost, all produced a higher level of satisfaction for the free-standing clinic patients. Conversely, the personal concern of the physician and the ability to see the same physician brought higher levels of satisfaction for the family practice clinic patients. The free-standing emergency center is clearly becoming a significant factor in the delivery of primary care with evidence to suggest that patients are willing to pay a premium for convenience.

Epidural anesthesia in low-risk obstetrical patients.

The use of epidural anesthesia in obstetrics has increased markedly in the last decade, and some authorities are now stating that epidural block may be the anesthetic method of choice for most women. In spite of this growth in popularity, no studies have been reported that deal with the outcomes of epidural anesthesia in low-risk obstetrical patients, that group of women for whom family physicians are most likely to provide care. A retrospective cohort study of factors associated with epidural anesthesia in a low-risk obstetrical population was performed. Epidural anesthesia was administered by obstetrical anesthesiologists, and patients were monitored by nurses experienced with epidural anesthesia. Although retrospective studies cannot establish cause-and-effect relationships, it was found, when compared with deliveries without epidural anesthesia, that epidural anesthesia deliveries were associated with changes in several parameters of labor and delivery. Although epidural anesthesia was observed to be a very safe procedure, three of the variables (higher use of low forceps, increased use of oxytocin, and greater total costs) may be of some clinical importance and should be considered by both the delivering physician and the patients when choosing obstetrical anesthesia.

Differences in the outcomes of acute episodes of care provided by various types of family practitioners.

This study was designed to compare the outcomes achieved in a series of acute care episodes by different levels of family practice providers working in the clinic setting. The study utilizes a method which depends upon the provider to estimate level of function expected and earliest date of recovery for each episode. When the patients are viewed as a single group, those patients treated by the medex appear to fare considerably better and those seen by a faculty member do worse; however, when each functional status group is examined separately, only the asymptomatic but clinically ill patients (45 cases) show a statistically significant difference in outcomes among the providers, with the medex having good results and the faculty poor results.

A method for assessing the outcome of acute primary care.

Some 1,700 acute care episodes were studied to assess the outcomes in terms of the extent to which patients regained their usual functional status. Involving active follow-up of each patient, the study serves as a prototype for measuring several components of quality of care including actual outcomes, patient expectation of outcome, physician expectation of outcome, and patient satisfaction with outcome and care. Because this study was conducted in a family practice residency training setting, we hope that it will serve as a model of how such information may be used to increase residents' sensitivity to the course of illness commonly seen in primary care, and to encourage the residents to set expectations for the care they give.

Criteria for releasing patients from psychiatric hospitals.

The authors conducted a pilot study to determine the kinds of criteria being used by mental health professionals in discharging patients from mental hospitals. Twenty-one criteria were identified in the first phase of the study, and 43 staff members later rated the items according to their perceived importance. Although there was general agreement on most of the items, reliable differences of opinion were expressed in some instances. The differences were attributed less to the respondents' professional discipline than to their hospital affiliation (VA or non-VA). The authors emphasize the need for developing a standardized list of discharge criteria and discuss uses for such criteria.

A cost-benefit analysis of immunization for pneumococcal pneumonia.

To determine whether immunization against pneumococcal pneumonia could be justified on the basis of a favorable benefit to cost ratio, we evaluated the projected impact of a program of pneumococcal vaccination on the population of a health maintenance organization. Retrospective data on average provider and patient costs associated with episodes of pneumococcal pneumonia were coupled with forecasts of the likely effectiveness of currently available vaccine and its impact on anticipated incidence of pneumonia. We found that when provider-centered and patient-centered costs and benefits were added, a program of immunizing those traditionally considered to be at high risk of contracting pneumococcal pneumonia (50 years of age and older; patients with chronic diseases of the heart, liver, lungs, or kidneys; and those with diabetes mellitus) was justified on a cost-benefit basis.

Community aftercare of patients discharged from Utah state hospital: a follow-up study.

To find out whether patients discharged from mental hospitals to the community are following recommended courses of aftercare treatment, the authors, with the assistance of five medical students, studied a sample of patients discharged from Utah State Hospital during 1973 and 1974. The discharge plans of 143 patients admitted from Salt Lake County indicated that 125 of them should have received aftercare services from a community mental health center. A review of CMHC records and interviews with the patients indicated that only 100 actually had contact with a center. Only 43 of the patients were still receiving aftercare services in the summer of 1975.

Neonatal mortality in Utah.

A cohort study of neonatal mortality (N = 106) in white singleton births (N = 14,486) in Utah for January-June 1975 was conducted. Using membership and activity in the Church of Jesus Christ of Latter-day Saints (LDS or Mormon) as a proxy for parental health practices, i.e., tobacco and alcohol abstinence, differential neonatal mortality rates were calculated. The influence of potential confounding factors was evaluated. Low activity LDS members were found to have an excess risk of neonatal death five times greater than high activity LDS, with an upper bound of a two-sided 95% confidence interval of 7.9. The data consistently indicate a lower neonatal mortality rate for active LDS members. Non-LDS were found to have a lower rate than either medium or low activity LDS.

Medical care for vacationers: health services at Yellowstone National Park.

Medical services provided to vacationers and employees in Yellowstone National Park were reviewed for the years 1975 through 1977. Both ambulatory and inpatient data were obtained, including diagnoses, place of residence, medications prescribed, and methods of payment. The types of problems and modes of treatment did not differ from typical primary care practices. Health maintenance was the most common reason for outpatient visits. The distribution of diagnoses among park visitors and employees was the same within age categories, although the employees' rate of utilization was nearly twice that of the visitors. Distance from home was directly related to the frequency with which visitors used clinic services.

Predicting rural health care utilization with archival data.

This study explored the usefulness of archival data in predicting rural health care utilization. A regression model was used to see how well observed utilization for local populations could be predicted by calculating expected values in advance from age- and sex-specific national rates applied to local age and sex profiles. Although the correlation between observed and expected utilization was reasonably high (r = 0.92), an attempt was then made to improve prediction by considering other data that do not require independent collection. These archival data included indicators of historic utilization (local Medicaid payments, the percentage of births to county residents occurring in the mother's county of residence, percentage of children immunized, and infant mortality) and services already available. Observed utilization data were obtained by surveys in eight rural counties, and the predictor was tested on three additional rural communities. A predictor equation that added to the expected utilization only one variable (the percentage of births to county residents occurring in the mother's county of residence) was found to account for approximately 95% of the variance in observed utilization. This predictor is recommended for planners who need convenient, low-cost market feasibility estimates for proposed project sites and a way to establish intermediate goals or incentives during early project development.

Costs and outcomes for different primary care providers.

This study examined the relationship between levels of medical training and direct costs for 1,700 episodes of acute illness treated in ambulatory-care clinics. Faculty, family practice residents, and physician assistants were included as the providers. Total cost and four component costs were examined. An outcome was defined as good if the patient returned to his usual level of functioning after an acute illness episode. Average total cost per episode was not related to type of provider, but there were significant (P less than .05) differences among providers in laboratory and medication costs. Faculty and physician assistants produced higher costs, especially for patients who experienced bad outcomes. Both costs and percentage of good outcomes achieved were similar in first-, second-, and third-year residents.

Effectiveness of implementing a trauma triage system on outcome: a prospective evaluation.

A 9-month prospective study was conducted in Salt Lake County to evaluate the efficacy of a field trauma triage system using the CRAMS score. Before the triage system was implemented trauma victims were taken to the nearest appropriate hospital. Post-implementation, trauma victims with field CRAMS scores of 1 through 6 were triaged to the Level I Trauma Center. Of the 113 study patients, 53 were in the pre-implementation phase and 60 in the post-implementation phase. The study patients with CRAMS scores of 4 or less had lower mortality when cared for at the Level I Trauma Center (p = 0.013). We conclude that trauma patients who are severely injured (CRAMS less than or equal to 4) have a significantly higher rate of survival if taken to the Level I Trauma Center. The use of the CRAMS triage system appears to be an effective approach toward improving trauma care in Salt Lake County.