Comparison of HTN management in patients with diabetes between rural and urban primary care clinics in Northeastern Colorado - a report from SNOCAP.

INTRODUCTION: In the USA, rural residents have a higher burden of disease and more limited access to care than urban residents. There are conflicting data on quality of care in rural settings. To evaluate this relationship, blood pressure (BP) control and decision-making at the point of care in patients with diabetes were examined for rural and urban medical providers in Northeastern Colorado. METHODS: Twenty-six primary care practices in two practice-based research networks in Colorado participated: 13 in rural settings and 13 urban. Questionnaires were completed after each encounter with an adult with type 2 diabetes. The survey obtained: (1) demographic information; (2) BP result; (3) whether action was taken; (4) if action was taken, type of action; and (5) if no action, what reasons were given for this inaction. Bivariate and multivariate analyses were performed to identify predictors of action. RESULTS: In total, 778 surveys were completed. Mean BP was 130/74 (+/-18.8/12.0) with BP in rural residents being slightly lower than for urban residents. Rural residents were more likely to be non-Hispanic white, on Medicare, on multiple medications, and less likely to be on Medicaid. Sixty-five percent of urban patients exceeded BP goals, as did 58% of rural patients. Action rates for those with elevated BP in rural areas were not significantly different than those in urban areas (OR 0.75 [0.45-1.25] p = 0.27). The reasons for inaction were similar. CONCLUSION: In this study of patients with diabetes, quality of care for elevated BP was similar in rural and urban areas.

Impact of double counting and transfer bias on estimated rates and outcomes of acute myocardial infarction.

CONTEXT: Ischemic heart disease is the leading cause of death in the United States. Recent studies report inconsistent findings on the changes in the incidence of hospitalizations for ischemic heart disease. These reports have relied primarily on hospital discharge data. Preliminary data suggest that a significant percentage of patients suffering acute myocardial infarction (MI) in rural communities are transferred to urban centers for care. Patients transferred to a second hospital may be counted twice for one episode of ischemic heart disease. OBJECTIVE: To describe the impact of double counting and transfer bias on the estimation of incidence rates and outcomes of ischemic heart disease, specifically acute MI, in the United States. DESIGN: Analysis of state hospital discharge data from Kansas, Colorado (State Inpatient Database [SID]), Nebraska, Arizona, New Jersey, Michigan, Pennsylvania, and Illinois (SID) for the years 1995 to 1997. A matching algorithm was developed for hospital discharges to determine patients counted twice for one episode of ischemic heart disease. Validation of our matching algorithm. PATIENTS: Patients reported to have suffered ischemic heart disease (ICD9 codes 410-414, 786.5). MAIN OUTCOME MEASURES: Number of patients counted twice for one episode of acute MI. RESULTS: It is estimated that double count rates range from 10% to 15% for all states and increased over the 3 years. Moderate sized rural counties had the highest estimated double count rates at 15% to 20% with a few counties having estimated double count rates a high as 35% to 50%. Older patients and females were less likely to be double counted (P <0.05). CONCLUSIONS: Double counting patients has resulted in a significant overestimation in the incidence rate for hospitalization for acute MI. Correction of this double counting reveals a significantly lower incidence rate and a higher in-hospital mortality rate for acute MI. Transferred patients differ significantly from nontransferred patients, introducing significant bias into MI outcome studies. Double counting and transfer bias should be considered when conducting and interpreting research on ischemic heart disease, particularly in rural regions.

Characteristics of and issues faced by rural female family physicians.

The purpose of this study was to identify characteristics of and issues faced by female family physicians practicing in rural areas. A 37-item survey was designed to obtain demographic information about the background, community and practice of rural female physicians. An open-ended question regarding the issues and problems faced by female physicians in rural communities was included. Study subjects were identified from the membership of the American Academy of Family Physicians (AAFP). The questionnaire was mailed to all 850 active female AAFP members practicing in communities with less than 50,000 inhabitants during the winter of 1999. Completed and usable surveys were received from 587 (69.9 percent). The average age of respondents was 45. The majority were married (81.1 percent) and had children (80.1 percent). Half of the women had grown up in communities of 25,000 or less population. Twenty-seven percent of the respondents had no rural exposure in medical school; 39 percent had no rural exposure in residency; and 16 percent had no rural exposure in medical school or residency. The majority of respondents (62 percent) practiced in communities of less than 10,000. A large majority (70 percent) of these women planned to stay in the community for 10 years or more, with 58.6 percent responding that they plan to stay indefinitely. Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural physicians and to assist medical schools and residencies in adequately preparing graduates for rural practice.

Low-molecular-weight heparin in preventing and treating DVT.

Low-molecular-weight heparin is a relatively recent addition to the list of therapies for prophylaxis and treatment of deep venous thrombosis (DVT). As a prophylactic, low-molecular-weight heparin is as effective as standard heparin or warfarin and does not require monitoring of the activated partial thromboplastin time or the International Normalized Ratio. Traditionally, treatment for DVT required patients to be hospitalized for administration of intravenous heparin. With subcutaneous injections of low-molecular-weight heparin, treatment of DVT can be initiated or completed in the outpatient setting with no increased risk of recurrent thromboembolism or bleeding complications. Low-molecular-weight heparin is an attractive option for use in patients with a first episode of DVT, no risk factors for bleeding and the ability to administer injections with or without the help of a visiting nurse or family member.

The family physician and house calls. A survey of Colorado family physicians.

BACKGROUND: Visiting patients at home has long been one of the activities of the family physician, but the practice of making house calls has diminished significantly during the second half of the 20th century. The goal of this study was to describe physicians' attitudes about house calls and their practice of making them in the rapidly changing health care environment of the United States. METHODS: A 30-item, self-administered questionnaire was designed to obtain demographic information about physicians and their attitudes toward house calls, practice experiences with making house calls, and any additional factors that influence making house calls. It was mailed to all members of the Colorado Academy of Family Physicians, during the summer of 1997. RESULTS: A 66% response rate was obtained from practicing physicians. Overall attitudes toward house calls were positive. Fifty-three percent of the respondents reported making house calls, and 8% reported making more than 2 house calls per month. Male physicians, those older than 40 years, those in rural settings, and those trained in a community-based residency were more likely to make house calls. Patient payer mix and practice setting were also related to whether a physician made house calls. House calls were most frequently made to geriatric patients, cancer patients, trauma patients, and patients with transportation difficulties. Many physicians reported using home health agencies for assessment and treatment of patients needing home care. CONCLUSIONS: Family physicians agree that house calls are good for patients. More than half of the respondents reported that they occasionally make house calls. However, few physicians routinely perform house calls.

Update on early medical and surgical abortion.

Abortion is one of the most common surgical procedures in the United States. Recent innovations in medicine make early pregnancy termination safe and effective. Our purpose is to review advances in early detection and confirmation of intrauterine pregnancy and discuss medical and surgical techniques for elective termination early in pregnancy. Manual vacuum aspiration is a safe and effective method for pregnancy termination through 10 weeks' gestation. Medical abortion using methotrexate or mifepristone with misoprostol is safe and effective for early pregnancy termination through 7 weeks' gestation.

Manual vacuum aspiration for first-trimester abortion.

OBJECTIVE: To assess the safety and effectiveness of manual vacuum aspiration for abortion in a primary care office setting. DESIGN: Retrospective chart audit. SETTING: Private family practice office. PATIENTS: A total of 1769 consecutive women who obtained an abortion in this office between January 1, 1993, and December 31, 1995, for whom 1677 medical charts were available for review. MAIN OUTCOME MEASURES: Rate of complete abortion, estimated blood loss, and rate of complications. Complications included early complications of uterine perforation, cervical injury, and hospitalization, and late complications of pelvic infection and retained products of conception. RESULTS: Overall, manual vacuum aspiration was 99.5% effective in terminating pregnancy through 12 weeks of gestation. There were no major complications, and the minor complications of retained products of conception and infection were easily treated. CONCLUSION: Manual vacuum aspiration performed in a primary care office setting is safe and effective in terminating pregnancy through the end of the 10th week of gestation.

Personal use of drug samples by physicians and office staff.

CONTEXT: Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients. OBJECTIVE: To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff. DESIGN, SUBJECTS, AND SETTING: An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency. MAIN OUTCOME MEASURE: Quantity of drug samples taken for personal or family use. RESULTS: Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples. CONCLUSION: Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.

Effects of spatial frequency of a vertically striped rotating drum on vection-induced motion sickness.

PURPOSE: The present study investigated the effects of differential spatial frequencies of a vertically striped, horizontally rotating drum on the observer's frequency of eye nystagmus, perceived velocity of self-motion, and symptoms of motion sickness. METHODS AND RESULTS: Two experiments were conducted. In Experiment 1, each of 10 subjects viewed 1 min of an optokinetic rotating drum at the speed of 10 rpm covered with 6, 12, 24, 48, and 96 pairs of black and white stripes, presented in counterbalanced order. The results indicated that subjects perceived significantly stronger circular vection (p < 0.05) and generated significantly higher frequencies of eye nystagmus (p < 0.05) when they were viewing 24 pairs of black and white stripes than when they were viewing any of the other combinations of 6, 12, 48, or 96 black and white stripes. In Experiment 2, 100 highly susceptible subjects viewed 16 min of an optokinetic rotating drum covered with one of the five different numbers of black and white stripe pairs: 6, 12, 24, 48, and 96. The results indicated that subjects in the group viewing 24 moving contrasts perceived significantly stronger circular vection (p < 0.001), reported significantly more severe symptoms of motion sickness (p < 0.001), and showed significantly greater ratios of EGG 4-9 cycles per minute spectral intensity between drum rotation and baseline periods (p < 0.004) than those in the groups of viewing 6, or 96 moving contrasts. CONCLUSION: These results demonstrated that the severity of vection-induced motion sickness is affected by differential spatial frequencies of the stripes of the rotating drum and may be affected by number of horizontal eye movements.

Continuation rates among injectable contraceptive users.

Few published data exist on the ongoing use of depot medroxyprogesterone acetate, the injectable contraceptive. Women who obtained the injectable from Planned Parenthood of the Rocky Mountains between January 1993 and March 1995 were followed to ascertain continuation rates for the method. Of the 5,178 women who received an initial injection, only 57% returned for a second administration; 63% of those who returned for their second injection went on to receive a third. The overall one-year continuation rate was 23%. No significant differences in continuation rates were found based on age, race or payment type.

PIP: Women acquire 3 months of contraceptive protection with each injection of depot medroxyprogesterone acetate (DMPA). Women who obtained DMPA from Planned Parenthood of the Rocky Mountains between January 1993 and March 1995 were followed to determine the continuation rates for use of the method. 79% of the 5178 women who received an initial injection are White, 64% were older than 22 years, and 10% were reimbursed for services through Medicaid. 57% of the 5178 women returned for a second administration. 63% of women who returned for a second injection continued method use to receive a third injection. The mean time between injections was 84 days, with a standard deviation of 6 days. The study found a 23% overall 1-year continuation rate. No significant differences in continuation rates were found according to age, race, or payment type. Difficulty tolerating side effects was the main reason for DMPA discontinuation among the 200 women who were followed upon discontinuing method use after the first injection. 12% of the sample was reported as lost to follow-up. Findings are discussed.

Intussusception.

Intussusception is the invagination of one bowel segment into another. It is an emergent condition that most commonly affects infants between five and nine months of age, but it can also occur in other age groups. The etiology is usually idiopathic in infants five to nine months of age; neonates, older children and adults more commonly have lead points such as a Meckel's diverticulum or a neoplasm. Early diagnosis is essential to avoid treatment delays, which can increase morbidity and mortality. It has been reported that patients with intussusception present with abdominal pain, vomiting and bloody stools, but this classic triad is often absent. More commonly, lethargy and irritability are the presenting signs. A rectal examination, with testing for occult blood, is an important part of the evaluation and is frequently positive. Barium enema is the gold standard for diagnosis and also has therapeutic potential for reducing the intussusception. Ultrasound is an accurate, low-risk screening tool when performed and interpreted by an experienced ultrasonographer. Surgical reduction is performed if nonoperative reduction is contraindicated or unsuccessful, or if a lead point is suspected.

Repeat abortion and use of primary care health services.

One-third (34%) of 2,001 women who sought an abortion in 1991-1992 in Wichita, Kansas, were repeat-abortion patients. Compared with first-time abortion patients, repeat-abortion patients were significantly older, more often black, and younger at their first pregnancy (p < .001). The two groups did not vary significantly by income or age at first intercourse. However, repeat-abortion patients were significantly more likely than first-time patients to have been using a contraceptive method at the time of conception (65% compared with 59%) and more likely to say they always or almost always used a method (63% and 53%, respectively). More than 40% of women in each group reported they had no personal physician. Further, 34% of repeat-abortion patients said they had no follow-up examination after their previous abortion, and 28% said they received no contraceptive counseling. Only half of women whose pregnancy was confirmed by their personal physician obtained an abortion referral from that physician.

PIP: To refine understanding of the characteristics of women who obtain a repeat abortion, the 2445 consecutive women who sought abortion at a Wichita, Kansas, clinic from July 1991 to June 1992 were administered a 100-item questionnaire prior to the procedure. 80% of abortion seekers were White and only 20% were currently married; the average age was 23.6 years. Of the 2001 women who completed the questionnaire, 23.7% had one prior abortion and another 10.5% had two or more prior abortions. Compared to women having their first abortion, repeat abortion patients were significantly older (22.5% vs. 25.7 years), more likely to be Black (8.5% vs. 16.1%), and more often married (17.4% vs. 22.8%). Of note were the high proportions of repeat abortion patients who were using a contraceptive method at the time of conception (65%) and were consistent users (63%); these rates were 59 and 53%, respectively, for first-time abortion patients. About 60% of women in both groups had a personal physician, and these women were significantly more likely than their counterparts with no regular source of care to be consistent users of contraception. On the other hand, only 10% of abortion patients were referred to the clinic by a primary care physician and the majority self-diagnosed their pregnancy or used a home-based test. 34% of repeat abortion patients had not received a follow-up examination in association with the prior abortion and 28% reported they were not given contraceptive counseling at that time. To reduce the need for repeat abortion, it is recommended that abortion clinic personnel ensure that all abortion patients without a primary care provider are referred to such a physician for ongoing comprehensive health care, including family planning.

The contraceptive implant and the injectable: a comparison of costs.

A comparison of the relative costs of the injectable contraceptive (depot medroxyprogesterone acetate) and the hormonal implant (Norplant) indicates that the implant is a less costly contraceptive option when it is used for its full five-year lifespan. Over a five-year period, the implant costs $107 annually, compared with $140 per year for the injectable. However, if a woman discontinues the implant before she has used it for at least four years, the injectable becomes the less costly option. Relatively high continuation rates--around 95% annually--are necessary to make the implant the more cost-effective contraceptive method.

PIP: The authors compared the relative costs of the injectable contraceptive depot medroxyprogesterone acetate (Depo-Provera) and the hormonal implant Norplant. Per-year costs for the implant were calculated using both published and theoretical yearly continuation rates. Woman-years of contraceptive use were then calculated to project the costs for a theoretical cohort of 100 women, and these costs were compared to the cost of Depo-Provera. Costs for the implant were $433.25 per insertion and $100.29 per removal based upon Current Procedural Terminology codes 11975 and 11976, and on Colorado Medicaid reimbursement rates for the two codes. The average Medicaid reimbursement in the US has been reported to be $466 for implant insertion and $90 for removal. The $35.19 cost of the injectable was based upon Current Procedural Terminology code X5560 and on the Colorado Medicaid reimbursement rate. Actual office charges are typically higher than medicaid reimbursement, so the costs reviewed in this analysis represent a low estimate, especially for the implant. It is also noted that many insurance companies will pay for neither contraceptive method. The analysis found Norplant to be the less costly of the two methods when used for its full five-year lifespan. Over a five-year period the implant costs $107 annually, compared with $140 per year for the injectable. If a woman discontinues the implant before she has used it for at least four years, however, the injectable becomes the less costly option. Annual continuation rates of approximately 95% are needed to make Norplant the more cost-effective of the two contraceptive methods.

Abortion attitudes and practices of family and general practice physicians.

BACKGROUND: Approximately 1.5 million abortions are performed each year in the United States. Little information has been published on the abortion attitudes and practices of family physicians. The object of this investigation was to assess the abortion attitudes and practices of family and general practice physicians in Kansas. METHODS: A 19-item self-administered survey questionnaire was designed and mailed to 856 family and general practice physicians in Kansas. RESULTS: A 63% survey response rate was obtained. Seventy-eight percent of the physicians reported that abortion should be legal, but only 56% of the respondents classified themselves as pro-choice. Conversely, only 8% reported that legal abortion should not be available, even though 33% classified themselves as pro-life. The majority of physicians reported that abortion is an appropriate option to save the life of the mother, in cases of rape or incest, and when a fetal anomaly is diagnosed. Only three respondents (0.5%) had performed abortions during the previous year. In general, female physicians and physicians over the age of 40 years (regardless of sex) were more likely to be pro-choice and to view a woman's personal decision as a circumstance in which abortion may be appropriate. CONCLUSIONS: Physician's views about abortion and their practice patterns are important components of health care for thousands of women each day.