Systematic reviews of selected dental caries diagnostic and management methods.

A systematic review of the English-language literature was conducted to address three related questions concerning the diagnosis and management of dental caries: a) the performance (sensitivity, specificity) of currently available diagnostic methods for carious lesions, b) the efficacy of approaches to the management of noncavitated or initial carious lesions, and c) the efficacy of preventive methods among individuals who have experienced or are expected to experience elevated incidence of carious lesions. From 1,328 caries diagnostic and 1,435 caries management reports originally identified, thirty-nine diagnostic studies and twenty-seven management studies were included in the final evidence tables. Point estimates or reasonable range estimates for the diagnostic validity of methods for the diagnosis of carious lesions could not be established from the literature reviewed. There are insufficient numbers of reports of diagnostic performance involving primary teeth, anterior teeth, and root surfaces. For posterior occlusal and proximal surfaces, quality issues and the variation among studies precludes establishing such estimates. The apparent differences in sensitivity among methods are generally smaller than the variation reported within methods. The literature on the management of noncavitated carious lesions consisted of five studies describing seven experimental interventions. Because these interventions varied extensively in terms of management methods tested as well as other study characteristics, no conclusions about the efficacy of these methods were possible. The literature on the management of individuals at elevated risk of carious lesions consisted of twenty-two studies describing twenty-nine experimental interventions. The strength of the evidence for the efficacy of fluoride varnish for prevention of dental caries in high-risk subjects was fair, and the evidence for all other methods was incomplete. Because the evidence for efficacy for some methods, including chlorhexidine, sucrose-free gum, and combined chlorhexidine-fluoride methods, is suggestive but not conclusive, these interventions represent fruitful areas for further research.

A systematic review of the effectiveness of antifungal drugs for the prevention and treatment of oropharyngeal candidiasis in HIV-positive patients.

OBJECTIVE: A systematic review of randomized clinical trials published between 1966 and April 2000 was undertaken to determine the strength of evidence for the effectiveness of antifungal drugs (nystatin, clotrimazole, amphotericin B, fluconazole, ketoconazole, and itraconazole) to prevent and treat oral candidiasis in human immunodeficiency virus-positive patients. STUDY DESIGN: An automated database search identified 366 articles. Six met inclusion and exclusion criteria with respect to prophylaxis; 12 met criteria for treatment of oral candidiasis. RESULTS: The evidence for the prophylactic efficacy of fluconazole is good, although insufficient to draw conclusions about the other antifungals. Evidence for treatment effectiveness is insufficient for amphotericin B but good for nystatin, clotrimazole, fluconazole, ketoconazole, and itraconazole. CONCLUSION: Suggestions for strengthening the evidence base include the following: use of larger, more well-defined groups; control for immunologic status, viral load, history of oral candidiasis, past exposure to antifungals, baseline oral Candida carriage, drug interactions, and antiretroviral therapy; and consistent use of compliance monitors, fungal speciation, and susceptibility testing.

A systematic review of selected caries prevention and management methods.

A systematic review of the periodic scientific literature was undertaken to determine the strength of the evidence for the efficacy of professional caries preventive methods applied to high risk individuals, and the efficacy of professionally applied methods to arrest or reverse non-cavitated carious lesions. An initial search identified 1435 articles, of which 27 were eventually included in the review. Among the 22 studies addressing the prevention of carious lesions in caries-active or high risk individuals, the strength of the evidence was judged to be fair for fluoride varnishes and insufficient for all other methods. Among the seven studies addressing the management of non-cavitated carious lesions, the strength of the evidence for efficacy was judged to be insufficient for all methods. The results do not indicate that the preventive and management methods reviewed are not efficacious; rather, they demonstrate that not enough is known to determine the efficacy of the methods. Suggestions for strengthening the limited evidence base involve the following: i) increasing the number of studies that examine prevention among high risk individuals and non-surgical management of non-cavitated lesions, ii) including a wider variety of subject ages, iii) targeting aspects of the efficacy questions not yet addressed, iv) strengthening research methods employed in the studies, and v) reporting methods and outcomes more completely.

New transient ischemic attack and stroke: outpatient management by primary care physicians.

BACKGROUND: Patients with transient ischemic attack (TIA) or stroke frequently first contact their primary care physician rather than seeking care at a hospital emergency department. The purpose of the present study was to identify a group of patients seen by primary care physicians in an office setting for a first-ever TIA or stroke and characterize their evaluation and management. METHODS: Practice audit based on retrospective, structured medical record abstraction from 27 primary care medical practices in 2 geographically separate communities in the eastern United States. RESULTS: Ninety-five patients with a first-ever TIA and 81 with stroke were identified. Seventy-nine percent of those with TIA vs 88% with stroke were evaluated on the day their symptoms occurred (P =.12). Only 6% were admitted to a hospital for evaluation and treatment on the day of the index visit (2% TIA; 10% stroke; P =.03); only an additional 3% were admitted during the subsequent 30 days. Specialists were consulted for 45% of patients. A brain imaging study (computed tomography or magnetic resonance imaging) was ordered on the day of the index visit in 30% (23% TIA, 37% stroke; P =.04), regardless of whether the patient was referred to a specialist. Carotid ultrasound studies were obtained in 28% (40% TIA, 14% stroke; P<.001), electrocardiograms in 19% (18% TIA, 21% stroke; P =.60), and echocardiograms in 16% (19% TIA, 14% stroke; P =.34). Fewer than half of patients with a prior history of atrial fibrillation (n = 24) underwent anticoagulation when evaluated at the index visit. Thirty-two percent of patients (31% TIA, 33% stroke; P =.70) were not hospitalized and had no evaluations performed during the first month after presenting to a primary care physician with a first TIA or stroke. Of these patients, 59% had a change in antiplatelet therapy on the day of the index visit. CONCLUSIONS: Further primary care physician education regarding the importance of promptly and fully evaluating patients with TIA or stroke may be warranted, and barriers to implementation of established secondary stroke prevention strategies need to be carefully explored. Arch Intern Med. 2000;160:2941-2946

Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities.

BACKGROUND: Most treatment of patients at risk for stroke is provided in the ambulatory setting. Although many studies have addressed the proportion of eligible patients with atrial fibrillation (AF) receiving warfarin sodium, few have addressed the quality of their anticoagulation management. OBJECTIVE: As a comprehensive assessment of quality, we analyzed the proportion of eligible patients receiving warfarin, the proportion of time their international normalized ratios (INRs) were within the target range, and, when an out-of-target range INR value occurred, the time until the next INR measurement was made. METHODS: Retrospective review of the medical records of 660 patients with AF managed by general internists and family practitioners in Rochester, NY, and the Research Triangle area of North Carolina. RESULTS: Only 34.7% of eligible patients with AF received warfarin. The INR values were out of the target range approximately half the time, and the response to these values was not always timely. For all the measures considered, both Rochester practices with access to an anticoagulation service had higher (albeit not ideal) quality of warfarin management than the remaining practices. CONCLUSIONS: We found significant deficiencies in the practice of warfarin management and suggestive evidence that anticoagulation services can partially ameliorate these deficiencies. More research is needed to describe the quality of anticoagulation management in typical practice and how this management can be improved.

Physician-reported readiness to change stroke prevention practices.

There are a series of possible impediments to the incorporation of new treatment modalities into clinical practice, and any intervention intended to alter practice must consider physicians' motivation and readiness to change. As part of a national survey in the United States, physicians from a variety of specialties were asked whether they were comfortable with, considering changing or expecting to make changes in their screening and treatment practices for a series of eight hypothetical patients at elevated risk of stroke. Readiness to change varied with the type of patient under consideration and with physician specialty, but not with a series of other physician and practice characteristics. Knowledge of physicians' states of readiness to change in combination with data relating to current practices and potential barriers to implementation should aid in targeting educational efforts and in the development of specific interventions to improve stroke prevention.

Knowledge of risk among patients at increased risk for stroke.

BACKGROUND AND PURPOSE: Patients who recognize their increased risk for stroke are more likely to engage in (and comply with) stroke prevention practices than those who do not. We describe perceived risk of stroke among a nationally diverse sample of patients at increased risk for stroke and determine whether patients' knowledge of their stroke risk varied according to patients' demographic and clinical characteristics. METHODS: Respondents were recruited from the Academic Medical Center Consortium (n = 621, five academic medical centers, inpatients of varying age); the Cardiovascular Health Study (n = 321, population-based sample of persons aged 65+ years); and United HealthCare (n = 319, five health plans, inpatients and outpatients typically younger than 65 years). The primary outcome was awareness of being at risk for stroke. RESULTS: Only 41% of respondents were aware of their increased risk for stroke (including less than one half of patients with previous minor stroke). Approximately 74% of patients who recalled being told of their increased stroke risk by a physician acknowledged this risk in comparison with 28% of patients who did not recall being informed by a physician. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. CONCLUSIONS: Over one half of patients at increased risk of stroke are unaware of their risk. Healthcare providers play a crucial role in communicating information about risk, and successful communication encourages adoption of stroke prevention practices. Educational messages should be targeted toward patients least likely to be aware of their risk.

US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke. Medical therapy in patients with carotid artery stenosis.

BACKGROUND AND PURPOSE: Aspirin or other platelet antiaggregants and anticoagulants are commonly used in many types of patients at elevated stroke risk. However, relatively little is known concerning how practicing physicians use these medications in their patients with extracranial carotid artery stenosis. The identification of variations in practice may help to both direct specific educational efforts and guide further research. METHODS: Between August 1993 and February 1994, we surveyed the stroke prevention practices of a stratified random sample of 2000 US physicians. The survey included clinical scenarios that probed the use of aspirin or other platelet antiaggregants and anticoagulants in symptomatic and asymptomatic patients with carotid artery stenoses of 50% to 70% or more than 70%, with and without known surgical contraindications. RESULTS: Sixty-seven percent of those eligible completed the survey (n = 1006). More than 85% of physicians responded that they always or often prescribe aspirin or other platelet antiaggregants regardless of degree of carotid artery stenosis, symptom status, or presence of surgical contraindications. However, the reported frequency of use of these medications varied independently according to physician specialty (P = .044). In contrast, in addition to physician specialty, the reported frequency of anticoagulant use varied independently with degree of carotid artery stenosis, symptom status, and presence of surgical contraindications (P < .0001 for each variable). Fifteen percent of physicians responded that they always or often use anticoagulants for asymptomatic patients with 50% to 70% carotid artery stenosis versus 43% who reported doing so for symptomatic patients with a similar degree of stenosis (P < .001); 28% often or always prescribe anticoagulants for asymptomatic patients with more than 70% carotid artery stenosis versus 49% who do so if symptoms are present (P < .001). The odds of noninternist primary care physicians responding that they always or often use anticoagulants were more than five times higher (odds ratio, 5.32; 95% confidence interval [CI], 3.79 to 7.45) than surgical specialists. Compared with surgical specialists, the odds ratios for the use of anticoagulants were 3.65 for internists (95% CI, 2.63 to 5.06) and 1.88 (95% CI, 1.40 to 2.53) for neurologists. CONCLUSIONS: These data show the following: (1) Aspirin or other platelet antiaggregants are used by most physicians regardless of degree of carotid artery stenosis, symptom status, or presence of surgical contraindications; (2) anticoagulants are prescribed selectively, with each of these variables influencing their use; and (3) the use of both classes of agents varies with physician specialty training.

US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke. Carotid endarterectomy.

BACKGROUND AND PURPOSE: Data from several randomized clinical trials concerning the efficacy of carotid endarterectomy (CE) in patients with symptomatic and asymptomatic stenoses of the extracranial carotid artery are now available. Yet, there are few data concerning the patterns of use of CE by physicians for their patients at risk for stroke. These data are critical for the rational allocation of resources and targeting of educational efforts. METHODS: Between August 1993 and February 1994, we surveyed the stroke prevention practices of a stratified random sample of 2000 US physicians. The survey queried the perceived availability and use of diagnostic studies and surgery for specific types of patients who might be considered candidates for CE. RESULTS: Of eligible physicians, 67% (n = 1006) completed the survey. Seventy percent reported that they always or often obtain carotid ultrasonography for evaluation of patients with asymptomatic bruits; 89% do so in patients with recent transient ischemic attack or minor stroke (P < .001). For asymptomatic patients, 13% always or often obtain a cerebral angiogram if carotid ultrasonography indicates 50% to 70% stenosis versus 33% if carotid ultrasonography indicates > 70% stenosis (P < .001). For asymptomatic patients with > 70% stenosis, a cerebral angiogram was reported as seldom or never used by 42% of physicians who viewed the test as readily available versus 67% if cerebral angiography was perceived as not readily available (P = .005). Multinomial multiple logistic regression analysis showed that symptom status, the degree of stenosis, perceived availability of CE, and physician specialty independently contributed to the explained variance in the reported use of CE (P < .001). The odds of performing CE were approximately four times greater in patients recent symptoms compared with asymptomatic patients (P < .001) and four times greater in patients with > 70% stenosis compared with patients with 50% to 70% stenosis (P < .001). Physicians who perceived CE as not being readily available were one third as likely to report using the procedure compared with physicians who reported having ready access (P = .004). CE was reported as being always or often used by more than 80% of neurologists and surgeons but by only about half of internists and noninternist primary care physicians for patients with newly symptomatic high-grade stenosis (P < .001). Almost one in four noninternist primary care physicians responded that they would seldom or never use CE for these patients. CONCLUSIONS: These data show that (1) symptom status and degree of carotid artery stenosis strongly influence the reported frequency with which CE is used by practicing physicians; (2) the perceived availability of cerebral angiography and CE significantly affects their reported frequency of use; and (3) physician specialty significantly influences the reported frequency of use of CE.

US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices.

BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.

Socioeconomic factors and Medicare supplemental health insurance.

This analysis was conducted to determine how personal and community characteristics affect coverage by private insurance to supplement Medicare. Data from the 1980 National Medical Care Utilization and Expenditure Survey were used. After controlling for health status, it was found that supplemental coverage was positively associated with education, income, number of self-reported chronic conditions, being white, being married, and having a regular source of care. Private coverage was negatively associated with Medicaid coverage and age. The only community characteristic associated with supplemental coverage was region. Consideration of local medical resources and economic measures did not change that.

Dental providers in international perspective.

This paper describes the dental provides in six study areas. The data were collected through interviews with samples of dentists who participated in the World Health Organization/US Public Health Service International Collaborative Study. Comparisons between dental providers in the different areas focus upon their personal characteristics, characteristics of their practices, their work patterns, the way they used their time, their professional activities and their satisfaction with dentistry. These descriptive data are related to consumer survey data obtained in another section of the International Collaborative Study.