Continuity of care, informed consent, and fiduciary responsibilities in for-profit managed care systems.

The replacement of fee-for-service systems by managed care systems offers opportunities for cutting medical costs, integrating health care delivery systems, and improving communication among physicians. Before these benefits can be realized, however, a number of problems must be addressed. First, managed care systems must find ways to foster continuity of care in a market that has thus far proved unstable. Second, managed care systems must find ways to protect the patient's right to fully informed consent even while educating patients about the importance of cost-effectiveness and why certain treatments might not be included in their health plan. Third, managed care systems must find ways to promote physicians' fiduciary responsibilities to patients and to respect physicians' clinical judgments even while creating legitimate incentives to provide cost-effective health care.

Prenatal smoking cessation counseling by Texas obstetricians.

BACKGROUND: Smoking during pregnancy causes 20 to 30 percent of low birthweight and 10 percent of infant mortality in the United States. Brief counseling can reduce rates of smoking. The study objectives were to describe Texas obstetricians' pregnancy smoking cessation counseling activity and to identify attributes associated with consistent, effective counseling. METHODS: A survey was mailed to a random sample of Texas obstetricians. RESULTS: A response rate of 44 percent (n = 204) was attained. A counseling coverage-effectiveness index was created based on the percentage of smokers counseled and use of specific techniques. Almost all respondents reported asking about smoking; fewer, however, reported counseling smokers. Physicians with low index scores, indicating inconsistent coverage, ineffective counseling, or both were dissatisfied with their current counseling, did not perceive counseling to decrease smoking, were not aware of the risks of smoking, and were unfamiliar with expert reports and recommendations for prenatal care. CONCLUSIONS: Obstetricians who are not reached by expert reports and guidelines from groups outside their specialty or who do not perceive the seriousness of maternal smoking are less likely to counsel consistently and to use the most effective techniques. Continuing medical education at local, state, and national levels should be directed toward increasing knowledge and skills about smoking cessation counseling of pregnant women.

Trial of labor or repeated cesarean section. The woman's choice.

OBJECTIVE: To develop recommendations for the preferred delivery method for a pregnant woman who underwent a previous low transverse cesarean section and who has no contraindications to labor. DATA SOURCES: MEDLINE searches and the references from retrieved articles yielded 759 citations. Search terms included trial of labor (TOL), trial of scar, vaginal birth after cesarean section (VBAC), and uterine rupture. STUDY SELECTION: Articles with primary outcomes data contrasting TOL and elective repeat cesarean section (ERCS) were analyzed. Studies from developing countries or before 1980 were excluded. DATA EXTRACTION: Data from 292 articles were extracted independently by at least 2 team members using a structured form. DATA SYNTHESIS: Outcome data were combined using commercially available software and are presented as absolute differences per 10,000, with 95% Bayesian confidence intervals. Maternal outcomes showed that TOL increased the risk for uterine rupture (23.9 [0.24%]); ERCS increased the risk for infection (522 [5.22%]) and bleeding (58.6 [0.59%]). Infant outcomes differed only for 5-minute Apgar scores of less than 7, which were more likely for infants whose mothers underwent TOL (85 [0.85%]). Other outcomes (eg, disability), patient preferences, and cost data did not lend themselves to meta-analysis and were examined separately. While two thirds of women desired TOL, one third preferred ERCS. Costs were 1.7 to 2.4 times greater for ERCS. CONCLUSIONS: A woman should be given information on both delivery methods and encouraged to undergo TOL, but her preference for ERCS should be respected.

The patient with gonococcal infection.

Despite the availability of effective antimicrobial therapy since the middle of the twentieth century, gonococcal disease remains a common and expensive public health problem. The patient who presents to the primary care office with gonococcal disease, or one who is found to be infected after screening, still faces significant emotional and economic barriers to effective treatment and control of the spread of the disease. Along with the emergence of resistant strains and the previously existing problems of asymptomatic carriers and reluctance to seek treatment, physicians are charged with the problems of identifying patients at risk for the disease, providing effective treatment for those infected, and preventing further spread of infection. Simple, effective, and inexpensive therapies that also treat the frequently present coinfections with other sexually transmitted diseases are not yet available. Antibiotic therapy must still be chosen with regard to the patient's history and circumstances. The approach to counseling the patient about avoidance of complications, prevention of reinfection, and prevention of transmission of infection must be mastered by the primary care physician if progress is to be made toward the eradication of gonococcal disease.

Pilot study report: obstetrical care by Texas family physicians.

Fewer family physicians are including obstetrics in their practices. This has caused concern about access to obstetrical care and has fueled the debate about the need for obstetrics curriculum in family practice residencies. Reasons frequently cited by previous research for this change in practice pattern include the rapidly escalating cost of liability insurance and the threat of lawsuit for obstetrical malpractice. The decrease in the availability of obstetrical care from family physicians has hampered access to obstetrical care, especially for rural Texans. Texas family physicians have not been surveyed previously about their obstetrical practices. For this pilot study I surveyed 205 of Texas' 4,700 family physicians and general practitioners (4%) about their past and present obstetric practices. The sample was randomly selected, and included both MDs and DOs. Of the 64.9% who responded, 28% were practicing obstetrics, 11% had never included obstetrics in their practices, and 61% had practiced obstetrics in the past. Forty percent of those who had discontinued obstetric practice did so after 1983. High malpractice premiums and fear of lawsuits were the most frequently chosen reasons for discontinuing the obstetric component of practice. Documenting this trend of decreasing availability of obstetrical care from family physicians, and sharing the data with policymakers, may help to prevent the disappearance of the family physician who delivers babies.