Family physicians' perceptions on how they deliver cost-effective care: a qualitative study from the Residency Research Network of Texas (RRNeT).

BACKGROUND AND OBJECTIVES: The aim of our study was to deepen our understanding of the factors that may explain the observational literature that more primary care physicians in an area contribute to better population health outcomes and lower health care costs. METHODS: This study used in-depth, qualitative interviewing of family physicians in both urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking subjects to give examples and personal narratives demonstrating cost-effectiveness and cost inefficiencies in their own practices. An iterative open-coding approach was used to analyze transcripts to search for unifying themes and sub-themes until consensus among investigators was achieved. RESULTS: Thirty-eight respondents gave examples of how their decision-making approaches resulted in improved patient outcomes and lower costs. Family physicians' cost-effective care was founded on two themes-characteristic attitudes and skills of the physicians themselves and a thorough knowledge of the whole patient. Family physicians also felt their approaches to gathering information and then making diagnostic and treatment decisions resulted in fewer tests and fewer treatments ordered overall. Family physicians also delivered care in less expensive facilities and generated lower overall charges for physician fees. CONCLUSIONS: Family physicians perceived that their approaches to patient care result in medical decision making priorities and care delivery processes that contribute to more cost-effective health care. These outcomes were achieved less by providing preventive services and strictly adhering to guidelines but rather by how they individualized the management of new symptoms and chronic conditions.

Nonnutritive sucking and necrotizing enterocolitis.

The purpose of this study was to explore the possible protective effect of nonnutritive sucking (NNS) against the development of necrotizing enterocolitis (NEC). A retrospective chart review was conducted to examine the histories of 12 preterm infants who were enrolled in a longitudinal study of the effects of NNS on energy expenditure, weight gain, and feeding readiness. Six infants were enrolled in the control group; they did not receive NNS but did develop NEC. Six infants were in the experimental group and did not develop NEC. The groups were compared on the basis of clinical correlates associated with NEC. These included race, gender, birth weight, five-minute Apgar, maternal bleeding, maternal age, and length of ruptured membranes. For infants who developed NEC, the number of clinical correlates ranged from one to four. For infants who received NNS, the range of clinical correlates was from one to five. It is not possible to conclude from this study that NNS protects preterm infants from NEC. Prospective studies of larger sample sizes that involve examination of the effect of NNS on gastric motility and enzyme and hormone secretion are needed.

Type-specific changes in fiber morphometry following denervation of canine extraocular muscle.

To investigate the changes that occur in extraocular muscle morphometry following denervation, 12 beagles were subjected to intracranial section of the left oculomotor nerve. The inferior and medial rectus muscles were removed from both orbits of four dogs killed at each 4-week postoperative interval. Fiber diameters and fiber-type ratios of denervated muscles were compared with those from paired muscles in the normal orbit. We found significant, persistent atrophy of the singly innervated fibers in both the global and orbital layers of denervated extraocular muscle. The multiinnervated fibers were predominantly spared from denervation atrophy. We also found a significant increase in the proportion of multiinnervated fibers in the orbital layer only. These results suggest a relative neurotrophic independence of multiinnervated fibers in extraocular muscle.

Object transformations in the play of language-impaired children.

The play behavior of 10 language-impaired children was observed. Their performances in play were compared to those of 10 normal-language children matched for chronological age as well as to those of 10 normal-language children matched for mean length of utterance. The children were observed as they played spontaneously with a standard group of toys and as they played with objects that required object transformations for successful play. The chronological age-matched normal subjects showed a trend toward performance of more object transformations in play than either the language-impaired or younger normal-language children. Additionally, although object transformations were observed in both segments, all children performed more object transformations with objects than with toys.

Patterns of discourse cohesion and coherence in Alzheimer's disease.

Patterns of discourse--as reflected in the use of propositions, cohesion devices, and in judgments of coherence--in the speech of 6 well elderly and 6 patients with senile dementia of the Alzheimer type (SDAT) during topic-centered interviews were compared. Compared to the well elderly, SDAT patients used significantly more words and conversational turns. The interviewer also used more words and turns when interviewing SDAT patients, making those interviews more lengthy and more interactive than those of the elderly comparison group. Although significant differences in propositional form and cohesion devices were not found, a pattern of cohesion disruptions in SDAT patients was identified that appears consistent with previously noted patterns of language dissolution. Coherence judgements by four listeners showed significant differences between the two groups. The breakdowns in coherence were related to one subtype of cohesion disruption, missing element. This suggests that incoherence may result in part from a loss of the ability to take the listener's perspective in developing thematic structure during conversation. It is argued that SDAT results not only in the impairment of linguistic abilities but also in the impairment of discourse abilities that contribute to Alzheimer patients' incoherent speech.

Facilitating word combination in language-impaired children through discourse structure.

The influence of an adult-child discourse structure on the production of early word combinations was examined in language-impaired children. The subjects were 10 children (2:8-3:4) at the single-word utterance level. Eight of the children were engaged in 10 experimental sessions utilizing vertical structures (e.g., Adult: "Who's this?" Child: "Daddy." Adult: "What's Daddy throwing?" Child: "Ball." Adult: "Yeah, Daddy's throwing the ball."), while the remaining children, serving as controls, were engaged in an alternate activity. Examination of pretest and posttest data as well as session data revealed a substantial increase in the number of multiword productions for most of the children in the experimental group but not for the children serving as controls. These findings indicate that vertical structures have a facilitating effect on the multiword productions of language-impaired children comparable to that found in an identical procedure with normally developing children. The use of a naturally occurring adult-child discourse structure as an intervention procedure is discussed.

Symbolic play in normal and language-impaired children.

The symbolic play of 15 normally developing (CA, 16-22 months) and 15 language-impaired children (CA, 32-49 months), whose productive language skills were at the single-word utterance level, was compared. Symbolic play was assessed formally through the Symbolic Play Test and informally through the observation of spontaneous play. The language-impaired children were found to be developmentally advanced when compared to the language-matched normal children in the level and direction of their symbolic play. Relative to age norms, however, the language-impaired children evidenced deficits in symbolic play. Thus, their linguistic and symbolic play abilities were not equally impaired. These findings are discussed in terms of their implications for the relationship between symbolic play and language and for the nature of specific language impairment.

Early lexical acquisition in children with specific language impairment.

This study examined the characteristics of early lexical acquisition in children with specific language impairment. Sixteen unfamiliar words and referents were exposed across 10 sessions to language-impaired and normal children matched for level of linguistic development. Posttesting revealed similar comprehension-production gaps in the two groups of children. In addition, both groups showed greater comprehension and production of words referring to objects than words referring to objects than words referring to actions. However, the language-impaired children's object word bias was not as marked as that of the normal children. For both groups, words containing initial consonants within the children's production repertoires were more likely to be acquired in production than words containing consonants absent from the children's phonologies. A similar tendency was not seen for comprehension.