Counseling smoking parents of young children: comparison of pediatricians and family physicians.

BACKGROUND: Secondhand smoke is a major cause of morbidity in young children, and exposure to smoking parents is the principal source. Physician visits for young children present an opportunity to effect behavioral change among smoking parents. OBJECTIVE: To survey pediatricians and family physicians in their knowledge and practice of smoking cessation counseling with parents. DESIGN: Cross-sectional mail survey. SETTING: Urban California. PARTICIPANTS: Pediatricians and family physicians in urban areas of California, younger than 65 years, practicing in an ambulatory setting, and randomly selected from the American Medical Association Physician Masterfile. MAIN OUTCOME MEASURES: Reported frequency of asking about tobacco use, using cessation counseling techniques with smokers, and perceived barriers to providing cessation services. RESULTS: Of the 1000 mailed surveys, 899 were eligible and 499 (56% response rate) were returned and completed. A higher proportion of pediatricians compared with family physicians were women (44% vs 29%; P<.01) and nonwhite (44% vs 32%; P =.01). Family physicians compared with pediatricians were more likely to report referring a parent to a smoking cessation program (41% vs 30%), giving pamphlets on smoking cessation (40% vs 28%), asking for a quit date (41% vs 18%), scheduling a follow-up visit to discuss quitting (27% vs 5%), and recommending nicotine replacement therapy (41% vs 13%) (for each comparison, P<.001). Pediatricians were more likely to report recording in the medical record smoking by a parent as a problem for the child (65% vs 48%; P<.001), but a higher proportion of pediatricians perceived that parents would ignore the advice (39% vs 24%; P<.001) and lacked interest in quitting smoking (45% vs 27%; P<.001). Pediatricians were more likely to agree that they lacked smoking cessation counseling skills (26% vs 7%; P<.001). Multivariate models showed that pediatricians were less likely to report performing 5 of 14 smoking cessation techniques in at least 50% of smoking parents. CONCLUSIONS: Pediatricians appear to lack training to implement smoking cessation counseling with smoking parents. Physicians in private practice are less likely to counsel smoking parents. Educational interventions for pediatricians are needed to decrease secondhand smoke exposure for young children.

Clozapine eligibility: the effect of stringent criteria on ethnic, gender and age subgroups of schizophrenic patients.

1. The purpose of this retrospective chart review study was to determine whether broad and stringent criteria differentially impact clozapine eligibility in ethnic, gender, and age subgroups of schizophrenic patients. 2. 505 patients charts were selected from a random cluster sample of mental health patients known to the city and county of San Francisco. Information related to clozapine eligibility was abstracted by trained non-clinical personnel. The impact of subgroup membership on eligibility was examined using logistic regression procedures. 3. Even under the broadest interpretation of FDA requirements for clozapine use, Asian patients were less likely to be eligible, since fewer Asian patients met clozapine treatment requirements. Under more stringent eligibility criteria, older patients were more likely to be excluded from eligibility when TD does not automatically satisfy treatment criteria, and younger patients were more likely to lose eligibility if the number of required adequate medication trials increases to three. 4. Broad eligibility criteria tend to differentially exclude Asian patients while more stringent criteria differentially exclude younger and older patients.

Effects of stringent criteria on eligibility for clozapine among public mental health clients.

OBJECTIVE: This study estimated rates of eligibility for treatment with clozapine among clients in a public mental health system using criteria with various degrees of restrictiveness. METHODS: A stratified, random cluster sample of 293 clients was selected from among all clients with schizophrenic disorders known to the mental health system of the city and county of San Francisco during 1991. Data on variables associated with eligibility for clozapine were abstracted from clinical records, and eligibility was estimated using broad and stringent criteria. RESULTS: An estimated 42.9 percent of the clients were eligible for clozapine using broad eligibility criteria that included a diagnosis of schizophrenia or schizoaffective disorder, two previous neuroleptic trials of at least 600 mg per day chlorpromazine equivalents for at least four weeks or tardive dyskinesia, Global Assessment of Functioning score less than 61, and no contraindications. Eliminating eligibility due to tardive dyskinesia alone, excluding persons with schizoaffective disorder, requiring six-week medication trials, and requiring three adequate medication trials instead of two resulted in substantial reductions in the rate of eligibility. CONCLUSIONS: Varying interpretations of the criteria for clozapine treatment listed in the medication package insert dramatically affect patients' eligibility for clozapine. Mental health agencies should endeavor to maintain a balance between restricting use of clozapine due to cost and providing it to the full spectrum of patients who might benefit from the medication.