Nonpharmacological management of agitation in hospitalized patients: a pilot study.

This article reports on the use of Simple Pleasures interventions to minimize agitation in hospitalized patients with late-stage dementia. The pilot project was not able to demonstrate statistical significance; however, the positive response to the education and provision of interventions has led to a hospital-wide dissemination of the interventions in the form of an activity box. No adverse effects of the interventions were found, and some patients experienced a significant decrease in agitation and use of sedative medications after exposure to the interventions. Hospital lengths of stay were shorter than expected and may also have been influenced by the intervention.

The development of resident "report cards" in the context of managed care education.

This article describes the development of residents' report cards as one component of a curriculum on physician profiling for primary care residents. Thirty-two first-year residents matriculating into family practice, internal medicine, pediatrics, and obstetrics-gynecology residency programs in 1998 were profiled. The patient information in the report cards was limited to data on a panel of Medicaid patients initially seen in the resident ambulatory care clinics. All subsequent patient care for that population was also included. The method was multi-step and complex, involving hospital billing personnel and cooperation with a managed care partner. A three-session educational program was developed to introduce the concept of physician profiling. The first session consisted of a panel discussion on managed care. The second session was devoted to a discussion of hypothetical physician profiles with inappropriate length of stays, days/1,000, low numbers of office visits combined with high urgent-care use, and high outpatient services utilization. Small groups of residents participated in a problem-identification process as if they were members of a group practice. Residents identified problems in the reports and made suggestions for behavioral changes. A final session presented residents with their own personal report cards. Residents were surveyed both at the beginning of their first year and before and after the educational intervention on profiling. Resident attitudes, which were negative toward managed care at the outset, became generally more positive. Comparisons of pre-test and post-test means on the five-point Likert scale, using a paired-samples t-test, revealed significant changes in the residents' attitudes overall.

Training tomorrow's clinicians today--managed care essentials: a process for curriculum development.

OBJECTIVE: To develop a managed care curriculum for primary care residents. DESIGN: This article outlines a 4-stage curriculum development process focusing on concepts of managed care organization and finance. The stages consist of: (1) identifying the curriculum development work group and framing the scope of the curriculum, (2) identifying stakeholder buy-in and expectations, (3) choosing curricular topics and delivery mechanisms, and (4) outlining the evaluation process. Key elements of building a curriculum development team, content objectives of the curriculum, the rationale for using problem-based learning, and finally, lessons learned from the partnership among the stakeholders are reviewed. RESULTS: The curriculum was delivered to an entering group of postgraduate-year 1 primary care residents. Attitudes among residents toward managed care remained relatively negative and stable over the yearlong curriculum, especially over issues relating to finance, quality of care, control and autonomy of practitioners, time spent with patients, and managed care's impact on the doctor-patient relationship. Residents' baseline knowledge of core concepts about managed care organization and finance improved during the year that the curriculum was delivered. Satisfaction with a problem-based learning approach was high. CONCLUSION: Problem-based learning, using real-life clinical examples, is a successful approach to resident instruction about managed care.

Treatment of bacterial endocarditis with vancomycin.

Five patients with bacterial endocarditis who were allergic to penicillin were treated successfully with vancomycin. The causative microorganisms were Streptococcus bovis, S faecalis, S agalactiae, S intermedius, and Staphylococcus aureus. Except for the strain of S faecalis, vancomycin was bactericidal against these organisms at easily achievable serum concentrations. To insure a bactericidal serum titer of 1:8 or greater, streptomycin was added in the therapy of the case caused by S faecalis. There was no toxicity from vancomycin therapy in our patients except for mild phlebitis at the infusion site. Vancomycin appears to be an effective alternative to penicillin in individuals with endocarditis due to susceptible organisms. Vancomycin in combination with an aminoglycoside may be appropriate therapy for enterococcal endocarditis.

Recruitment in a primary care trial on smoking cessation.

The purpose of this study was to describe and compare the rates of recruitment during a randomized clinical trial on smoking cessation in two primary care practices. One site was a five-physician private family practice setting with about 15,000 patients. During 34 days, 576 patients were screened, of whom 22% were smokers. Among the smokers screened, 54% consented, 33% refused consent, and 13% were called in too early to consent. The other site was a six-physician academic medical practice with about 16,000 patients. During 53 days, 1,692 subjects were screened, of whom 16.2% were smokers. Among the smokers, 19% consented, 81% refused consent, and none were called in early. The enrollment of smokers was 3.3 times greater in the private practice than the academic practice. At the first site, study personnel screened 26.6 subjects per day, whereas the practice receptionist screened only 13.4 subjects per day (P less than .01). A randomized trial of having subjects read the informed consent versus having study personnel read it to them showed no differences in recruitment. The data suggest that private practices may have greater potential for subject recruitment than academic sites, that using study personnel improves recruitment, and that having study personnel actively involved in informed consent does not improve recruitment.

Training medical students in evidence-based medicine: a community campus approach.

BACKGROUND AND OBJECTIVES: Clinicians need skills in critical appraisal of medical literature to improve quality of care. This report on evidence-based medicine (EBM) curricula describes 1) the role of family medicine educators, 2) timing, 3) value of a standard format across multiple communities, and 4) outcomes in attitudes and skills. METHODS: In 1992, a nine-session curriculum delivered across six community campuses was introduced during the third year of medical school in the College of Human Medicine at Michigan State University. Evaluation compared 1) responses on the Association of American Medical Colleges graduation questionnaires from classes who received the curriculum with the 1994 class who did not (424 students), 2) responses to questions on group process performance, and 3) focused surveys of two classes. RESULTS: Trained classes reported higher levels of confidence in critical appraisal and research skills than the 1994 class and other schools. Respondents reported the small-group process as effective, greater appreciation of the training after 1 year of residency than at graduation, and no change in research activity. CONCLUSIONS: Family medicine educators can lead a new curriculum in EBM and maintain consistent standards across multiple communities. Many questions remain concerning the ideal curricular design to help clinicians apply the best research to patient care.

Screening for asymptomatic bacteriuria in pregnancy. A decision and cost analysis.

Screening women for asymptomatic bacteriuria on the first prenatal visit is a standard of obstetric care. Treating women with positive results decreases the risk of pyelonephritis and possible prematurity. This study uses decision and cost analysis to compare the utility of screening for asymptomatic bacteriuria with not screening. Data are based on published reports and average charges for services. Costs are based on 1988 charges, projected for the expected results of outpatient screening, possible suppressive therapy, and risks of pyelonephritis. Screening is based on the combined sensitivities and specificities of the MacConkey and CLED (cysteine-lactose-electrolyte-deficient agar) panels of the dip-slide culture. Under the baseline assumptions, the risk of pyelonephritis is estimated to be 2 cases per 100 screened women vs 3.5 cases per 100 unscreened women. The anticipated cost of screening 100 women is $9,939, compared with $12,824 for not screening 100 women. Screening is cost saving unless the cost of screening is above $26, the length of hospitalization for pyelonephritis is fewer than 2.2 days, the risk of asymptomatic bacteriuria falls below 2%, the risk of pyelonephritis with asymptomatic bacteriuria falls below 13%, or the efficacy of treatment in preventing pyelonephritis falls below 38%.

Family physician management of HIV and AIDS: a Vermont study.

BACKGROUND: The purpose of this study was to survey family physicians regarding the barriers to providing primary care for persons with human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) in a small, rural state with a low incidence of infection. The study focused on issues facing family physicians, such as lack of training and experience, skill in managing the complications of HIV and AIDS, fears about transmission, patients' fears about seeing a physician who treats patients with HIV or AIDS, and lack of community consultative and ancillary services. METHODS: All 132 members of the Vermont Academy of Family Physicians were mailed a 33-item survey questionnaire; 106 (80%) responded. RESULTS: Fifty-seven percent of family physicians currently provide medical care for HIV-positive asymptomatic patients, and 45% provide care for symptomatic patients. Seventy-three percent of family physicians either currently manage or are willing to be trained to manage HIV complications. CONCLUSIONS: The results of this study indicate that a majority of physicians are willing to provide a wide spectrum of medical treatment and services to patients with HIV or AIDS.

Enhancing smoking cessation of low-income smokers in managed care.

BACKGROUND: Although office-based and telephone support services enhance the rate of smoking cessation in managed care systems, it is not clear whether such services are effective for very low-income smokers. We evaluated the comparative effectiveness of usual care (physician-delivered advice and follow-up) and usual care enhanced by 6 computer-assisted telephonic-counseling sessions by office nurses and telephone counselors for smoking cessation in very low-income smokers in Medicaid managed care. METHODS: A randomized clinical trial comparing the 2 approaches was conducted in 3 Michigan community health centers. All clinicians and center staff received standard training in usual care. Selected nurses and telephone counselors received special training in a computer-assisted counseling program focusing on relapse prevention. RESULTS: The majority of the study population (233 adult smokers with telephones) were white (64%) women (70%) with annual incomes of less than $10,000 (79%) and with prescriptions of nicotine replacement therapy (>90%). At 3 months, quit rates (smoke-free status verified by carbon monoxide monitors) were 8.1% in the usual-care group and 21% in the telephonic-counseling group (P=.009) by intention-to-treat analysis. Special tracking methods were successful in maintaining participants in treatment. CONCLUSIONS: Smoking cessation rates are enhanced in a population of very low-income smokers if individualized telephonic-counseling is provided. State and Medicaid managed care plans should consider investing in both office-based nurse and centralized telephonic-counseling services for low-income smokers.

Restructuring a family practice obstetrics curriculum.

Maintaining a high-quality curriculum for family practice residency training in obstetrics has become increasingly difficult. In 1984 the faculty of the University of Vermont Department of Family Practice needed to upgrade its obstetric curriculum in a community where family practice obstetrics was nonexistent. The key steps to a new curriculum included the recruitment of family practice faculty with experience in obstetrics, expanded communication with the Department of Obstetrics and Gynecology, the development of baseline attending privileges in family practice obstetrics, the formation of educational tracks for residents, and the promotion of chart audits. Also important were faculty role modeling, intradepartmental meetings, intensive elective rotations, and community education. This case report of program development in family practice obstetrics may serve as a model to help other residency programs.

Enhancing smoking cessation rates in primary care.

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) guidelines on smoking cessation recommend that primary care physicians provide both brief advice against smoking and follow-up care for all smokers. Surveys show that although physicians understand the importance of smoking cessation, the actual implementation of these guidelines is limited. The main objective of our study was to evaluate the comparative effectiveness of 2 different approaches to smoking cessation counseling: practice-based and community-based. METHODS: Both smoking cessation approaches consisted of 1 recruitment session and 6 computer-assisted counseling sessions. In the practice-based approach, counseling was provided by office nurses and telephone counselors; in the community-based approach, the counseling was given by telephone counselors only. Four practices in 3 mid-Michigan communities participated, including 120 physicians and 487 patients who were smokers. The physicians were trained to provide brief advice for smoking cessation consistent with the AHCPR guidelines; the nurses and telephone counselors were trained in relapse prevention, computer skills, and individual case management. Sixty-two percent of the participants obtained free nicotine replacement therapy. RESULTS: At 6 months, quit rates (7-day smoke-free status) were 35% in the practice-based group and 36% in the community-based group. Participants who completed at least 4 sessions showed higher quit rates than those who did not. CONCLUSIONS: Nurses in primary care practices and counselors can be trained to deliver effective relapse-prevention counseling during office visits and by telephone. Our study showed an increase in the reported rates of smoking cessation by using these counseling methods.

Physician interest in breast cancer screening education. A survey of Vermont family physicians.

A mailed survey of 141 Vermont family physicians (74% participating) was conducted to determine their breast cancer screening practices and beliefs and their interest in receiving training in breast cancer screening. Of these, only 12% reported that at least three fourths of their female patients older than 50 years received mammograms at least once a year, compared with 33% who reported providing breast self-examination instruction and 35% who administered clinical breast examination with at least three fourths of these patients at least once a year. Nevertheless, 55% of the physicians rated mammography as a very effective breast-screening procedure; 28% rated breast self-examination and 16% rated clinical breast examination as very effective. Three fourths of the physicians showed great interest in learning more about breast palpation, breast self-examination instruction, and mammography. Individual instruction in the office was preferred over a group workshop format, and a trained nonphysician health professional was considered as acceptable as a physician to provide the instruction. Results suggest that breast cancer screening education for family physicians is a high priority, and that physicians will welcome such training, particularly if it is office-based.

Pertussis vaccination.

With 3.2 serious events per million doses, the risks associated with pertussis vaccination are greater than for any other routine immunization. The most significant side effects are neurologic, but these are rare when compared with the neurologic effects of pertussis infection itself. High fever, persistent or high-pitched cry, seizures, encephalopathy and shock are absolute contraindications to further pertussis vaccination. A new acellular vaccine shows promise.