Family practice research journal最新文献

Objective: Bad debt is one measure of the cost of medical indigence on health care institutions. This two-part study identifies a methodology for and presents findings from measuring bad debt in a collection of office-based practices.

Methods: In Part I of the study, data were gathered on site from 26 practices in Sullivan County, New Hampshire, after first conducting a survey of bad debt losses at these offices. Survey findings were compared to on-site findings and it was determined that only the practices with computerized record-keeping systems were able to supply accurate data by survey alone. In Part II, 71 randomly chosen computerized practices in New Hampshire and Vermont (identified in a screen of 275 practices) were surveyed on bad debt.

Results: The practices from Part II wrote off an average of $23,115 per physician in 1990 from bad debt in a region in which primary care physician income averages approximately $70,000.

Conclusions: The author calculates that bad debt losses are greater than either Medicare or Medicaid losses. Uninsured patients account for 21.6% of office visits but 45% of practice write-offs. Bad debt accounts for a 16% loss from total earnings from regular office visits. Office-based practices in this study are shouldering a significant portion of the cost of care of their uninsured and underinsured patients.

Objective: Self-report and somnographic data from 135 volunteer, disease-free, women (37-59 years) were used to determine the prevalence of perceived poor sleep and to compare women with and without "poor" sleep on menopausal status, somnographic sleep, psychological distress, and somatic symptom cluster frequencies.

Methods: Data from identical measures done on two groups of perimenopausal-age women, one recruited for menopausal age and the other for same age but sleep problems plus controls, were tested using a two-way analysis of variance for the main effects of recruitment group and the presence or absence of "poor" sleep as well as the joint effects of both.

Results: "Poor" sleep was reported by more than one-third of the women, but menopausal status and perceived sleep quality were not statistically related. Women with "poor" sleep took longer to fall asleep, spent longer in bed, and had higher scores for psychological distress and for four out of five somatic symptom clusters (p < or = 0.03), compared to women with "good" sleep.

Conclusion: In sum, midlife women reporting poor sleep are likely to have trouble falling asleep and to have higher psychological distress and somatic symptoms, especially musculoskeletal discomfort and fatigue, coinciding with their perceived poor sleep.

Clinics representing more than half of Minnesota's family physicians participated in a statewide study on the practice of family medicine conducted by the Minnesota Academy of Family Physicians. The survey was designed to provide direction for individual physicians, administrators, and the Minnesota Academy of Family Physicians as an organization. The survey identified some concerns regarding access to care. In the central portion of the state, 71% of the full-time equivalent family physicians were in practices with Medicaid patient restrictions. In the most sparsely populated towns, 35% of the reporting family physicians who provided obstetrical care three years ago discontinued that service due to the cost or availability of professional liability coverage. Statewide in 1989, 57% of the family physician positions recruited for by the practices studies were unfilled at year's end, with 82% unfilled in the most sparsely populated areas.

Objective: Interpretation of abnormal Papanicolaou smear reports and the subsequent management of the patient frequently present significant decision-making problems for clinicians. The purpose of this study was to evaluate family physician clinical decision-making strategies for abnormal cervical cytology reports using simulation techniques.

Methods: One hundred fifteen practicing family physicians evaluated two simulations of women with abnormal cervical cytology, the first with inflammatory cytology and the second with a high-grade squamous intraepithelial lesion.

Results: Most physicians (66%) selected an etiology evaluation and specific treatment approach to an inflammatory report, while 26% of respondents chose empiric treatment. For the high-grade squamous intraepithelial lesion simulation, 88% of physicians chose the appropriate management response of colposcopic evaluation.

Conclusions: Practice experience, level of involvement, clinician gender, and type of cervical cytology classification influenced family physician clinical decision-making. The majority of responses to an inflammatory or high-grade squamous intraepithelial lesion report was appropriate based on current scientific data.

Although much has been written about the importance of collaboration among physicians in practice-based research, the relationship between the clinical investigator and nonphysician professionals in this setting has received less attention. Nurses, physician assistants, and other office support staff can provide valuable insights pertinent to research design and project implementation. Because nonphysician professionals frequently play a large part in implementing a research project, how well the investigator collaborates with them often determines the success or failure of the project. We suggest the following guidelines: 1. Consider the research interests of the nonphysician collaborators. 2. Adapt the project to office routine. 3. Limit the demands on staff. 4. Use detailed protocols. 5. Orient all collaborators. 6. Be available and visible. 7. Provide feedback and reward to all collaborators.

Objective: Hypertension is one of the most common diagnoses resulting in an office visit to the physician. We examined the relationship between the variation in the interval between follow-up visits for hypertensive patients and the control of blood pressure.

Methods: The sample consisted of 113 patients who made 399 visits. Data included current medical problems, medications, type of health insurance, and socioeconomic status for each patient.

Results: The mean number of days between visits was 70.6 with a standard deviation of 76.3. No significant relationship was found between visit interval and severity of hypertension (p = 0.14). Sample size made it possible to detect a 20% difference with a likelihood of 0.80 at a significance level of 0.05.

Conclusions: Our findings are limited by our focus on patient behavior rather than physician recommendation concerning the interval between visits, and by the distinct possibility that many of the visits were made for reasons other than follow-up of hypertension.

Objective: Identify barriers to immunization and evaluate the timing of immunization in private practice settings.

Methods: Design was a comparison of childhood immunization data with a survey of physicians who administered the vaccines. Setting was primary care offices in rural and urban/suburban Minnesota. Subjects were children under 7 years old who were receiving either Diphtheria, Tetanus, and Pertussis vaccine, Diphtheria and Tetanus vaccine, or the first Measles, Mumps and Rubella vaccine and their primary care physicians. Main outcome measures were time from birth to the third Diphtheria, Tetanus, and Pertussis vaccine (DTP) and from birth to the first Measles, Mumps, and Rubella vaccine (MMR) and their determinants.

Results: The third Diphtheria, Tetanus, and Pertussis vaccine and first Measles, Mumps, and Rubella vaccine were late in 32% and 41% of children, respectively. We observed a significant difference, based upon insurance status, in Diphtheria, Tetanus, and Pertussis vaccine timing (p = 0.0001) but not in Measles, Mumps, and Rubella vaccine timing. Significant correlates of earlier Diphtheria, Tetanus, and Pertussis immunization include physician residency training, suburban/urban practice locale, and the likelihood that the physician would refer children based upon insurance coverage to health departments for immunization.

Conclusions: Important determinants of immunization in the private sector include reimbursement and physician training about prevention.

Epidural analgesia offers excellent relief from the pain of uterine contractions during labor. It is well tolerated by both mother and baby. However, recent reports suggest that epidurals increase the rate of both cesarean sections and instrumental deliveries, with their attendant costs and morbidities. At our community hospital, 100 consecutive labors using epidural anesthetics were contrasted with 100 consecutive labors managed without them. No significant differences were found in birth weights, Apgar scores, cesarean section rate, or complications. Forceps use was greatly increased, from 13% to 37% (p < 0.01).

Objective: The purpose of this study was to compare the relative informational yield of Geriatric Home Assessments with medical charts of patients seen in family practice settings.

Methods: The information from comprehensive Geriatric Home Assessments of 28 well-established patients, conducted by small groups of medical students in a family practice clerkship, was compared with information available in the medical charts of these patients for the previous three years.

Results: For no problem studied was identification in the medical chart as high as from the Geriatric Home Assessment. Problems with family/social support, inadequate dental care, and immunization deficiencies were frequently noted in the Geriatric Home Assessment but only rarely in the medical chart. Concordance between Geriatric Home Assessment and medical charts was greatest for depression/anxiety, sensory loss, smoking, dizziness, and sleep problems.

Conclusions: While evaluation of the utilization of information was beyond the scope of the current study, the results suggest the potential usefulness of complementing office care with home assessments in establishing a data base for the medical management of elderly patients in primary care settings.