Archives of family medicine最新文献

Context: While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly.

Objective: To assess whether a person's race or ethnicity is associated with low trust in the physician.

Design, setting, and participants: Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32,929).

Main outcome measure: Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules.

Results: After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites.

Conclusions: Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed. Arch Fam Med. 2000;9:1156-1163

Background: Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts.

Objective: To combine the patient data of a community health center (CHC) with health care survey data to display the CHC service area, the community's health care access needs, and relationships among access, poverty, and political boundaries.

Design: Georeferencing, analyzing, and mapping information from 2 databases.

Setting: Boone County, Missouri.

Participants: Community health center patients and survey respondents.

Main outcome measures: Maps that define the CHC service area and patient demographics and show poor health care access in relation to the CHC service area, CHC utilization in relation to poverty, and rates of health care access by geopolitical region.

Results: The CHC serves a distinctly different area than originally targeted. Subpopulations with unmet health care access needs and poverty were identified by census tract. These underserved populations fell within geopolitical boundaries that were easily linked to their elected officials.

Conclusions: Geographic information systems are powerful tools for combining disparate data in a visual format to illustrate complex relationships that affect health care access. These systems can help evaluate interventions, inform health services research, and guide health care policy. Arch Fam Med. 2000;9:971-978

Objective: To assess costs of pertussis morbidity among families in a community setting.

Design: Prospective survey.

Results: Sixty-nine families (87 individuals) were studied. Twelve of 14 families with household contacts included an ill adolescent or parent. This individual was the first identified pertussis case within the household in 8 families. A family member required an average of 1.6 visits before (range, 0-7 visits) and after (range, 0-9 visits) pertussis was diagnosed; children younger than 1 year needed 2.5 and 2 visits, respectively. Symptomatic improvement occurred after a mean of 31 days (range, 4-134 days) after pertussis diagnosis and full recovery after a mean of 66 days (range, 5-383 days). Adults experienced the longest recovery time (median, 93 days) compared with other age groups. The average medical costs for an infant, child, adolescent, and adult were $2822, $308, $254, and $181, respectively. Parents lost an average of 6 workdays (range, 1-35 days) to care for an ill child; for these parents, costs associated with work loss averaged $767 per family. An average of 1.7 and 0.7 lost workdays accrued to bring an ill child to a physician's office and the emergency department, respectively. A majority (58%) of parents working while family members were ill with pertussis reported decreased work productivity ranging from 25% to 99%. Work-related costs contributed more than 60% of the overall costs of pertussis.

Conclusions: The adverse financial effect of pertussis on 69 families in Monroe County, New York, was $145,903 ($2115 per family) and supports the need for booster immunizations in adolescents and adults. Arch Fam Med. 2000;9:989-996

Background: New rulings nationwide require health services researchers to obtain patient consent before examining personally identifiable data. A selection bias may result if consenting patients differ from those who do not give consent.

Objective: To compare patients who consent, refuse, and do not answer.

Design: Patients completing an in-office survey were asked for permission to be surveyed at home and for their records to be reviewed. Survey responses and practice billing data were used to compare patients by consent status.

Setting: Urban family practice center.

Patients: Of 2046 eligible patients, 1106 were randomly selected for the survey, were approached by staff, and agreed to participate. Approximately 87% of the nonparticipants were eliminated through a randomization process.

Main outcome measure: Consent status.

Results: A total of 33% of patients did not give consent: 25% actively refused, and 8% did not answer. Consenting patients were older, included fewer women and African Americans, and reported poorer physical function than those who did not give consent (P<.05). Patients who did not answer the question were older, included more women and African Americans, and were less educated than those who answered (P<.02). Visits for certain reasons (eg, pelvic infections) were associated with lower consent rates. On multivariate analysis, older age, male sex, and lower functional status were significant predictors of consent.

Conclusions: Patients who release personal information for health services research differ in important characteristics from those who do not. In this study, older patients and those in poorer health were more likely to grant consent. Quality and health services research restricted to patients who give consent may misrepresent outcomes for the general population. Arch Fam Med. 2000;9:1111-1118

Background: Family medicine is a relatively new specialty that has been trying to develop a research base for 30 years. It is unclear how institutional research success and emphasis have affected the research productivity of family medicine departments.

Objective: To examine the research infrastructure, productivity, and barriers to productivity in academic family medicine in research intense and less intense institutions.

Design, setting, and participants: A survey of 124 chairs among institutional members of the Association of Departments of Family Medicine. Departments were categorized as being associated with research intense institutions (defined as the top 40 in National Institute of Health funding) or less intense institutions.

Main outcome measures: Prioritization of research as a mission, number of funded research grants, total number of research articles published, and number of faculty and staff conducting research.

Results: The response rate was 55% (N = 68). Of 5 potential ratings on the survey, research was the fourth highest departmental priority in both categories of institutions. Departments in research intense institutions were larger, had more faculty on investigational tracks, and employed more research support staff (P<.05). Neither category of department published a large number (median = 10 in both groups) of peer-reviewed articles per year. Controlling for the number of full-time equivalent faculty, the departments in less intense institutions published a median of 0.7 articles, while the research intense institutions published 0.5 (P =.30). Departments in research intense institutions received more grant funding (P<.005) in both unadjusted and adjusted analyses. Chairs reported a scarcity of qualified applicants for research physician faculty openings.

Conclusion: Future initiatives should focus on prioritizing research and creating a critical mass of researchers in family medicine. Arch Fam Med. 2000;9:1100-1104

Hyperlipidemia and the atherosclerotic conditions that result from it are well recognized as major contributors to coronary heart disease (CHD). Fortunately, several large-scale clinical trials have shown that there are effective treatments that can substantially lower atherogenic lipid levels and thereby reduce the risk of CHD mortality and morbidity. However, duplication of these dramatic trial results can be negatively affected in "real life" clinical practice by an important issue: compliance. No medications will work if patients do not take them. Unfortunately, patients who need lipid-lowering therapy are likely to need it long-term, perhaps for a lifetime. Yet, many do not adhere to the prescribed medication regimen. This article reviews some major studies of compliance for lipid-lowering drugs. The reasons why patients do not take them as prescribed vary: poor education, lack of understanding, cost, provider indifference, and others. Achieving compliance requires a multifaceted approach. It can be enhanced by encouraging patients to talk openly about their medication habits and by convincing them of the long-term benefits of reaching and maintaining target low-density lipoprotein cholesterol levels. Although more studies focusing on compliance specifically regarding CHD are needed, the current literature does provide some guidance. Arch Fam Med. 2000;9:1169-1175