Archives of family medicine最新文献

Background: There is a dearth of validated information about lesbian and bisexual women's health. To better understand some of these issues, we used population-based data to assess variations in health behaviors, health status, and access to and use of health care based on sexual orientation.

Methods: Our study population was drawn from a population-based sample of women, the 1997 Los Angeles County Health Survey. Participants reported their sexual orientation and these analyses included 4697 women: 4610 heterosexual women, 51 lesbians, and 36 bisexual women. We calculated adjusted relative risks to assess the effect of sexual orientation on important health issues.

Results: Lesbians and bisexual women were more likely than heterosexual women to use tobacco products and to report any alcohol consumption, but only lesbians were significantly more likely than heterosexual women to drink heavily. Lesbians and bisexual women were less likely than heterosexual women to have health insurance, more likely to have been uninsured for health care during the preceding year, and more likely to have had difficulty obtaining needed medical care. During the preceding 2 years, lesbians, but not bisexual women, were less likely than heterosexual women to have had a Papanicolaou test and a clinical breast examination.

Conclusions: In this first population-based study of lesbian and bisexual women's health, we found that lesbians and bisexual women were more likely than heterosexual women to have poor health behaviors and worse access to health care. These findings support our hypothesis that sexual orientation has an independent effect on health behaviors and receipt of care, and indicate the need for the increased systematic study of the relationship between sexual orientation and various aspects of health and health care. Arch Fam Med. 2000;9:1043-1051

Microscopic polyangiitis (MPA), previously called hypersensitivity angiitis, is a systemic necrotizing vasculitis that involves many organ systems including the skin, joints, kidneys, and lungs. Microscopic polyangiitis most commonly affects adults in the fourth and fifth decades of life, with only a few cases reported in children. We describe a pediatric patient with microscopic polyangiitis. Arch Fam Med. 2000;9:1189-1192

Background: Considerable discussion has focused on treatment methods for patients with acute bronchitis.

Objective: To examine whether antibiotic or bronchodilator treatment is associated with differences in follow-up visit rates for patients with acute bronchitis.

Methods: A retrospective medical chart review was conducted for patients with a new episode of acute bronchitis over a 3-year period in the Practice Partner Research Network (29,248 episodes in 24,753 patients). Primary outcomes of interest were another visit in the next 14 days (early follow-up) or 15 to 28 days after initial treatment (late follow-up).

Results: Antibiotics were used more commonly in younger patients (<18 years), whereas older patients (>65 years) were more likely to receive no treatment. Younger patients treated with antibiotics were less likely to return for an early follow-up visit, but no differences were seen in adults and older patients. Late follow-up rates were not affected by the initial treatment strategy. When patients did return for a follow-up visit, no new medication was prescribed to most (66% of younger patients and 78% of older adults). However, compared with patients who did not receive an antibiotic at their first visit, patients initially treated with an antibiotic were about 50% more likely to receive a new antibiotic at their second visit.

Conclusions: Initial prescribing of an antibiotic reduces early follow-up for acute bronchitis in younger patients but seems to have no effect in adults. However, reductions in future follow-up visits might be outweighed by increases in antibiotic consumption because patients who return for a follow-up visit seem to receive additional antibiotic prescriptions. Arch Fam Med. 2000;9:997-1001

Advance care planning is the process of planning for future medical care, particularly for the event when the patient is unable to make his or her own decisions. It should be a routine part of standard medical care and, when possible, conducted with the proxy decision maker present. It is helpful to think of the process as a stepwise approach. The steps include the appropriate introduction of the topic, structured discussions covering potential scenarios, documentation of preferences, periodic review and update of the directives, and application of the wishes when needed. The steps can be integrated flexibly into routine clinical encounters by the physician and other members of the health care team. The process fosters personal resolution for the patient, preparedness for the proxy, and effective teamwork for the professionals. The process also has pitfalls of which to be aware. Arch Fam Med. 2000;9:1181-1187

Objective: To examine the relation between alcohol consumption and self-reported compliance with prescribed therapies for type 2 diabetes mellitus among underserved minority patients.

Design: Cross-sectional sampling of consecutive patients with diabetes was performed following routine visits to their primary care physicians. Interviewers measured compliance using the Summary of Diabetes Self-Care Questionnaire and alcohol use using the timeline followback method and the Alcohol Use Disorders Identification Test.

Setting: Seven inner-city medical clinics that provide primary care services to low-income residents of South Central Los Angeles, Calif.

Participants: A total of 392 ethnic minority patients (61% Hispanic, 29% African American) with type 2 diabetes mellitus.

Main outcome measures: Self-report compliance with prescribed diet, exercise, home glucose monitoring, medications, and outpatient follow-up.

Results: Drinking any alcohol-containing beverage within 30 days was associated with poorer adherence to prescribed dietary recommendations for the consumption of fiber (t = 2.4; P<.05), fat (t = 4.2; P<.01), sweets (t = 2.7; P<.01), and energy (calories) (t = 2.0; P<.05). Drinkers were also less likely to exercise for at least 20 minutes per day (t = 2.2; P<.05), comply with oral medication regimens (t = 4.6; P<.01), or attend outpatient follow-up visits (r = -0.11; P<.05). Alcohol use did not significantly alter compliance with home glucose monitoring, insulin use, or hemoglobin A(1c) levels, although there was a trend toward higher hemoglobin A(1c) levels among drinkers (11.0 vs 10.4). Multivariate analysis of the data demonstrates that when demographic characteristics, health care utilization, and other diabetes-related variables are held constant, the relation between alcohol use and dietary compliance remained significant.

Conclusion: Alcohol consumption may be associated with poorer compliance with recommendations for some self-care behaviors among inner-city minority patients with diabetes. Arch Fam Med. 2000;9:964-970

Objective: To identify specific caretaker and utilization characteristics predictive of the use of the emergency departments (EDs) for nonurgent reasons. Each year more than 20 million children in the United States seek medical care in EDs. Between one third and one half of these visits are for nonurgent reasons.

Design: A descriptive study conducted during a 6-month period.

Setting: Two urban hospital EDs.

Measure: A questionnaire was designed to elicit information about specific caretaker characteristics and their reasons for using the ED for their child's nonurgent medical care.

Subjects: Two hundred caretakers and children brought to the ED for nonacute medical care. Caretakers in this study included mothers (82%) with a mean age of 30 years, single caretakers (70%), and unemployed caretakers (60%). The average age of the children was 6.2 years.

Results: Most caretakers (92%) reported having a continuity physician for their children. Caretakers who reported being taken to the ED when they were children (P<.002) and those with Medicaid insurance (P<.001) were more likely to view the ED as the usual site of care. Being a single parent was a predictor for nonurgent visits (P<.05).

Conclusions: Predicting which caretakers are at risk for using the ED for nonurgent care when their children are sick provides the primary care physician a means of identifying specific patients who may benefit from interventions designed to promote a more cost-effective approach to using medical resources. Arch Fam Med. 2000;9:1086-1092

Objective: To determine primary care physicians' perceived importance and frequency of performance of skin cancer screening in comparison with other cancer screening examinations.

Design: Descriptive survey study.

Participants: Five thousand US family physicians and internal medicine specialists randomly selected from the Official American Board of Medical Specialists Directory of Board-Certified Medical Specialists.

Main outcome measures: Self-reported importance and performance of cancer screening examinations.

Results: Eligible physicians (1363 total: 814 family physicians and 549 internists) completed the survey with a response rate of 30%. Overall, 52% of respondents rated skin cancer screening as "extremely" important, compared with 79% for digital rectal examination, 88% for clinical breast examination, and 87% for Papanicolaou testing. Thirty-seven percent of physicians reported performing complete body skin examinations on 81% to 100% of patients, compared with digital rectal examination, for which 78% of physicians reported performing the examination on 81% to 100% of patients, or the clinical breast examination, for which 82% of physicians reported performing the examination on 81% to 100% of patients. A higher percentage of physicians in practice for more than 30 years ranked skin cancer screening as extremely important and reported a higher frequency of screening examinations. Physicians in a suburban practice setting reported performing skin examinations more often than those in urban or rural settings. Overall, the self-reported frequency of skin examination was strongly correlated with the physician's importance rating of skin cancer screening.

Conclusions: A majority of primary care physicians rate skin cancer screening as extremely important. The reported importance of skin cancer screening and frequency of skin cancer examination among primary care physicians is significantly less than for other cancer examinations. This likely represents a multitude of factors, including logistic constraints and lack of consensus on the efficacy of skin cancer screening. Arch Fam Med. 2000;9:1022-1027