Medical care for vacationers

Medical services provided to vacationers and employees in Yellowstone National Park were reviewed for the years 1975 through 1977. Both ambulatory and inpatient data were obtained, including diagnoses, place of residence, medications prescribed, and methods of payment. The types of problems and modes of treatment did not differ from typical primary care practices. Health maintenance was the most common reason for outpatient visits. The distribution of diagnoses among park visitors and employees was the same within age categories, although the employees' rate of utilization was nearly twice that of the visitors. Distance from home was directly related to the frequency with which visitors used clinic services.Drs. Woolley, Wright, and Patrick and Mrs. Ford are with the Department of Family and Community Medicine, University of Utah College of Medicine, Salt Lake City, Utah, and Dr. Kronhaus is with Health Systems Research Institute, 715 East 3900 South, Salt Lake City, Utah. Work for this study was supported by Department of Health, Education and Welfare Contract No. 298-76-R-0006, Evaluation of the Utilization Effectiveness of Rural Health Programs. Reprints may be obtained from Dr. Ross Woolley, Department of Family and Community Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.     

Cost savings associated with using immunization information systems for Vaccines for Children administrative tasks.

Our objective was to investigate the potential cost savings of immunization information systems (IIS) in performing some administrative tasks associated with the federal Vaccines for Children (VFC) program at the state and practice levels. VFC is an entitlement program providing free vaccine to eligible children. We timed the staff of the Utah Department of Health (UDOH) and 72 private VFC practices for administrative VFC-related tasks from September 2003 through March 2004. Time measurements included time for practices to produce VFC reports and for UDOH staff to assess practice coverage levels and process VFC reports manually or via the Utah Statewide Immunization Information System (USIIS). Median cost savings to the state health department could be as much as $11 740 annually. Utah VFC practices could save up to a maximum of $446 annually per practice by using USIIS for VFC tasks. If applied to the 218 enrolled private practices statewide, this would result in a median total cost savings of $17,615 ($15,519 for reports and $2,096 for pulling medical charts).     

Measuring outcomes of care in an ambulatory primary care population

This study developed a practical method for determining the functional outcome status of patients in an ambulatory setting. Health status of 1,840 primary care patients was compared at three points in time: patient's usual status, status at the initial visit, and status at time of telephone follow-up. Follow-up status was also compared with the physician's expectation, which was estimated at the time of the initial visit. Of the patients, 62% showed improvement, 31% remained at the same level, and 7% deteriorated from the time of their initial clinic visit. Physicians tended to overestimate either the speed or degree with which patients return to their usual functional status; 32% of the patients studied reported themselves as being less well than usual at the time of follow-up.Dr. Kane is Associate Professor, Drs. Woolley, Gardner, Snell, and Leigh are Assistant Professors, and Dr. Castle is Professor and Chairman of the Department of Family and Community Medicine, University of Utah College of Medicine, 50 North Medical Drive, Salt Lake City, Utah, 84132. Requests for reprints should be addressed to Dr. Kane. Work for this study was supported by Contract No. HSM 110-72-232 with the Health Services Administration, Department of Health, Education, and Welfare.     

Self-reported referral patterns in practices of Family/General Practitioners,Internists, and Obstetricians/Bynecologists

A profile of referrals can help to define the characteristics of a physician's practice. Self-reported referral patterns in the practices of Family/General Practitioners (FP/GP), Internists (IM), and Obstetricians/Gynecologists (OB/GYN) in Maryland were assessed with a questionnaire mailed to an area sample of 1,715 physicians. A 65% response rate was obtained after three mailings (weighted N=1,487). Self-reported referrals received per month averaged 16% of patients seen (six percent FP/GP, 13% OB/GYN, 23% IM), and were more frequent among self-employed, younger, metropolitan and female physicians who spent less time in patient care. Self-reported referrals made per month averaged ten percent (10% FP/GP), 11% IM, and eight percent OB/GYN), and were higher for physicians in metropolitan areas. The correlation between percentage referrals received and percentage referrals made was r=.19 (r=.03 FP/GP, r=.21 IM, r=.25 OB/GYN). Self-reported practice referral patterns are similar to referrals reported in prior studies, and can be used to consider specialty differences in referral behavior of physicians.Jeffery Sobal, Ph.D., M.P.H. is an Assistant Professor in the Department of Family Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland, 21201. Herbert L. Muncie, Jr., M.D. is an Associate Professor in the Department of Family Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland, 21201. Carmine Valente, Ph.D. is the Director of the Center for Health Education, Inc., 1204 Maryland Avenue, Baltimore, Maryland, 21201. David M. Levine, M.D., Sc.D. is a Professor in the Department of Medicine at the Johns Hopkins University School of Medicine, Baltimore, Maryland 21205. Bruce R. DeForge, M.A. is a Research Associate in the Department of Family Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland, 21201. Requests for reprints should be addressed to: Jeffery Sobal. The authors would like to thank the Department of Family Medicine at the University of Maryland School of Medicine (Grant 2D32PE13000 from the U.S. Department of Health and Human Services), the Center for Health Education, Inc., Johns Hopkins University School of Hygiene and Public Health, Blue Cross/Blue Shield of Maryland, Inc., and the Medical and Chirurgical Faculty of the State of Maryland for support for this research. An earlier version of this paper was presented at the annual meeting of the North American Primary Care Research Group.     

The use of asbestos-cement pipe for public water supply and the incidence of cancer in selected communities in Utah

We tested the hypothesis that there is an association between the use of asbestos-cement piping for drinking water supplies and the incidence of gastrointestinal and kidney cancer. Cancer incidence in 14 Utah communities that had used predominantly asbestos-cement piping for transporting their drinking water supplies for 20 years or more were compared to 27 Utah communities that had never used asbestos-cement piping.Cancer incidence was tabulated for 11 cancer sites for the years 1967–1976. Increased Standard Incidence Ratios (SIRs) were found for cancer of the kidney in men (SIR 192) and leukemia (a control site) in women (SIR 203). No increased SIRs were found for the opposite sex at these sites or for the other gastrointestinal sites singly or in combination. There was no increase in age-adjusted cancer incidence for the 11 sites in 4 of the 14 study communities that had used asbestos-cement piping for 30 years or more. Limitations of the study were that the water supplies were nonaggressive, and leaching from the pipes was minimal if at all. Furthermore, the latent period for observation was very short, suggesting that these results should be considered preliminary.Terry D. Sadler, M.S.C.M., is with the Rocky Mountain Center for Occupational and Environmental Health, Departments of Internal and Family and Community Medicine, University of Utah, and the Salt Lake City-County Health Department. William N. Rom, M.D., M.P.H., and Joseph L. Lyon, M.D., M.P.H., are with the Rocky Mountain Center for Occupational and Environmental Health, Departments of Internal and Family and Community Medicine, University of Utah. James O, Mason, M.D., Dr. P.H., is with the Utah Department of Health, Salt Lake City, Utah     

Why Do Rural Primary Care Physicians Sell Their Practices?

This study evaluates why rural primary care physicians sell their practices. A random sample of rural primary care practices in California, Utah, Ohio, Texas, and Virginia were surveyed to investigate changes in ownership of the practices during the period 1995-1998. These five states were selected because they represent areas with different experiences with physician-hospital integration and varied rates of managed care penetration. A series of logistic regressions were conducted to examine the factors that led independent physicians to sell their practices to either nonlocal buyers, local hospitals, or local physicians. Findings suggest that sales to nonlocal buyers represent the majority of practice ownership changes. The motivations for ceding control to nonlocal buyers center on managed care concerns, recruitment concerns, and administrative burdens. Sellers were also concerned about their level of net income prior to being acquired. However, the preacquisition financial concerns of sellers were not significantly stronger than the financial concerns of practices that remained independent. The environmental conditions that motivate rural physicians to sell their practices are not expected to improve. Therefore, additional sales of rural primary care practices to nonlocal buyers are expected. Further research is necessary to determine whether this shift in control will lead to changes in the quality or accessibility of care.     

A comparison of health promotion practices of general practitioners and residency trained family physicians

Physicians who specialize in family medicine and general practice have the potential to assume a major role in helping patients change their health promotion practices. Little is known about the proportion of routine consultation time devoted to primary prevention counseling or the factors that influence the provision of this kind of patient education. A survey of General and Family Practitioners was conducted to determine the extent to which these physicians perform health promotion counseling as well as their perceptions regarding constraints affecting their efforts, confidence in their ability to change patient's behaviors, and the training required to enhance their efforts. Differences, with respect to their health promotion practices, between General and Family Practitioners, were also examined. One hundred and ninety-five physicians completed the survey for a response rate of 68%. When year of graduation from medical school was controlled there was little difference in the health promotion practices of General and Family Practitioners. This study suggests residency training in the specialty of family medicine does not provide residents with the knowledge, confidence and skills to perform health prevention counseling at a level different than that practiced by General Practitioners.Linda Attarian M.P.H. is a Research Associate at the Department of Family Medicine, University of North Carolina, Chapel Hill. Michael Fleming M.D. is Assistant Professor in the Department of Family Medicine, University of North Carolina, Chapel Hill. Patricia Barron, M.P.H. is a Research Associate at the Department of Family Medicine, University of North Carolina, Chapel Hill. Victor Strecher Ph.D. is Assistant Professor in the Department of Health Education, University of North Carolina, Chapel Hill.     

Patients' understanding of prescribed drugs

Patients must understand their physicians' recommendations if they are to follow medical advice. This study assesses the degree to which patients and physicians share basic information about medications. Patients who regularly attend the medical clinics of a large, urban teaching hospital were asked to recall the identity, purpose, and dose schedule of medications that were prescribed for them. Patients' responses were compared to the medications actually prescribed by their physicians. Patients identified 90% of medications prescribed during the visits, knew the purpose of 83%, and the correct dose schedule for 80%. Only 58% of patients knew the dosage schedule of all their medications correctly. Patients' knowledge of prescribed durgs was inversely related to the number of their medical problems and the number of medications prescribed. Lack of effective communication between physicians and patients about medications may be an important reason why patients do not follow medical advice.The authors were with the Department of Medicine and the Department of Epidemiology and Health, McGill University and the McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, Canada. Reprint requests should be addressed to Dr. S. Fletcher, Department of Medicine Medical Clinics, North Carolina Memorial Hospital, Chapel Hill, North Carolina 27514. This investigation was supported in part by a National Health Research Scholar Award, No. 605-1189-22 from the Department of National Health and Welfare, Canada, by the Robert Wood Johnson Clinical Scholars Program, and by an Establishment Grant, No. 750046, made by the Conseil de la Recherche en Santé du Québec. Portions of this paper were published in abstract form inClinical Research, Volume 24, 1976.     

Emergency room management of patients with sore throats in a teaching hospital: Influence of non-physician factors

The care of 169 patients with sore throats was evaluated retrospectively to determine if the quality of medical care received in a teaching hospital's emergency room is associated with the degree of control managing physicians have over the medical care process. Diagnostic evaluation (temperature, throat and cervical node examination, and throat culture) was controlled by physicians and was judged adequate in 78% to 98% of the patients. Therapy, defined as appropriate antibiotics prescribed only for patients with positive throat cultures for group A beta-hemolytic streptococcus, was dependent on hospital support services, and the patients, as well, and was judged adequate for 62% of the patients; however, in only one of the 67 patients treated with antibiotics was the culture result known before treatment. The bacteriology laboratory processed the cultures slowly; no administrative mechanism existed to follow up patients. Thus, when medical care involved factors outside physicians' direct control, lower quality care was given.From the Department of Medical Care and Hospitals, the Johns Hopkins University School of Hygiene and Public Health and the Department of Medicine, Baltimore City Hospitals. Address reprint requests to Dr. Fletcher, Department of Medicine, McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, H3A 1A1, Canada. This work was supported in part by grants from the Carnegie Corporation, the Commonwealth Fund of New York City, and the Robert Wood Johnson Foundation, and by grants 5 H01 HS 00110 and 5 T01 HS 00012 from the National Center for Health Services Research and Development and 5 D04 AH 00076 from the National Institutes of Health, Department of Health, Education and Welfare. Dr. Fletcher was a Carnegie Commonwealth Clinical Scholar.     

A model program for training residents in medical practice management

The Department of Family and Community Medicine of the Bowman Gray School of Medicine has developed a seminar series to train physicians to effectively and efficiently manage their practices.     

Predicting rural health care utilization with archival data

This study explored the usefulness of archival data in predicting rural health care utilization. A regression model was used to see how well observed utilization for local populations could be predicted by calculating expected values in advance from age- and sex-specific national rates applied to local age and sex profiles. Although the correlation between observed and expected utilization was reasonably high (r=0.92), an attempt was then made to improve prediction by considering other data that do not require independent collection. These archival data included indicators of historic utilization (local Medicaid payments, the percentage of births to county residents occurring in the mother's county of residence, percentage of children immunized, and infant mortality) and services already available. Observed utilization data were obtained by surveys in eight rural counties, and the predictor was tested on three additional rural communities. A predictor equation that added to the expected utilization only one variable (the percentage of births to county residents occurring in the mother's county of residence) was found to account for approximately 95% of the variance in observed utilization. This predictor is recommended for planners who need convenient, low-cost market feasibility estimates for proposed project sites and a way to establish intermediate goals or incentives during early project development.Dr. Wright and Mr. Altman were formerly with the Department of Family and Community Medicine, University of Utah College of Medicine. Dr. Kronhaus is a Robert Wood Johnson Clinical Scholar at the University of North Carolina, Chapel Hill. Dr. Woolley is with the Department of Family and Community Medicine, University of Utah College of Medicine. Dr. Kane is Professor at UCLA Schools of Medicine and Public Health and a Senior Researcher at The Rand Corporation. Work for this study was supported by the Department of Health, Education, and Welfare (Contract No. 298-76-R-0006). Reprints may be obtained from Robert L. Kane, The Rand Corporation, 1700 Main Street, Santa Monica, CA 90406.     

Trial of rural practice evaluation: mutual rotation by family physicians

OBJECTIVES: We aimed to investigate the usefulness of mutual rotation by family physicians in providing an evaluation of rural medical practices. METHODS: Between June and October 1994, each of four family physicians rotated to the practices of the other three, where they worked as a transient locum for 4-5 days and evaluated each practice. They were field faculty physicians of the Department of Community and Family Medicine, Jichi Medical School, and based at general practices accredited for undergraduate and postgraduate training. Two school- based faculty physicians also participated in the study as spare members. RESULTS: The rotation was conducted four times to complete the mutual rotation programme. There was some difference in evaluation among the practices, which indicated the characteristics of the practices. The evaluation accorded relatively well among the participants. CONCLUSIONS: Mutual rotation by family physicians provides an objective and practicable evaluation of general practices and contribute to upholding their quality, which is crucial to medical education.      

Medical care as a commodity

A 10% household sample of high- and low-income census tracts was interviewed to assess the extent of doctor shopping. In 632 households studied, 53% of high socioeconomic status and 51% of low socioeconomic status families had shopped for or changed doctors of their own volition. During the previous year, 4% of each socioeconomic group had consulted more than one doctor without referral for the same episode of illness. Shoppers could be distinguished from non-shoppers—shoppers were younger, were better informed about medical specialties, were less self-reliant, more hypochondriacal, expressed less hostility toward physicians, and had less positive attitudes toward the medical care system. The differences between shoppers and non-shoppers were generally similar for both high and low socioeconomic status groups. In addition, 52% of the families studied had been forced to change doctors because of circumstances beyond their control, i.e., the patient moved or the doctor moved, retired, or died.Dr. Olsen is Instructor, Dr. Kane is Associate Professor, and Dr. Kasteler is Assistant Professor in the Department of Family and Community Medicine, University of Utah College of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.     

Process and outcome evaluation of preventive care for infants in two types of practices

Process and outcome of preventive and promotive infant care have been evaluated in a maternal and child health (MCH) service and compared with that of a comprehensive care family practice (FP), both serving a low middle class population in West Jerusalem. Both services are provided by the Community Health Center of the Department of Social Medicine. Community oriented primary care is integrated into the practices, including ongoing surveillance of the communities' health status. Preventive and promotive programs have been developed, implemented and evaluated.The process evaluation indicated a similar use of the preventive service in the MCH and FP services. Some of the routines were carried out to a lesser extent in the FP than in the MCH framework, such as growth monitoring, hearing tests and advice on iron supplementation. The small difference in compliance with routines did not affect a child's growth between birth and one year of age, but the anemia rate in the FP practice was higher than in the MCH practice. The high level of care and relatively small differences in process and outcome between the two types of services have been achieved by ongoing inservice training, a high level of personnel, similar protocols and supervision in both practices.H. Palti, M.D. M.P.H., Associate Professor, Head of Maternal and Child Health Unit, Department of Social Medicine, Hadassah, and School of Public Health, Hebrew University and Hadassah, P.O.Box 12000, Jerusalem 91120, Israel; D. Haustein, M.D. M.P.H., former student at the School of Public Health, Hebrew University and Hadassah, Jerusalem. Present address: Chabrier 179, San Isidro, Lima 27, Peru; R. Gofin, M.D. M.P.H., Lecturer & Physician, Department of Social Medicine, Hadassah, and School of Public Health, Hebrew University and Hadassah, P.O.Box 12000, Jerusalem 91120, Israel; B. Knishkowy, M.D. M.P.H., Family Physician, Department of Social Medicine, Hadassah, and School of Public Health, Hebrew University and Hadassah, P.O.Box 12000, Jerusalem 91120, Israel; B. Adler, M.Sc., Statistician, Department of Social Medicine, Hadassah, and School of Public Health, Hebrew University and Hadassah, P.O.Box 12000, Jerusalem 91120, Israel.This study was supported by The Temin Endowment Fund. We wish to express our thanks to staff of MCH and FP practices of the Hadassah Community Research and Health Center, for their ongoing contribution to the MCH programs.     

Understanding Immigrant Chinese Americans’ Participation in Cancer Screening and Clinical Trials

The purpose of this study was to identify potential barriers and facilitators to Chinese immigrant participation in cancer screening and clinical trials. A series of focus groups, in English, Cantonese, and Mandarin, were conducted with physicians, community leaders, and first generation members of the Manhattan Chinatown community. Participants were asked to discuss their beliefs about cancer, cancer screening, clinical trials, and cancer health education materials. Focus group data were stratified by respondent group and analyzed for thematic content. Eleven physicians, 15 community leaders, and 38 community members participated. Some community members were not familiar with cancer screening as a preventive measure and had not received common screens such as PAP smears or mammograms. They described widespread misconceptions about cancer that act as screening deterrents, e.g. testing for cancer can cause cancer. Community members were unfamiliar with clinical trials and would not participate in a clinical trial unless “sick,” and only on the recommendation of their physicians. Physicians did not see the relevance or value of clinical trials for their patients. Among first generation Chinese immigrants, there are many perceptual barriers to cancer screening and clinical trials recruitment. There is a need for effective culturally tailored health education on these health topics to address persistent misconceptions about cancer and to increase knowledge about cancer screening and clinical trials. Health education efforts and clinical trial recruitment in this community must involve community physicians. Jennifer S. Lin, MD was Senior Chief Resident at New York University School of Medicine, Department of Medicine and is currently a Bowen-Brooks Fellow, New York Academy of Medicine; Alyssa Finlay, MD was a General Internal Medicine Fellow at New York University School of Medicine, Department of Medicine, Primary Care and is currently an Epidemic Intelligence Service Officer, Center for Disease Control; Angela Tu, MD is a Resident at New York University School of Medicine, Department of Medicine, Primary Care; Francesca M. Gany, MD, MS is Director at the Center for Immigrant Health and Assistant Professor at New York University School of Medicine, Division of General Internal Medicine, Primary Care.     

Cost-Effectiveness Analysis of a Pharmacist-Led Medication Therapy Management Program: Hypertension Management

ObjectivesUncontrolled hypertension is a common cause of cardiovascular disease, which is the deadliest and costliest chronic disease in the United States. Pharmacists are an accessible community healthcare resource and are equipped with clinical skills to improve the management of hypertension through medication therapy management (MTM). Nevertheless, current reimbursement models do not incentivize pharmacists to provide clinical services. We aim to investigate the cost-effectiveness of a pharmacist-led comprehensive MTM clinic compared with no clinic for 10-year primary prevention of stroke and cardiovascular disease events in patients with hypertension.MethodsWe built a semi-Markov model to evaluate the clinical and economic consequences of an MTM clinic compared with no MTM clinic, from the payer perspective. The model was populated with data from a recently published controlled observational study investigating the effectiveness of an MTM clinic. Methodology was guided using recommendations from the Second Panel on Cost-Effectiveness in Health and Medicine, including appropriate sensitivity analyses.ResultsCompared with no MTM clinic, the MTM clinic was cost-effective with an incremental cost-effectiveness ratio of $38 798 per quality-adjusted life year (QALY) gained. The incremental net monetary benefit was $993 294 considering a willingness-to-pay threshold of $100 000 per QALY. Health-benefit benchmarks at $100 000 per QALY and $150 000 per QALY translate to a 95% and 170% increase from current reimbursement rates for MTM services.ConclusionsOur model shows current reimbursement rates for pharmacist-led MTM services may undervalue the benefit realized by US payers. New reimbursement models are needed to allow pharmacists to offer cost-effective clinical services.     

Primary prevention of adolescent pregnancy: Promoting family involvement through a school curriculum

In prevention work, practices are suggested by theories. Thus, the idea that family-centered prevention is beneficial already embodies a theoretical perspective about why certain approaches to prevention are more appropriate than others. Logic and research evidence both suggest that the family is an indispensable resource in the primary prevention of destructive sexual decisions by adolescents. This paper describes how one project draws upon the family to accomplish primary prevention. An Alternative National Curriculum (AANC) is currently being disseminated in selected public schools in three states, while promoting parent-teen involvement. This project is sponsored by the Office of Adolescent Pregnancy Programs (OAPP), Department of Health and Human Services, which has a legislative mandate under Title XX of the Public Health Service Act to sponsor family-centered demonstration projects that help prevent premarital teen sexual relations and pregnancy. A specific theoretical view of human nature, family life, and societal well-being has been drawn upon to produce AANC. It focuses on ethical and responsible behavior, the importance of family linkages, and how quality family living across generations can be achieved.Terrance D. Olson and Christopher M. Wallace are with the Department of Family Sciences, Brigham Young University, Provo, Utah 84602. Brent C. Miller is with the Department of Family and Human Development, Utah State University, Logan, Utah 84322.     

Assessing Disparities in Adult Vaccination Using Multimodal Approaches in Primary Care Offices: Methodology

Racial disparities in invasive pneumococcal disease and pneumococcal polysaccharide vaccination (PPV) persist despite significant progress. One reason may be that minority patients receive primary care at practices with fewer resources, less efficient office systems, and different priorities. The purposes of this paper are: (1) to describe the recruitment of a diverse array of primary care practices in Pittsburgh, Pennsylvania serving white and minority patient populations, and the multimodal data collection process that included surveys of key office personnel, observations of practice operations and medical record reviews for determining PPV vaccination rates; and (2) to report the results of the sampling strategy. During 2005, 18 practices participated in the study, six with a predominantly minority patient population, nine with a predominantly white patient population, and three with a racial distribution similar to that of this locality. Eight were solo practices and 10 were multiprovider practices; they included federally qualified health centers, privately owned practices and faculty and University of Pittsburgh Medical Center community practices. Providers represented several racial and ethnic groups, as did office staffs. PPV rates determined from 2,314 patients’ medical records averaged 60.3 ± 22.6% and ranged from 11% to 97%. Recruitment of practices with attention to location, patient demographics, and provider types results in a diverse sample of practices and patients. Multimodal data collection from these practices should provide a rich data source for examining the complex interplay of factors affecting immunization disparities among older adults. Zimmerman, Nowalk, Raymund, Tabbarah, and Fox are with the Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Zimmerman and Terry are with the Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA; Wilson is with the UPMC St. Margaret Family Medicine Residency, Pittsburgh, PA, USA.