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Abstract
BACKGROUND Reducing sun exposure during childhood may prevent skin cancer later in life. Sun protection increased immediately following implementation of the SunSafe multicomponent, community-based intervention delivered in 1996 through schools, day care centers, primary care offices, and beach recreation areas. Whether sun protection levels would remain higher than preintervention levels the following summer was unknown. METHODS A randomized controlled trial based in 10 New Hampshire towns addressed children's use of protective clothing, shade, and sunscreen at freshwater beach areas. The intervention was provided initially between March and May 1996. A brief project follow-up contact was provided to schools, day care centers, beaches, and primary care offices between March and May 1997 to restock intervention materials and to answer questions. Observations of 1490 children during June through August of 1997 were compared with observations made prior to any intervention between June and August of 1995. RESULTS In intervention towns, the proportion of children using at least some sun protection increased by 0.15 from 0.58 in 1995 to 0.73 in 1997 while the proportion in control towns increased by 0.03 (P = 0.033). This increase was due to more use of sunscreen, but not more use of protective clothing or shade. In 1997, care-givers of children in intervention towns reported receiving more sun protection information from school and health care sources than control town caregivers (62% versus 33%, P < 0.006). CONCLUSIONS In intervention communities, a higher proportion of children used sun protection in 1997 than at baseline. Increases from 1995 to 1997 were similar in magnitude to short-term increases between 1995 and 1996 that we have been previously reported.
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine and Department of Pediatrics, Dartmouth Medical School, Hanover, New Hampshire 03755, USA.
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Dietrich AJ, Olson AL, Sox CH, Winchell CW, Grant-Petersson J, Collison DW. Sun protection counseling for children: primary care practice patterns and effect of an intervention on clinicians. Arch Fam Med 2000; 9:155-9. [PMID: 10693733 DOI: 10.1001/archfami.9.2.155] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To describe current primary care sun protection advice for children and assess the effect on clinicians of an intervention to enhance their sun protection advocacy. SETTING Primary care practices caring for children in New Hampshire with special attention to clinicians serving 10 towns that were involved in a randomized controlled trial of the multicomponent SunSafe intervention involving schools, recreation areas, and primary care practices. DESIGN/INTERVENTION A statewide survey of all primary care clinicians serving children addressed their self-reported sun protection advocacy practices. Clinicians in 10 systematically selected rural towns were involved in the subsequent intervention study. The primary care intervention provided assistance to practices in establishing an office system that promoted sun protection advice to children and their parents during office visits. MAIN OUTCOME MEASURES Sun protection promotion activities of primary care clinicians as determined by their self report, research assistant observation, and parent interviews. RESULTS Of 261 eligible clinicians responding to the statewide survey, about half provide sun protection counseling "most of the time" or "almost always" during summer well care visits. Pediatricians do so more often than family physicians. Clinicians involved in the intervention increased their use of handouts, waiting room educational materials, and sunscreen samples. Compared with control town parents, parents in intervention towns reported an increase in clinician sun protection advice. CONCLUSIONS The SunSafe primary care intervention increased sun protection counseling activities of participating clinicians. A single-focus preventive service office system is feasible to include in community interventions to promote sun protection.
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
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Sox CH, Dietrich AJ, Goldman DC, Provost EM. Improved access to women's health services for Alaska natives through community health aide training. J Community Health 1999; 24:313-23. [PMID: 10463474 DOI: 10.1023/a:1018798406751] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This project demonstrates the effect of increasing the skills of Community Health Aides (CHAs) on the use of specific preventive health services by women in remote Alaska villages. Eight CHAs were trained in specimen collection for Pap and sexually transmitted disease testing, and in clinical breast examination. Skill competency was monitored. Computerized medical records of all women between the ages of 18 and 75 in the four villages with trained CHAs and in four comparison villages (n = 1093) were checked for Pap status prior to CHA training and again 12 months later. All eight CHAs achieved competency and provided services in their village clinics with telephone support from an experienced clinician. The post-training year Pap test rate of women who were overdue for a Pap test was 0.44 in the villages with trained CHAs; the rate among the women in the comparison villages was 0.32 (p = .079).
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Affiliation(s)
- C H Sox
- Dartmouth Medical School, Hanover, NH 03755, USA
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Ristola MA, von Reyn CF, Arbeit RD, Soini H, Lumio J, Ranki A, Bühler S, Waddell R, Tosteson AN, Falkinham JO, Sox CH. High rates of disseminated infection due to non-tuberculous mycobacteria among AIDS patients in Finland. J Infect 1999; 39:61-7. [PMID: 10468131 DOI: 10.1016/s0163-4453(99)90104-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE to determine the rate of disseminated infection due to non-tuberculous mycobacteria (NTM) among Finnish AIDS patients, and to analyse the epidemiology of these infections. METHODS in a prospective cohort study HIV-infected patients with CD4 counts < 200 x 10(6)/l were interviewed, and had mycobacterial blood cultures performed at baseline and at 6 months, then subsequently for clinical indications; autopsies were performed on patients who died. The cohort was followed at least for 24 months or to death. Water samples were collected from the homes of patients and from the environment and cultured for organisms of the Myobacterium avium complex (MAC). Environmental and clinical isolates were compared using pulsed field gel electrophoresis (PFGE). RESULTS NTM infection occurred in 22 (43%) of 51, 19 isolates were Mycobacterium avium, two M. genavense and one M. intracellulare. Multivariate analysis identified urban residence (P=0.04) and eating raw fish (P=0.04) as independent risk factors. Molecular analysis revealed two clusters of related isolates (three M. avium, two M. genavense) among urban residents. CONCLUSION AIDS patients in Finland have high rates of disseminated infection due to NTM. Clusters of identical organisms and association with urban residence suggests that these are newly acquired infections in advanced AIDS.
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Affiliation(s)
- M A Ristola
- Department of Medicine, Helsinki University Central Hospital, Finland
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Grant-Petersson J, Dietrich AJ, Sox CH, Winchell CW, Stevens MM. Promoting sun protection in elementary schools and child care settings: the SunSafe Project. J Sch Health 1999; 69:100-106. [PMID: 10332645 DOI: 10.1111/j.1746-1561.1999.tb07216.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Elementary schools and child care settings in rural New Hampshire participated in a sun protection program that reached more than 4,200 children. The program was part of a successful multifaceted community intervention targeting children ages 2-9. Program components included curricular materials, training and support for school/child care staff, and parent outreach. Evaluation showed good uptake of the curriculum by teachers and child care providers, improvements in sun protection policy in participating schools and child care settings, and significant knowledge and attitude improvements in fourth grade children tested, as well as actual behavior change. The study highlighted the importance of flexible, developmentally appropriate curricular materials and active engagement of principals and directors in policy review. In addition, for parent outreach programs to be successful, children needed to participate.
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Dietrich AJ, Olson AL, Sox CH, Stevens M, Tosteson TD, Ahles T, Winchell CW, Grant-Petersson J, Collison DW, Sanson-Fisher R. A community-based randomized trial encouraging sun protection for children. Pediatrics 1998; 102:E64. [PMID: 9832592 DOI: 10.1542/peds.102.6.e64] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We evaluated the impact of an intervention promoting sun protection behavior among children 2 to 11 years of age through schools and day care centers, primary care practices, and recreation areas. METHODS Ten towns in New Hampshire were paired, then assigned randomly to intervention or control status. The multicomponent SunSafe intervention was provided to children and caregivers through primary care practices, day care centers, schools, and beach recreation areas. Training support and materials were provided by the SunSafe project, but project staff had no direct contact with children or parents in providing the intervention. All intervention components promoted the same message: avoid the sun between 11 AM and 3 PM, cover up using hats and protective clothing, use sun block with a sun protection factor >/=15, and encourage sun protection among family and friends. The impact of the intervention was determined by observing children's sun protection behavior at the beach during baseline compared with 1 year later. The primary outcomes of interest were changes in the proportion of children per town using at least some sun protection and changes in the proportion of children fully protected. Children were clustered by town, with the town thus being the unit of analysis. The primary care practice component included one practice meeting for clinicians and staff at which project staff presented background on skin cancer and how to promote its prevention; a sun protection office system manual based on our previous work, which provided specific direction on how to share responsibility among office staff and clinicians in carrying out routines that promote sun protection; and educational posters, pamphlets, and self-adhesive reminder notes designed to enhance sun protection counseling. SunSafe removable tattoos and stickers were offered to children at well-child and illness visits during the summer months. Schools each received three project staff visits: a brief visit with the principal to describe the intervention and to answer questions; an in-service program to educate teachers about skin cancer and to introduce curricular materials; and help with one parent outreach program. Larger day care centers each received one project staff visit. An additional six smaller day care centers received curricular materials through the mail but no visits. Two similar sets of curricular materials were used, one for grade schools and the other for preschools and day care centers. Both emphasized the importance of sun protection rather than the danger of skin cancer. Materials emphasized dynamic activities modeled after the "Slip, Slop, Slap" and "SunSmart" programs and included new material developed to suit regional needs. Both manuals offered structured plans but also provided a variety of activities from which teachers could choose. Teachers agreed to devote a minimum of two class periods to these materials. For recreation areas, lifeguards in each of the intervention communities attended an in-service meeting, during which background about skin cancer prevention was presented by project staff. The project also provided displays about the ultraviolet (UV) light index and about sun protection to be posted at each beach. Subsequently, project staff called beach staff in each community each morning with the predicted UV index for the day to post on the display. Educational pamphlets about the UV index and free sun-block samples were available to beachgoers through the lifeguards. One brief follow-up visit by project staff was made to each beach area to provide reinforcement. RESULTS We observed 1930 children. Use of some sunscreen on at least one body area increased in all 5 intervention towns compared with paired control towns. In intervention towns, this mean proportion increased from 0.56 of those observed at baseline to 0.76 of those observed postintervention, with a minimal increase among control town children. (ABSTRACT TRUNCATED
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine, Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Dietrich AJ, Tobin JN, Sox CH, Cassels AN, Negron F, Younge RG, Demby NA, Tosteson TD. Cancer early-detection services in community health centers for the underserved. A randomized controlled trial. Arch Fam Med 1998; 7:320-7; discussion 328. [PMID: 9682685 DOI: 10.1001/archfami.7.4.320] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Achieving cancer early-detection goals remains a challenge, especially among low-income and minority populations. DESIGN/SETTING A randomized trial based in 62 community health centers for the underserved in New York, New Jersey, and western Connecticut. Family physicians were on staff at most of the centers. INTERVENTION Workshops, materials, and ongoing advice for center leaders promoted implementation of a preventive services office system to identify patients in need of services at each visit through use of medical record flow sheets, other tools, and staff involvement. EVALUATION END POINTS: The proportion of randomly selected patients by center who were up to date for indicated services at baseline (n = 2645) and follow-up (n = 2864) record review. RESULTS Only 1 service (breast self-examination advice) increased more in intervention centers. Seven of 8 target services increased significantly for the 62 centers overall. During the study, the medical director changed in 26 centers (42%). Keeping the same medical director at intervention centers was associated with improvements in services. CONCLUSIONS Cancer early-detection services are improving in community health centers, but the intervention had only a small impact, as determined by record review. To have an impact, the intervention required that there be no change in medical director. The relationship of changes in the practice environment to services delivered is complex and deserves more study.
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA.
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Dietrich AJ, Carney PA, Winchell CW, Sox CH, Reed SC. An office systems approach to cancer prevention in primary care. Cancer Pract 1997; 5:375-81. [PMID: 9397706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE The provision of preventive services holds a central place in primary care. Achievement of prevention standards offers a challenge. The authors address the efficacy of an office systems approach to improving cancer prevention and early detection services, provide a guide to assessing the appropriateness of office systems dissemination in practices targeted for improvement, and describe the range of dissemination strategies available. OVERVIEW Preventive service office systems depend on establishing practice routines, using tools such as flow sheets, and sharing responsibilities among practice clinicians, staff, and patients. Systems have been shown to be efficacious in a variety of settings. Computers provide a significant enhancement to paper-based tools. Some practices develop office systems themselves, whereas others require external support. Before attempting to disseminate preventive services offices systems, disseminators should ensure that adequate assistance can be provided, that assistance follows a format that is acceptable to target practices, and that target practices are receptive to assistance and able to cooperate. Dissemination strategies include journal articles, continuing education programs, manuals and tool kits, facilitation, and academic detailing. The relative expense and efficacy of these approaches require further assessment. CLINICAL IMPLICATIONS Office systems hold promise in enhancing provision of cancer prevention services in primary care. The practice should be approached as a team, and should include practice clinicians as well as nonclinical staff members. Current research should provide answers over the next few years about the cost-effectiveness of various approaches and the most feasible ways to promote dissemination to practices that need it.
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine, Norris Cotton Comprehensive Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03755, USA
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9
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Abstract
BACKGROUND Excessive sun exposure during childhood has been associated with subsequent development of skin cancers. Children have been advised to avoid sun exposure, use protective clothing, and apply sunscreen lotions, but how completely these recommendations are followed has not been studied. OBJECTIVE To determine the extent of sun protection among children visiting lake beaches, the methods used, and the characteristics associated with more protection. DESIGN Direct observations of children were linked with concurrent care giver/parent interviews. SUBJECTS/SETTING A total of 871 children 2 to 9 years of age and their parents/care givers at freshwater beaches in 10 small New Hampshire towns during July and August 1995. OUTCOME MEASURES Protection of the head, torso, and legs according to method used (hats, shirts, pants, sunscreen, or shade). RESULTS Fifty-four percent of children were protected by at least one method for all three body surface regions, although 17% had no protection for any region. Sunscreen was used either alone or in combination with clothing for at least one region in 79%. Hats were used by 3%, shirts by 22%, and pants to the knee by 49%. Only 12% of observed children were in the shade. The region that was protected most often was the legs for boys (due to swim suit styles) followed by the torso for both sexes. The region most often unprotected was the legs for girls followed closely by the face for both boys and girls. Girls were significantly more likely to have no protection (31.2% female vs 7% male, chi2 83.3) due to better leg protection from swim trunks to the knees popular with boys. Full protection of all three regions was more common for children younger than 5 (odds ratio [OR] = 1.8, 95% confidence interval, [CI] 1.3-2.5), for children perceived to usually or always burn (OR = 2.0, 95% CI 1.4-2.7), for children whose parents had more than a high school education (OR = 1.8, 95% CI 1.3-2.5), and if the parents indicated receiving sun protection information from a school or clinician during the previous year (OR = 1.7, 95% CI 1.2-2.3). Approximately 51.6% of parents recalled receiving childhood solar protection advice in the past year from either their physician, a nurse, or a school/day care setting. CONCLUSIONS Sunscreen provided the most common form of solar protection. Hats and shade were used rarely, and shirts were also underused. Although the sun protection of these children visiting the beach was substantial, nearly half were still not fully protected. Clinician advice within the past year was associated with better protection. Clinicians could increase their influence by providing more specific counseling about how to achieve full protection. Use of multiple methods of protection rather than just sunscreen and full protection rather than protection for just one or two body regions should be emphasized. It is helpful to remind families to protect the regions most frequently omitted from protection: girls' legs and boys' and girls' faces. Advice can be enhanced with patient education materials such as included in the "Slip" (on a shirt), "Slop" (on sunscreen), and "Slap" (on a hat) program developed in Australia and available through the American Cancer Society.
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Affiliation(s)
- A L Olson
- Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
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Sox CH, Dietrich AJ, Tosteson TD, Winchell CW, Labaree CE. Periodic health examinations and the provision of cancer prevention services. Arch Fam Med 1997; 6:223-30. [PMID: 9161346 DOI: 10.1001/archfami.6.3.223] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To learn about cancer prevention services in primary care practices and to understand physician factors that affect the provision of these services. DESIGN Survey of physicians and their patients in 1992. SETTING Cooperating physicians (n = 72) of a random selection of community general internist and family physician practices in New Hampshire and Vermont. PATIENTS Patients (n = 2775) of the study physicians for at least 1 year, aged 42 years or older, with no life-threatening threatening illness, who recently visited the physician. MAIN OUTCOME MEASURES Proportion of sample patients per practice provided age- and sex-appropriate cancer prevention services in the previous year. RESULTS In this primary care population, a high proportion of patients received appropriate services in 1992. A periodic health examination within the past year was an important predictor for the receipt of many cancer prevention services. Female physicians provided more periodic health examinations than male physicians; internists provided more than family physicians. CONCLUSIONS The strongest determinant of receiving preventive services is having a periodic health examination. If clinicians and policymakers decrease emphasis on the periodic health examination as a major opportunity to provide indicated preventive services, they should ensure that a satisfactory alternative strategy is in place.
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Affiliation(s)
- C H Sox
- Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA
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11
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Abstract
PURPOSE To determine the proportion of regional primary care physicians who would attend grand rounds on preventive services and their interest in and use of free follow-up enabling and reinforcing assistance to implement changes in their practice routines. METHOD From January to July 1992 grand rounds on early detection of cancer were offered by Dartmouth Medical School at 38 acute care community hospitals in New Hampshire and Vermont. The target audience of 679 family physicians and general internists was identified through state medical society and hospital attending lists. The hour-long grand rounds program described preventive service guidelines and an office system that promoted their implementation. Follow-up practice support with planning, office staff training, and materials were offered to augment the effects of the grand rounds. Attendance was determined by sign-in documents. In addition, all attendees were asked to complete a survey regarding practice and personal characteristics and interest in follow-up assistance. Statistical comparisons were made using chi square and Fisher's exact tests. RESULTS In all, 261 family medicine physicians and general internists (38.4%) attended. Certain categories of physicians were more likely to have attended: internists, those younger than 55 years, and physicians on the staffs of hospitals located in small towns. Assistance was requested by 70.1% of the attendees; many requested more than one type of assistance. Physicians from hospitals in smaller towns were more likely to show interest in follow-up assistance and use it when offered. CONCLUSION Many of the grand rounds attendees were receptive to follow-up assistance that could improve the preventive services they provided. Most hospitals offer grand rounds, and many organizations have interest in and resources for helping physicians provide high-quality care. Future research should establish the best linkage to the actual care provided in practices and explore the relevance of similar approaches to clinical areas beyond prevention.
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire 03755-3833, USA.
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Marsh BJ, von Reyn CF, Edwards J, Ristola MA, Bartholomew C, Brindle RJ, Gilks CF, Waddell R, Tosteson AN, Pelz R, Sox CH, Frothingham R, Arbeit RD. The risks and benefits of childhood bacille Calmette-Guérin immunization among adults with AIDS. International MAC study groups. AIDS 1997; 11:669-72. [PMID: 9108949 DOI: 10.1097/00002030-199705000-00015] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To define the risks of disseminated bacille Calmette-Guérin (BCG) or disseminated Mycobacterium tuberculosis in adults with AIDS who were immunized with BCG in childhood. DESIGN HIV-infected patients with CD4 < 200 x 10(6)/l were enrolled from five study sites (New Hampshire, Boston, Finland, Trinidad and Kenya). Prior BCG immunization was determined and blood cultures for mycobacteria were obtained at study entry and at 6 months. Acid-fast bacilli were identified as Mycobacterium tuberculosis complex (MTBC) using DNA probes. MTBC isolates were then typed by both IS6110 restriction fragment length polymorphism and polymerase chain reaction/restriction enzyme analysis. SETTING Most patients in New Hampshire and Finland were outpatients; most patients in Trinidad were inpatients with terminal illness; and most patients in Kenya were outpatients, although 44 were inpatients with terminal illness. PARTICIPANTS A total of 566 patients were enrolled, including 155 with childhood BCG immunization; 318 patients had a single study visit and culture, and 248 patients had two study visits and cultures. MAIN OUTCOME MEASURES Isolation and identification of mycobacteria from blood cultures. RESULTS Blood cultures were positive for MTBC in 21 patients; none were positive for M. bovis BCG, and 21 were M. tuberculosis-positive. In Trinidad, seven (87%) out of eight isolates of M. tuberculosis were indistinguishable by IS6110 typing; BCG immunization was associated with a decreased risk of bacteremic infection with M. tuberculosis (P = 0.05). CONCLUSIONS The risk of disseminated BCG among adult AIDS patients with childhood BCG immunization is very low. Childhood BCG immunization is associated with protection against bacteremia with M. tuberculosis among adults with advanced AIDS in Trinidad.
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Affiliation(s)
- B J Marsh
- Infectious Disease Section, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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Rebelsky MS, Sox CH, Dietrich AJ, Schwab BR, Labaree CE, Brown-McKinney N. Physician preventive care philosophy and the five year durability of a preventive services office system. Soc Sci Med 1996; 43:1073-81. [PMID: 8890408 DOI: 10.1016/0277-9536(96)00025-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A group of 30 community physicians who practiced in northeastern United States and who participated in the Cancer Prevention in Community Practice project in 1988 were interviewed five years later. The aim of the interviews was to assess the long-term impact of the preventive services office system which had been introduced by the project. The qualitative analysis of interviews revealed three distinct physician philosophies about the provision of preventive services: a Request Only focus, responding to specific patient inquiries about prevention but taking no initiative to recommend indicated services; a Health Maintenance Visit focus, providing indicated services only during visits specifically scheduled for preventive care; and an Opportunistic Prevention focus, providing indicated preventive services at every chance. Physicians demonstrated these philosophies in their overall view of disease prevention, perceived obstacles to delivery of preventive care, as well as in their continued use of flow sheets and their impression of the value of the Cancer Prevention in Community Practice project. The long-term impact of the office system was the most apparent in the Opportunistic Prevention group. We conclude that the durability of a preventive services office system is influenced by a physician's preventive care philosophy.
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Affiliation(s)
- M S Rebelsky
- Maine-Dartmouth Family Practice Residency, Augusta, ME 04330, USA
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Fordham von Reyn C, Arbeit RD, Tosteson AN, Ristola MA, Barber TW, Waddell R, Sox CH, Brindle RJ, Gilks CF, Ranki A, Bartholomew C, Edwards J, Falkinham JO, O'Connor GT. The international epidemiology of disseminated Mycobacterium avium complex infection in AIDS. International MAC Study Group. AIDS 1996; 10:1025-32. [PMID: 8853737 DOI: 10.1097/00002030-199610090-00014] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine rates of disseminated Mycobacterium avium complex (MAC) infection among AIDS patients in developed and developing countries, and to determine whether different rates reflect differences in exposure or immunity, or both. DESIGN Prospective cohort study. SETTING University hospitals and outpatient AIDS programs. METHODS HIV-infected subjects with CD4 counts < 200 x 10(6)/l were interviewed and had CD4 lymphocyte counts, blood cultures for mycobacteria (baseline and at 6 months), and skin tests with purified protein derivative (PPD) and M. avium sensitin. RESULTS Among 566 study patients rates of disseminated MAC were 10.5-21.6% in New Hampshire, Boston and Finland compared to 2.4-2.6% in Trinidad and Kenya (P < 0.001). PPD skin test reactions > or = 5 mm were present in 20% of patients from Kenya compared to 1% at other sites (P < 0.001). Among patients from the United States and Finland, multiple logistic regression indicated that occupational exposure to soil and water was associated with a decreased risk of disseminated MAC, whereas the following were associated with an increased risk of disseminated MAC: low CD4 count, swimming in an indoor pool, history of bronchoscopy, regular consumption of raw or partially cooked fish/shellfish and treatment with granulocyte colony-stimulating factor. CONCLUSIONS Rates of disseminated MAC in AIDS are higher in developed than developing countries and are due to both differences in exposure and differences in immunity. These data provide a rationale for prevention of MAC through both active immunization and reduction in exposure to the organism.
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Affiliation(s)
- C Fordham von Reyn
- Infectious Disease Section, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA
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Dietrich AJ, Sox CH, Tosteson TD, Woodruff CB. Durability of improved physician early detection of cancer after conclusion of intervention support. Cancer Epidemiol Biomarkers Prev 1994; 3:335-40. [PMID: 8061583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Physicians can potentially play an important role in the early detection of cancer. Interventions designed to encourage these activities have been shown to improve physician performance for up to 1 year. To assess their real value, improved physician performance must be judged over the longer term. The Cancer Prevention in Community Practice Project assisted a random subset of practices in implementing cancer early detection office systems. One year later, these practices were found to have provided more indicated breast and colorectal cancer early detection services than practices that did not receive assistance. This report addresses whether 12-month improvements in breast and colorectal cancer early detection were durable at 24 months despite no appreciable ongoing project support. A cross-sectional survey of 20-30 established patients/practice was conducted 24 months after the introduction of the intervention. These results were compared with base-line, 6-, and 12-month cross-sectional surveys to determine whether increases in indicated services and recommendations persisted. A longitudinal model for binomial data was used to quantitatively assess durability of effects. Ninety-nine practices participated, and 81 provided data at all 4 evaluation intervals. In office systems practices, improvements in stool occult blood testing and self breast examination recommendations to patients were maintained between 12 and 24 months while improvements in mammography recommendations and clinical breast examinations declined somewhat but remained superior to performance in control practices. Some improvements in physician early detection of cancer performance were maintained between 12 and 24 months. Future studies of physician behavior change should include follow-up beyond 12 months.
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Affiliation(s)
- A J Dietrich
- Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire 03755
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von Reyn CF, Barber TW, Arbeit RD, Sox CH, O'Connor GT, Brindle RJ, Gilks CF, Hakkarainen K, Ranki A, Bartholomew C. Evidence of previous infection with Mycobacterium avium-Mycobacterium intracellulare complex among healthy subjects: an international study of dominant mycobacterial skin test reactions. J Infect Dis 1993; 168:1553-8. [PMID: 8245545 DOI: 10.1093/infdis/168.6.1553] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Skin tests with 0.1 mL of intermediate-strength Mycobacterium tuberculosis purified protein derivative (PPD) and 0.1 mL of Mycobacterium avium sensitin were conducted on 484 healthy subjects from diverse geographic sites. Reactions of > or = 5 mm to one antigen that exceeded the reaction to the other by > or = 3 mm were considered M. avium- or PPD-dominant. PPD-dominant reactions were more frequent at sites where routine Bacille Calmette-Guérin immunization is done or where there are high rates of tuberculosis: New Hampshire, 2%; Boston, 7%; Finland, 14%; Trinidad, 26%; and Kenya, 28%. However, rates of M. avium-dominant reactions ranged from 7% to 12% at all sites. Analysis of dominant reactions based on a more stringent 10-mm minimum reaction size showed similar trends. These data suggest that exposure to MAC is similar in developed and developing countries but that broad mycobacterial immunity is greater in developing countries and may contribute to the lower rates of disseminated MAC infections in AIDS in these areas.
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Affiliation(s)
- C F von Reyn
- Infectious Disease Section, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756
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Brandeau ML, Owens DK, Sox CH, Wachter RM. Screening women of childbearing age for human immunodeficiency virus. A cost-benefit analysis. Arch Intern Med 1992; 152:2229-37. [PMID: 1444682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In light of the increasing problem of perinatal human immunodeficiency virus (HIV) transmission, the issue of screening women for HIV is receiving considerable attention. We analyzed the costs and benefits of screening women of childbearing age for HIV. The analysis was based on a dynamic model of the HIV epidemic that incorporated disease transmission and progression, behavioral changes, and effects of screening and counseling. We found that the primary benefit of screening programs targeted to women of childbearing age lies not in the prevention of HIV infection in their newborns but in the prevention of infection in their adult contacts. Because of this benefit, screening medium- and high-risk women is likely to be cost-beneficial over a wide range of assumptions about program cost and behavioral changes in response to screening.
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Affiliation(s)
- M L Brandeau
- Department of Industrial Engineering and Engineering Management, Stanford University, CA 94305-4024
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Sox HC, Hickam DH, Marton KI, Moses L, Skeff KM, Sox CH, Neal EA. Using the patient's history to estimate the probability of coronary artery disease: a comparison of primary care and referral practices. Am J Med 1990; 89:7-14. [PMID: 2242131 DOI: 10.1016/0002-9343(90)90090-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE According to probability theory, the interpretation of new information should depend on the prior probability of disease. We asked if this principle applies to interpreting the history in patients with chest pain. We compared the prevalence of coronary artery disease (CAD) in patients who had similar histories but who came from populations with different disease prevalence. PATIENTS AND METHODS We studied two high-disease-prevalence populations (patients referred for coronary arteriography) and two low-disease-prevalence populations (patients from primary care practices). We used clinical characteristics of one arteriography population to develop a logistic rule for estimating the probability of coronary artery narrowing. The number of clinical findings determined the logistic score, which was proportional to the prevalence of CAD. RESULTS The prevalence of CAD was much lower in the primary care population than in the arteriography population, even when patients with similar logistic scores, and thus similar clinical histories, were compared. CONCLUSION A clinician must take account of the overall prevalence of disease in the clinical setting when using the patient's history to estimate the probability of disease. Failure to observe this caution may lead to errors in test selection and interpretation.
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Affiliation(s)
- H C Sox
- Stanford University School of Medicine, Palo Alto Veterans Administration Medical Center, California
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Sox HC, Koran LM, Sox CH, Marton KI, Dugger F, Smith T. A medical algorithm for detecting physical disease in psychiatric patients. Hosp Community Psychiatry 1989; 40:1270-6. [PMID: 2512242 DOI: 10.1176/ps.40.12.1270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An algorithm for screening psychiatric patients for physical disease was empirically derived from a comprehensive assessment of 509 patients in California's mental health system. The first 343 patients were used to develop the algorithm, and the remaining 166 were used as a test group. Calculations were made for several versions of the algorithm, and the data were compared with the diagnoses listed in the patients' admission mental health record. The algorithmic procedure was more accurate and more cost-effective than the medical evaluation procedures used by the state mental health system. When applied to the test group, the algorithm detected up to 90 percent of patients who had an active, important physical disease at a cost of $156 per patient. The mental health system had detected 58 percent of test-group patients with a disease at a cost of $230 per patient.
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Affiliation(s)
- H C Sox
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire 03755
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Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, Imai K, Kelsey TG, Rose TG, Levin LC. Medical evaluation of psychiatric patients. I. Results in a state mental health system. Arch Gen Psychiatry 1989; 46:733-40. [PMID: 2787623 DOI: 10.1001/archpsyc.1989.01810080063007] [Citation(s) in RCA: 162] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Thorough medical evaluation of 529 patients drawn from eight program categories in California's public mental health system revealed active, important physical disease in 200 patients who had 291 diseases. Fourteen percent of the patients had diseases known to themselves but not to the mental health system, and 12% of the patients had diseases newly detected by the study team. We estimate that of the more than 300,000 patients treated in the California public mental health system in fiscal year 1983 to 1984, 45% had an active, important physical disease. The mental health system had recognized only 47% of study patients' physical diseases, including 32 of 38 diseases causing a mental disorder and 23 of 51 diseases exacerbating a mental disorder. Patients treated in public sector mental health facilities should receive careful medical evaluations.
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Affiliation(s)
- L M Koran
- Department of Psychiatry and Behavioral Sciences, Stanford (Calif.) Medical Center
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Abstract
Because of its central importance in medical diagnosis, sources of bias in the patient history must be identified. We report here a study of interobserver agreement in chest pain histories. Histories were obtained by physicians, nurse practitioners, and self-administered questionnaires. We used a discriminant rule to classify the histories as being more or less typical of angina pectoris. A sub-group of the subjects underwent coronary arteriography after the histories were obtained. In subjects with positive coronary arteriograms, physicians consistently obtained histories typical of angina pectoris more often than a self-administered questionnaire. There was no significant systematic bias when comparing physician interviews to the questionnaire among subjects with negative arteriograms nor when comparing two physicians' interviews or a nurse practitioner interview to a questionnaire. When compared to physician interviews, nurse practitioner interviews produced histories less typical of angina pectoris. We conclude that there are systematic differences between the histories obtained by physicians, nurse practitioners, and self-administered questionnaires. Questionnaires can produce biased patient histories and should be carefully validated before being used in patient care activities or health care research.
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Abstract
P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider discontinuity and provider continuity. The outcome of the continuity group was significantly different from that of the discontinuity group. During an 18-month period, patients who had been randomized to the continuity group had fewer emergent admissions (20% v 39%) and a shorter average length of stay (15.5 v 25.5 days). These patients also perceived that the providers were more knowledgeable, thorough, and interested in patient education. We conclude that continuity of outpatient provider care for men aged 55 years and older results in more patient satisfaction, shorter hospitalizations, and fewer emergent hospital admissions.
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Orient JM, Kettel LJ, Sox HC, Sox CH, Berggren HJ, Woods AH, Brown BW, Lebowitz M. The effect of algorithms on the cost and quality of patient care. Med Care 1983; 21:157-67. [PMID: 6827870 DOI: 10.1097/00005650-198302000-00004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In a Veterans Administration ambulatory care facility staffed by experienced nurse practitioners, we observed the length of visits, time utilization for various activities, and the use of diagnostic tests before and after introducing algorithms for 12 common chief complaints. Charges for diagnostic tests decreased as much as 40 per cent, primarily because of reduced utilization of radiographs such as spine films. Nurse practitioner productivity was unaffected once the nurse practitioners became familiar with the algorithms. Outcome of illness did not change measurably, but the process of care improved as reflected by more complete data collection documented in the medical record.
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Abstract
Laboratory tests are purported to affect patients even if they have no diagnostic values. We tested this hypothesis by measuring clinical outcomes of 176 patients thought clinically to have nonspecific chest pain. They were randomly allocated either to have a routine electrocardiogram and serum creatine phosphokinase tests (test group) or to have all diagnostic tests withheld (no-test group). Fewer patients in the tests group (20%) reported short-term disability after the index visit than patients in the no-test group (46%) (p = 0.001). Logistic discriminant analysis confirmed that the use of diagnostic tests was an independent predictor of recovery. Patients in the test group felt that care was "better than usual" more often (57%) than patients in the no-test group (31%) (p = 0.001). After the index visit, the two groups were equally worried about serious disease and equally sparing in their use of other medial care for chest pain.
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Abstract
The purpose of this study was to identify clinical characteristics that could predict the diagnosis in ambulatory patients with abdominal pain. We studied 552 unselected ambulatory male patients whose average age was 47 years and whose median duration of pain was 3 weeks. Potentially serious disease occurred in 21% of the patients. Single abnormal findings had a low predictive value for serious disease. However, by using combinations of clinical findings, we could construct and test a decision rule to identify a group of patients who had a low prevalence of serious disease. This "low risk" group contained 36% of all patients with abdominal pain. Laboratory tests were almost always normal in these patients. Our findings suggest a diagnostic strategy for evaluating abdominal pain: When the initial examination shows that there is little chance of serious disease, laboratory tests should be deferred or omitted altogether. In patients who have a very low likelihood of potentially serious disease, it may be useful to regard "nonspecific abdominal pain" as a positive diagnosis, rather than a diagnosis of exclusion.
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Sox HC, Sox CH, Tompkins RK. The training of physician's assistants. The use of a clinical algorithm system for patient care, audit of performance and education. N Engl J Med 1973; 288:818-24. [PMID: 4144344 DOI: 10.1056/nejm197304192881605] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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