Analysis of questions asked by family physicians regarding patient care

Objectives To characterize the information needs of family physicians by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. Design An observational study in which investigators visited physicians for two half-days and collected their questions. Taxonomies were developed to characterize the clinical topic and generic type of information sought for each question. Setting Eastern Iowa. Participants Random sample of 103 family physicians. Main outcome measures Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; and information resources used. Results Participants asked a total of 1,101 questions. Questions about drug prescribing, obstetrics and gynecology, and adult infectious disease were most common, comprising 36% of the total. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were "What is the cause of symptom X?" "What is the dose of drug X?" and "How should I manage disease or finding X?" Answers to most questions (n = 702 [64%]) were not immediately pursued, but of those pursued, most (n = 318 [80%]) were answered. Physicians spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search. Conclusions Family physicians in this study did not pursue answers to most of their questions. Questions about patient care can be organized into a limited number of generic types, which could help guide the efforts of knowledge-base developers.

Impact of complications on outcomes following aortic and mitral valve replacements in the United States

AIM

Heart valve replacement surgeries account for 20% of all cardiac procedures. In-hospital mortality rates are approximately 6% for aortic valve replacements and 10% for mitral valve replacements. The objectives of the study are to provide nationally representative estimates of complications following aortic and mitral valve replacements and to quantify the impact of different types of complications on in-hospital outcomes.

METHODS

The Nationwide Inpatient Sample was analyzed for years 2000-2003. The effect of complications on in-hospital mortality, length of stay (LOS), and hospital charges were examined using bivariate and multivariable logistic and linear regression analyses. The confounding effects of age, sex, primary diagnosis, type of valve replacement, type of admission, comorbid conditions, and hospital characteristics were adjusted.

RESULTS

A total of 43,909 patients underwent aortic valve replacement as the primary procedure during the study period and 16,516 patients underwent mitral valve replacement. Complications occurred in 35.2% of those undergoing aortic valve replacements and in 36.4% of those undergoing mitral valve replacements. Almost half of these are cardiac complications and a quarter involve hemorrhage/hematoma/seroma. Complications were significantly associated with in-hospital mortality, LOS, and hospital charges even after adjusting for patient and hospital characteristics.

CONCLUSION

Complications are prevalent and exert a considerable influence on outcomes following aortic and mitral valve replacements. Quality initiatives should focus on minimizing complications and improving processes of care that would enable complications to be better resolved if they occur.

A taxonomy of generic clinical questions: classification study

OBJECTIVE

To develop a taxonomy of doctors' questions about patient care that could be used to help answer such questions.

DESIGN

Use of 295 questions asked by Oregon primary care doctors to modify previously developed taxonomy of 1101 clinical questions asked by Iowa family doctors.

SETTING

Primary care practices in Iowa and Oregon.

PARTICIPANTS

Random samples of 103 Iowa family doctors and 49 Oregon primary care doctors.

MAIN OUTCOME MEASURES

Consensus among seven investigators on a meaningful taxonomy of generic questions; interrater reliability among 11 individuals who used the taxonomy to classify a random sample of 100 questions: 50 from Iowa and 50 from Oregon.

RESULTS

The revised taxonomy, which comprised 64 generic question types, was used to classify 1396 clinical questions. The three commonest generic types were "What is the drug of choice for condition x?" (150 questions, 11%); "What is the cause of symptom x?" (115 questions, 8%); and "What test is indicated in situation x?" (112 questions, 8%). The mean interrater reliability among 11 coders was moderate (kappa=0.53, agreement 55%).

CONCLUSIONS

Clinical questions in primary care can be categorised into a limited number of generic types. A moderate degree of interrater reliability was achieved with the taxonomy developed in this study. The taxonomy may enhance our understanding of doctors' information needs and improve our ability to meet those needs.

Evaluation of pregnant women exposed to respiratory viruses

Prenatal patients are often exposed to respiratory viruses at home and at work. Understandably, these patients may be concerned and want immediate answers and advice from their physicians. While most women who are exposed to chickenpox are immune, serologic testing can be performed and susceptible patients can be treated with varicella-zoster immune globulin. If the prenatal patient is infected with the varicella-zoster virus, the risk of fetal manifestations is less than 2 percent. Women who have been exposed to fifth disease can undergo serologic testing to determine the likelihood of infection. If the prenatal patient becomes infected with fifth disease during the first 20 weeks of gestation, the risk of fetal manifestations is about 9 percent and includes nonimmune hydrops and death. Cytomegalovirus, which is the most common congenital infection, is generally asymptomatic in the mother. Infected fetuses have a 25 percent chance of developing early or late neurologic manifestations. The evidence of harm from other common respiratory viruses is inconsistent.

Community characteristics associated with elder abuse

OBJECTIVES

To help define the relationship between elder abuse rates and counties' demographics, healthcare resources, and social service characteristics.

DESIGN

County-level data from Iowa were analyzed to test the association between county characteristics and rates of elder abuse between 1984 and 1993 using univariate correlation analysis and stagewise linear regression.

SETTING

Ninety-nine counties in Iowa.

PARTICIPANTS

Iowa residents aged 65 years and older.

MEASUREMENTS

County-level population-adjusted numbers of abused elderly, abused children, children in poverty, high school dropouts, physicians and other healthcare providers, hospital beds, social workers and caseworkers in the Department of Human Services (DHS).

RESULTS

Community characteristics that had a positive association with rates of reported or substantiated elder abuse at the P < .001 level were population density, children in poverty, and reported child abuse. Lower substantiated elder abuse rates were associated at P < .05 with higher community rates of high school dropouts, number of chiropractors, and number of nurse practitioners. After adjusting for number of DHS caseworkers and reported child abuse rates (a surrogate for workload) a district effect persists for substantiated elder abuse cases (P = .002).

CONCLUSION

County demographics are risk factors for reported and substantiated elder abuse. The strongest risk factor for reported elder abuse was reported child abuse. The difference in districts may reflect differences in resources and/or differing characteristics of caseworkers who substantiate elder abuse. The risk factors may reflect conditions that influence the amount of elder abuse or the detection of existing elder abuse.

Videotaping obstetric procedures. Assessment of obstetricians and family physicians

OBJECTIVE

To compare the attitudes and practice of Iowa obstetricians (OBs) and family physicians (FPs) regarding patients' desires to videotape obstetric procedures.

DESIGN

All Iowa OBs (172) and FPs (438) who practice obstetrics received a questionnaire exploring their attitudes and practice patterns regarding videotaping obstetric procedures. Data were analyzed using chi 2, odds ratios with 95% confidence intervals, and multiple logistic regression.

SETTING

The state of Iowa.

MAIN OUTCOME MEASURES

Degree to which physicians allow videotaping and characteristics that contribute to any differences between OBs and FPs.

RESULTS

The response rate was 87.8% (536 of 610 participants). Obstetricians were more likely than FPs to prevent patients from filming medical procedures (40.8% vs 19.1%, respectively, P < .001), modify their actions and conversation when video cameras were present (34.5% vs 25.5%, respectively, P = .046), and be tempted to turn off the camera when complications arose (35.1% vs 14.0%, respectively, P < .001). Younger OBs (aged, 25-40 years) were more likely than older OBs (aged, 41-80 years) to disallow videocameras (52.7% vs 33.3%, respectively, P = .02). Legal concerns were cited by more than 80% of OBs and FPs who disallowed videotaping.

CONCLUSIONS

A significant difference was noted between OBs and FPs in their willingness to allow video recording of obstetric procedures. Legal concerns were cited by most OBs and FPs who had disallowed videotaping.

Analysis of questions asked by family doctors regarding patient care

OBJECTIVES

To characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases.

DESIGN

Observational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question.

SETTING

Eastern Iowa.

PARTICIPANTS

Random sample of 103 family doctors.

MAIN OUTCOME MEASURES

Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; information resources used.

RESULTS

Participants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were "What is the cause of symptom X?" "What is the dose of drug X?" and "How should I manage disease or finding X?" Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered. Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search.

CONCLUSIONS

Family doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers.

Informed consent and general surgeons' attitudes toward the use of pain medication in the acute abdomen

To determine general surgeons' attitudes about the use of pain medications in the acute abdomen, a questionnaire was mailed to all practicing general surgeons in Iowa. The questionnaire sought to determine the frequency with which pain medications were administered either before informed consent was obtained or before the patient with an acute abdomen was examined, and, in cases when pain medications were withheld, the reasons for withholding. The response rate was 72% (131 of 182). Seven percent of patients with an acute abdomen received pain medications by a general surgeon before being seen and 22% received pain medication by another physician in the emergency department (ED). Fifty-three percent of general surgeons responded that they believe pain medications preclude a patient from signing a valid informed consent; 78% reported that concerns about informed consent enter into their decision to withhold pain medications. Sixty-seven percent agreed that pain medications interfere with diagnostic accuracy, and 82% consider diagnostic accuracy when deciding to withhold pain medication.

What clinical information resources are available in family physicians' offices?

BACKGROUND

When faced with questions about patient care, family physicians usually turn to books in their personal libraries for the answers. The resources in these libraries have not been adequately characterized.

METHODS

We recorded the titles of all medical books in the personal libraries of 103 randomly selected family physicians in eastern Iowa. We also noted all clinical information that was posted on walls, bulletin boards, refrigerators, and so forth. Participants were asked to describe their use of other resources such as computers, MEDLINE, reprint files, and "peripheral brains" (personal notebooks of clinical information). For each physician, we recorded how often the resources were used to answer clinical questions during 2 half-day observation periods.

RESULTS

The 103 participants owned a total of 5794 medical books, with 2836 different titles. Each physician kept an average of 56 books in the office. Prescribing references (especially the Physicians' Desk Reference) were most common (owned by 100% of the participants), followed by books on general internal medicine (99%), adult infectious disease (89%), and general pediatrics (83%). Books used to answer clinical questions were more likely to be up to date (copyright date within 5 years) than unused books (74% vs 27%, P <.001). Items posted on walls included drug dosage charts and pediatric immunization schedules. Only 26% of the physicians had computers in their offices.

CONCLUSIONS

Drug-prescribing textbooks were the most common type of book in family physicians' offices, followed by books on general internal medicine and adult infectious diseases. Although many books were relatively old, those used to answer clinical questions were generally current.

Malpractice claims against family physicians are the best doctors sued more?

BACKGROUND

Physicians who have been sued multiple times for malpractice are assumed to be less competent than those who have never been sued. However, there is a lack of data to support this assumption. Competence includes both knowledge and performance, and there are theoretical reasons to suspect that the most knowledgeable physicians may be sued the most.

METHODS

We conducted a retrospective cohort study of family physicians who were included in the Florida section of the 1996 American Medical Association's Physician Masterfile and who practiced in Florida at any time between 1971 and 1994 (N = 3686). The main outcome was the number of malpractice claims per physician adjusted for time in practice. Using regression methods, we analyzed associations between malpractice claims and measures of physician knowledge.

RESULTS

Risk factors for malpractice claims included graduation from a medical school in the United States or Canada (incidence rate ratio [IRR] 1.8; 95% confidence interval [CI], 1.6-2.1), specialty board certification (IRR 1.8; 95% CI, 1.6-2.1), holding the American Medical Association Physician's Recognition Award (IRR 1.4; 95% CI, 1.2-1.7), and Alpha Omega Alpha Honor Society membership (IRR 1.8; 95% CI, 1.1-3.0). Among board-certified family physicians, sued physicians who made no payments to a plaintiff had higher certification examination scores than nonsued physicians (53.48 vs 51.38, P < .01). The scores of sued physicians who made payments were similar to those of nonsued physicians (51.05 vs 51.38, P = .93).

CONCLUSIONS

Among Florida family physicians, the frequency of malpractice claims increased with evidence of greater medical knowledge.

Clinical diagnosis and the order of information

BACKGROUND

Information order can influence judgment. However, it remains unclear whether the order of clinical data affects physicians' interpretations of these data when they are engaged in familiar diagnostic tasks.

METHODS

Of 400 randomly selected family physicians who were given a questionnaire involving a brief written scenario about a young woman with acute dysuria, 315 (79%) returned usable responses. The physicians had been randomized into two groups, and both groups had received the same clinical information but in different orders. After learning the patient's chief complaint, physicians received either the patient's history and physical examination results followed by the laboratory data (the H&P-first group) or the laboratory data followed by the history and physical examination results (the H&P-last group). The results of the history and physical examination were supportive of the diagnosis of UTI, while the laboratory data were not. All physicians judged the probability of a urinary tract infection (UTI) after each piece of information.

RESULTS

The two groups had similar mean estimates of the probability of a UTI after learning the chief complaint (67.4% vs 67.8%, p = 0.85). At the end of the scenario, the H&P-first group judged UTI to be less likely than did the H&P-last group (50.9% vs 59.1%, p = 0.03) despite having identical information. Comparison of the mean likelihood ratios attributed to the clinical information showed that the H&P-first group gave less weight to the history and physical than did the H&P-last group (p = 0.04).

CONCLUSIONS

The order in which clinical information was presented influenced physicians' estimates of the probability of disease. The clinical history and physical examination were given more weight by physicians who received this information last.

Identifying left lower lobe pneumonia at chest radiography: performance of family practice residents before and after a didactic session

RATIONALE AND OBJECTIVES

The authors sought to determine whether the lateral chest radiograph is helpful in identifying left lower lobe pneumonia among inexperienced readers.

MATERIALS AND METHODS

The authors selected all patients who presented to a family practice training program with radiologic and clinical evidence of left lower lobe pneumonia (n = 65). They then selected an equal number of patients in whom chest radiographs were taken to "rule out pneumonia" and were found to be normal. Eight 1st-year family practice residents were asked to read the radiographs before and after a didactic session that emphasized lateral chest radiograph interpretation. The radiographs were presented under two viewing conditions: posteroanterior (PA) only versus PA and lateral. Receiver operating characteristic (ROC) curve methods were used to compare the effect of both the didactic session and the viewing condition on diagnostic accuracy.

RESULTS

There were no significant differences in performance before and after the didactic session and no differences between the two viewing conditions. After including only abnormal radiographs that demonstrated the "spine sign" (an apparent increased opacification of the lower vertebral bodies on the lateral view), the residents performed better when presented with both PA and lateral radiographs than when presented with the PA radiograph only (area under ROC curve, .8158 vs .7418, respectively; P = 0.24).

CONCLUSION

In patients with left lower lobe pneumonia whose radiographs demonstrated the spine sign, diagnostic accuracy improved when the lateral chest radiograph was viewed.

Russian family practice training program: a single step on a long journey

BACKGROUND AND OBJECTIVES

Since 1992, when the Russian government recognized family practice as a medical specialty, efforts have begun to progress from the idea stage to the delivery of patient care via family practice methods. We describe an educational effort to help teach Russian physicians family practice skills.

METHODS

Five young Russian physicians were selected from an initial pool of 15 candidates on the basis of standardized testing, English language skills, and their potential to teach future Russian family physicians. Clinical, teaching, and business curricula were developed and used during the 6-month training period for the five selected physicians. Trainees were evaluated by mentors' and preceptors' written evaluations and by the American Board of Family Practice In-training Examination before, during, and at completion of the training. Subsequently, a fully equipped family practice office was opened in St Petersburg to serve as an on-site training facility.

RESULTS

The trainees' self-perceived knowledge in community medicine, geriatrics, medical decision making, patient education, behavioral science, preventive medicine, and general family practice topics improved over the course of training. The composite scores on the in-training examinations improved from baseline (30 versus 308). Preceptors noted the greatest improvements in the use of clinical instruments, proficiency in physical exams, accessing medical information, and formulating differential diagnoses. The St Petersburg family practice office opened on October 1, 1996. The trainees now participate in the care of patients in this office and teach a new class of family medicine interns.

CONCLUSION

The training program we describe has allowed Russian physicians to acquire new skills and knowledge that they can use and adapt to training future Russian family physicians.

Neonatal respiratory distress in the community hospital: when to transport, when to keep

Neonatal respiratory distress is a common problem confronting family physicians. Although respiratory distress may represent a benign, self-limited process, it may also be the first sign of sepsis or serious cardiopulmonary disease. Because it is crucial to differentiate the two, we offer a practical approach to the treatment of neonatal respiratory distress at community hospitals. Our method, the Rule of 2 Hours, is based on readily accessible clinical findings. We believe it will help physicians detect babies at risk for serious problems, but will not result in unnecessary referral of neonates that are simply adapting to extrauterine life.

Legal implications of birth videos

There is little information available in the peer-reviewed literature on the medical and legal aspects of videotaping obstetric procedures. To manage legal risks, some large medical centers do not allow families to videotape the birth. One liability insurer is now attempting to limit video cameras in labor and delivery suites throughout its state. These policies can have significant implications for physicians and their patients. In an effort to examine approaches to the problem, we gathered the experiences of physician and attorney members of the American College of Legal Medicine through letters and telephone conversations, and we performed a review of the available medical and legal literature. Based on this research and review, we present the benefits and risks of permitting families to videotape the birth process, and we make recommendations for reducing potential liability.

The effect of physician characteristics on compliance with adult preventive care guidelines

BACKGROUND AND OBJECTIVES

This study identified physician characteristics and attitudes related to self-reported compliance with adult prevention guidelines.

METHODS

A questionnaire was mailed to family practice and internal medicine residents and faculty at the University of Iowa (n = 209). The questionnaire's 78 items fell into seven categories, including physician demographics, history-taking practices, counseling practices, self-perceived effectiveness in changing patient behavior, beliefs about preventive care, knowledge about preventive care, and perceived barriers to the delivery of preventive care.

RESULTS

Compliance with history-taking recommendations was independently associated with high knowledge scores, female physician gender, and high self-perceived effectiveness in changing patient behavior. The only factor that was independently associated with counseling efforts was self-perceived effectiveness in changing patient behavior.

CONCLUSIONS

Factors that were independently associated with self-reported preventive care efforts include female physician gender, knowledge about preventive care guidelines, and perceived effectiveness in changing patient behavior. After controlling for these factors, other variables such as lack of time, lack of reminder systems, attitudes about preventive care, and amount of formal preventive care education were not related to self-reported compliance with counseling and history-taking recommendations.

Lifelong self-directed learning using a computer database of clinical questions

Physicians often have self-perceived knowledge gaps when they are seeing patients. Traditional continuing medical education is designed to meet the knowledge gaps of groups rather than individual physicians with specific patient problems. Physicians with clinical information needs are advised to critically evaluate high-quality original research in order to practice "evidence-based medicine." But this advice may be unrealistic for busy clinicians. We propose a system for documenting self-perceived information needs using a computer database. Concise answers to these needs are included in the database along with reference citations supporting the answers. The system tracks continuing education efforts, directs patient care decisions, and focuses lifelong learning on relevant topics. We emphasize the importance of being sensitive to personal information needs and the benefits of maintaining a record of these needs.

Home visit program for teaching elder abuse evaluations

BACKGROUND AND OBJECTIVES

A home visit program was designed to teach family practice residents how to evaluate patients for elder abuse and capacity (the ability to make one's own decisions).

METHODS

Residents assessed potential abuse victims reported to Arizona's Adult Protective Service (APS) in their homes. Written evaluations prepared immediately following each home visit were abstracted for diagnoses (including abuse), recommendations, and patient demographics. Follow-up surveys by APS case workers determined whether the home visit recommendations were accomplished. Graduates of the residency were surveyed about their perceptions of the educational value of the program and their practice characteristics.

RESULTS

The residents evaluated 201 patients. The mean age was 77, and 73% of patients were female. Seventy-five percent were incapacitated, 65% of these because of dementia. Ninety-one percent were abused, and the types of abuse included neglect (69%), exploitation (20%), physical abuse (8%), and unknown (3%). Recommendations were accomplished in the majority of cases: medical advice (68%), services (65%), medical evaluations (58%), guardian (53%), and conservator (52%). Graduates who participated in this program (1985-1992) rated their ability to diagnose elder abuse and to assess the patient's home environment significantly higher than earlier graduates who did not participate in the program (1977-1984). Earlier graduates made more home visits and provided more statements for guardianship than later graduates.

CONCLUSIONS

The home visit program gave residents exposure to a population of elderly who were abused, demented, and living at home. This program provided clinical substance to build an effective teaching experience and furnished APS with a needed service.

An introduction to time-trend analysis

Healthcare professionals often are presented with data that appear to indicate an upward or downward trend over time. For example, admissions of acquired immunodeficiency syndrome (AIDS) patients appear to be increasing, cesarean section rates appear to be decreasing, or nosocomial pneumonia rates appear to be increasing. Critical decisions sometimes are based on such trends, which often are presented without a statistical analysis. Those responsible for decision making may be left wondering whether these apparent trends represent only chance variation. Graphs showing trends over time generally present one of three kinds of outcome data: counts (eg, three AIDS admissions), proportions (eg, 10 cesarean sections per 100 total deliveries), or person-time data (eg, 13 cases of nosocomial pneumonia per 10,000 patient days). Using familiar examples and a minimum of technical language, we illustrate the analysis of time trends.

Practice patterns during the third stage of labor: the effect of physician age and specialty

BACKGROUND

Elective manual removal of the placenta and routine uterine exploration following vaginal delivery are controversial procedures. Although advocated in the past, little is known about current attitudes and practices related to these procedures.

METHODS

Using a mailed questionnaire, we surveyed all 178 Iowa obstetrician-gynecologists and a random sample of 163 Iowa family physicians to determine their practice patterns related to selected aspects of the third stage of labor. The data were analyzed using odds ratios and multiple logistic regression.

RESULTS

The analysis was based on answers from 302 physicians. Physicians in the oldest age quartile were three times more likely than physicians in the youngest age quartile to routinely explore the uterus after a vaginal delivery (P < .01). After controlling for specialty, younger physicians were more likely to believe that manual removal of the placenta is a risk factor for endometritis (adjusted odds ratio [OR] 0.7 for each 10-year increase in age, 95% confidence interval [CI] 0.6 to 1.0). Controlling for age, family physicians were more likely than obstetrician-gynecologists to routinely order prophylactic antibiotics after manually removing the placenta (adjusted OR 2.0, 95% CI 1.1 to 3.7).

CONCLUSIONS

Both physician age and specialty were associated with selected practice patterns involving the third stage of labor. Older physicians were less likely to believe that manually removing a placenta increases the risk of postpartum endometritis, and they were more likely to routinely explore the uterus after a vaginal delivery.

Diagnosing left lower lobe pneumonia: usefulness of the 'spine sign' on lateral chest radiographs

BACKGROUND

Left lower lobe pneumonia may be obscured by the heart on the postero-anterior (PA) chest radiograph. In such cases, the lateral projection may be helpful, especially if it exhibits the "spine sign", which is an interruption in the progressive increase in lucency of the vertebral bodies from superior to inferior. We investigated whether the spine sign would help family physicians diagnose left lower lobe pneumonia on chest radiographs.

METHODS

We selected the chest radiographs of all patients with left lower lobe pneumonia who were seen between 1983 and 1995 at a family practice training program (N = 78) and an equal number of chest radiographs of patients without pneumonia. Six family physicians read these radiographs under two viewing conditions: PA only vs PA and lateral. We used receiver operating characteristic (ROC) curve methodology to compare the two viewing conditions.

RESULTS

There was no significant difference in performance between the two viewing conditions. The lateral view was helpful in some patients but misleading in others. Among patients with pneumonia, the lateral view was helpful when the spine sign was present, but it was misleading when the spine sign was absent.

CONCLUSIONS

In this study of family physicians, the lateral chest radiograph did not improve overall diagnostic accuracy in patients with left lower lobe pneumonia. Among pneumonia patients with the spine sign, however, the lateral view was often helpful.

Benign fever following vaginal delivery

BACKGROUND

In patients with fever following vaginal delivery, physicians must differentiate benign self-resolving fevers from fevers with more serious causes, especially endometritis. To help differentiate these clinical entities, we explored the characteristics and risk factors for benign "single-day" postpartum fever.

METHODS

We conducted a retrospective cohort study of 2137 vaginal deliveries. Patients were randomly selected from the 25,687 vaginal deliveries that took place between 1979 and 1992 at The University of Iowa Hospitals and Clinics. The data were analyzed using odds ratios and multiple logistic regression.

RESULTS

Benign fevers occurred in 3.3% of patients, while endometritis was diagnosed in 1.6%. After controlling for confounding variables, two clinical factors were independently associated with single-day fever: primiparity (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.0 to 5.7) and use of a uterine pressure catheter (OR, 2.4; 95% CI, 1.5 to 3.7). These factors were not associated with endometritis. The first postpartum temperature elevation ( > or = 38.0 degrees C) occurred earlier in patients with single-day fever than in patients with endometritis (4.0 +/- 4.6 hours postpartum vs 30.2 +/- 27.0 hours postpartum, P < .001). The maximum temperature elevation was lower, on average, in patients with single-day fever than in patients with endometritis (38.2 degrees +/- 0.2 degrees C vs 38.9 degrees +/- 0.6 degrees C, P < .001).

CONCLUSIONS

Single-day fever was more likely to occur in primiparous women and in women who were monitored with a uterine pressure catheter. Most women with benign single-day fevers had early low-grade fevers, whereas women with endometritis had higher fevers that occurred later in the postpartum period.

Differences in practice patterns between obstetricians and family physicians: use of serum screening

OBJECTIVE

Our purpose was to compare the use of the Iowa Expanded Serum Screening program (maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol) by obstetricians and family physicians.

STUDY DESIGN

A registry was used to identify all obstetricians (160) and family physicians (404) who practice obstetrics in Iowa. A questionnaire exploring attitudes and practice patterns related to serum screening was mailed to these physicians.

RESULTS

The response rate was 80.3% overall. There were significant differences in the offering of serum screening (p < 0.001) for following three responses: obstetricians were more likely to offer screening through the Iowa Expanded Serum Screening Program than were family physicians (89.3% vs 57.2%) and less likely to offer screening outside the state program (9.9% vs 39.0%), whereas family physicians were more likely to not offer screening (0.8% vs 3.8%). When the responses of the physicians who offer screening were analyzed, several differences emerged: (1) obstetricians were more likely than family physicians to offer screening to all obstetric patients (99.2% vs 92.1%, p < 0.05), whereas family physicians were more likely to offer testing to patients with perceived risks for neural tube defects or chromosomal abnormalities and to those patients who requested it, (2) obstetricians were more likely to recommend screening than family physicians (39.0% vs 25.7%, p < 0.05), who more often discouraged testing, although the latter did not reach statistical significance, (3) family physicians more than obstetricians felt that screening was not necessary if the patient would not terminate the pregnancy for neural tube defects (41.6% vs 19.1%, p < 0.001) or chromosomal abnormalities (39.7% vs 21.4%, p < 0.01), and (4) obstetricians used nurses to counsel patients to a much greater extent than family physicians did (44.6% vs 14.0%, p < 0.001).

CONCLUSION

There is a significant difference in practice patterns between obstetricians and family physicians in their reported use and presentation of maternal serum screening. Guidelines based on outcome studies should be developed and followed by obstetricians and family physicians.

Understanding logistic regression analysis through example

Logistic regression is a valuable statistical tool that is often used in primary care research. When researchers explore the association between a possible risk factor and a disease, they attempt to control the effects of extraneous factors (confounders) that can obscure the true association. Using logistic regression, researchers can simultaneously control for the effects of multiple confounders. When investigators use logistic regression, they make subjective decisions about which factors to include in the analysis and in the final predictive model. Critical readers must understand basic concepts of logistic regression and potential problems with its use before they can accurately interpret study results. This article uses a familiar example to explain the principles of logistic regression to make it understandable to nonstatisticians.

The association between manual removal of the placenta and postpartum endometritis following vaginal delivery

OBJECTIVE

To determine whether manual removal of the placenta after vaginal delivery is a risk factor for postpartum endometritis.

METHODS

A retrospective cohort study of vaginal deliveries compared 1052 patients who had manual removal of the placenta with 1085 patients whose placentas delivered spontaneously. Subjects were selected randomly from the 25,687 vaginal deliveries at the University of Iowa Hospitals during 1979-1992. The presence of endometritis was determined using information in medical records. The data were analyzed using odds ratios (OR) and multiple logistic regression.

RESULTS

After controlling for confounding variables, manual removal of the placenta was associated with postpartum endometritis (adjusted OR 2.9, 95% confidence interval [CI] 1.7-4.9). Other risk factors for endometritis included maternal age less than 17 years (OR 3.3, 95% CI 1.5-7.2), postpartum anemia (OR 2.9, 95% CI 1.9-4.5), and membranes ruptured longer than 24 hours (OR 2.5, 95% CI 1.4-4.3).

CONCLUSION

Manual removal of the placenta is a risk factor for postpartum endometritis after vaginal delivery.

Perceived causes of family physicians' errors

BACKGROUND

Competent physicians occasionally make critical errors in patient care that can lead to long-lasting remorse and guilt. The perceived causes of self-admitted physician errors have not been previously explored.

METHODS

Fifty-three family physicians were interviewed in depth and asked to describe their most memorable errors and the perceived causes. The authors analyzed transcripts of the audiotaped interviews to determine the frequencies of the different causes. Errors were classified according to four general categories.

RESULTS

Family physicians collectively reported a mean of 8 different causes for each case in which an error was made (range, 1 to 16). In 47% of the cases, the patient died following the error, whereas in 26% of the cases, there was no adverse outcome. Only 4 of the 53 errors led to malpractice suits, and none were addressed by peer review organizations. Seven (10%) of the 70 physicians who were invited to participate could not recall having made any errors. Family physicians attributed their most memorable errors to 34 different causes, which fit into the following categories: physician stressors (eg, bing hurried or distracted), process-of-care factors (eg, premature closure of the diagnostic process), patient-related factors (eg, misleading normal findings), and physician characteristics (eg, lack of knowledge).

CONCLUSIONS

Family physicians attribute their memorable errors to a wide variety of causes, but most commonly to hurry, distraction, lack of knowledge, premature closure of the diagnostic process, and inadequately aggressive patient management. Physicians who understand common causes of errors may be better prepared to prevent them.

Community attitudes and knowledge about advance care directives

BACKGROUND

Patients and their physicians are increasingly being encouraged to discuss end-of-life decisions. The purpose of this study was to enhance understanding of the public's attitudes and knowledge about medical decision making and advance care directives.

METHODS

Eight focus groups of community members discussed their understanding of and attitudes about advance care directives. Transcripts of these discussions were analyzed using coding categories created from the transcripts.

RESULTS

Eighty-three people attended the focus groups. Most discussions of advance care directives involved family members in the setting of family or personal illness. Elderly persons commonly confused wills with living wills. Most who had given advance directives did so either to make others follow their wishes or to ease family burdens. Among the great variety of reasons for not using advance directives was a perceived lack of personal relevance, as well as conceptual, moral, and practical difficulties. Participants were divided about whether it was appropriate for physicians to initiate discussions about life-sustaining care with their patients. We discerned three themes affecting individuals' opinions about personal decision making about advance directives: (1) trust in family and the medical system, (2) need for control, and (3) knowledge about advance directives.

CONCLUSIONS

Although living wills are advocated by many authorities, and many of our participants endorsed their use, our participants also cited numerous cautions and impediments to their use. As the role of advance care directives changes, physicians will need to be aware of their patients' perceptions, as well as the legalities of these documents.

The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision

OBJECTIVE

To determine the relative importance of factors influencing physicians to use tube feedings in patients lacking decision-making capacity.

DESIGN

Survey.

SETTING AND PARTICIPANTS

Four hundred thirty-nine members of the Missouri Academy of Family Physicians.

MEASUREMENTS

Using a mailed questionnaire, physicians were asked for a decision about feeding tube placement in an 89-year-old man who was unable to swallow or communicate after a stroke. Changing the conditions of the scenario, we then evaluated the influence of patient age, duration of disability, a living will, the Cruzan decision, and family preferences on the physician's decision.

RESULTS

After reading the initial case history, 47% of physicians opposed tube feedings. Physicians who were told that the patient signed a living will specifically excluding tube feedings were more likely to oppose tube feedings than those who were told that he signed only a standard living will (53% vs 42%; P = 0.02). Forty-two percent of physicians who initially suggested a feeding tube changed their recommendation if the family opposed it. Sixty-six percent of physicians who initially opposed a feeding tube changed their recommendation if the family "pushed" for it. Thirty-three percent of physicians who initially opposed tube feedings under the living will scenario would favor tube feedings if the patient had not signed a living will. Twenty-two percent of physicians who initially opposed tube feedings would change to favor them if the issue had arisen before the Cruzan decision.

CONCLUSIONS

Among this group of physicians, there was no consensus on whether tube feedings should be initiated. However, it was found that the family's opinion was the most influential factor affecting the physician's recommendation about tube feedings. Most physicians endorsed family preferences for tube feedings even when this intervention was specifically opposed in the patient's living will.

Confounding bias and effect modification in epidemiologic research

The medical literature contains many studies of the clinical effectiveness of diagnostic tests and therapeutic interventions. Common problems in experimental design occur that influence the usefulness of original research. Confounding bias and effect modification are two important factors that affect whether clinicians ought to apply the findings of clinical research to the care of their patients. Investigators should minimize confounding biases in their work. Effect modification should be described so that readers can decide which of their patients will benefit from a particular study. This article uses a number of clinical examples to help the clinician and investigator understand the influences of bias and effect modification on clinical research.