Removable Denture Wearing as a Risk Predictor for Pneumonia Incidence and Time to Event in Older Adults

INTRODUCTION

Older adults are more susceptible to a common respiratory infection: pneumonia. Nearly 1 million older adults per year are hospitalized for community-acquired pneumonia in the United States.

OBJECTIVE

To examine whether wearing removable dentures are associated with an increased risk of pneumonia incidence in a geriatric population.

METHODS

We conducted a retrospective cohort study among patients >65 y of age within a large academic health system (University of Rochester Medical Center). The medical and dental electronic records from 2010 to 2018 were reviewed and used for data collection. The exposure was removable denture wearing. The main outcome variables were the incidence of pneumonia and time to event of pneumonia. A Cox proportional hazards regression was used to examine the association between pneumonia onset and wearing removable dentures, adjusting for demographics, socioeconomic status, and medical and dental conditions.

RESULTS

A total of 2,364 patients were included, with 1,189 (50.29%) in the denture-wearing group and 1,175 (49.70%) in the non-denture wearing group. The annual pneumonia incidence rate per 100,000 persons was 1,191 in the denture-wearing group and 128 per 100,000 persons in the non-denture wearing group, with a crude incidence rate ratio of 9.33 (95% CI, 5.41 to 18.81; P < 0.0001). The mean ± SD age of the pneumonia onset was 78.0 ± 10.0 and 78.6 ± 9.0 y among denture-wearing and nonwearing groups (P = 0.84). The time to event of pneumonia was associated with removable denture wearing (yes/no; hazard ratio, 7.68 [95% CI, 3.91 to 15.08]; P < 0.001) after adjusting for covariates.

CONCLUSIONS

Wearing removable dentures was found to be a risk predictor for pneumonia incidence among the geriatric population even after accounting for other risk factors.

KNOWLEDGE TRANSFER STATEMENT

Wearing removable dentures was found to be a risk predictor of pneumonia incidence among older adults. Although the current study does not imply a causal relationship between denture wearing and pneumonia, clinicians and older patients could reference the study results when choosing dental prostheses to restore missing teeth.

Patients’ experiences with navigation for cancer care

e17520

Background: Patient navigation is a promising strategy for improving cancer care. We examined (1) how navigation influences patients’ perspectives on their cancer care and (2) the most effective (i.e., meaningful or valuable) aspects of navigation from the patient's viewpoint. Methods: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in Monroe County, NY. We interviewed patients about their specific experiences with cancer care including their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance. Results: Thirty-five patients (32 female, 3 male) newly diagnosed with breast (n = 28) or colorectal (n = 7) cancer who completed the study and were interviewed from May 2007 through March 2008. Patients who received navigation were very positive about their experience. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving (such as with insurance or financial stressors), and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support. Conclusions: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. However, when describing their actual experience of navigation, navigated patients frequently mentioned receiving emotional support as well as assistance with information needs, problem-solving, and logistical aspects of cancer care coordination.

No significant financial relationships to disclose.

Communication about physical activity in an underserved patient population

17012

Background: Promoting physical activity may help reduce the incidence of several cancers. The 5A model, used to promote other patient behavior changes in clinical practice, may be applicable to physical activity. Our goal was to determine clinicians’ use of the 5A (Ask, Advise, Agree, Assist, Arrange) guidelines when communicating about physical activity and cancer risk with an underserved patient population. Methods: Analysis of 50 audiotaped transcribed office visits with adult patients and their clinicians in two community health centers in Rochester, NY. We conducted post-visit interviews to assess patient recall of communication about physical activity.We used descriptive statistics to assess patient demographics and the frequency of each of the 5As occurring in the audiotaped visits. Analysis of the transcripts of the visits explored other contextual factors related to use of the 5As for communication about physical activity and cancer risk. Results: Patients were predominantly female (70%) and were African American (50%), Caucasian (35%) and other/mixed ethnicity (15%). In the 50 office visits, there were twelve (24%) Ask, twelve (24%) Advise, three (6%) Agree, two (4%) Assist, and one (2%) Arrange statement. Physical activity communication was mostly (92%) clinician-initiated; the only discussion which included all 5As was patient-initiated. No discussion linked physical activity to cancer risk or cancer prevention. Patients recalling the most communication about physical activity with their clinician reported that it was contextualized to their specific health needs, included support and encouragement, and consisted of clear, simple advice. Conclusions: Communication about physical activity incorporating the Agree and Arrange steps of the 5As was infrequent. Cancer prevention interventions should target these steps and prompt the patient to initiate communication to improve physical activity in underserved populations. This project was supported by a grant from the National Cancer Institute, R25- CA102618.

No significant financial relationships to disclose.

A brief measure of patients self-reported chemotherapy-related memory problem: Psychometric studies

19655

Background: Memory is a central component of individuals’ functional systems of behavior, (i.e., cognition, emotionality, and executive functioning) that can be deleteriously affected by cancer treatment. It is important to identify and understand the effects of cancer treatment on memory in order to develop effective interventions to ameliorate these problems. This study involves structural and reliability analyses of a brief measure of chemotherapy-related memory problem to facilitate prompt and reliable preliminary assessments in oncology research and practice. Methods: Patients (N = 821) included in this analysis were part of a larger randomized clinical trial on cancer-related fatigue. These patients completed the Fatigue Symptom Checklist (FSCL) at four time points. Five items from the FSCL that assess memory problems were aggregated into a brief self-report memory problem measure (SRMP). Results: Reliability assessment of the SRMP revealed a Cronbach coefficient alpha of 0.90. The data was found suitable for latent structure analysis using various criteria: Kaiser-Myer-Olkin, Bartlett’s Test of sphericity, Kaiser’s (1959) simplest criterion test of γ >1, and the presence of item-correlation coefficients of r = .30. Principal components analysis showed one component with eigenvalue (γ) exceeding 1, that explained 72% of the variance. Subsequent reliability assessments of the SRMP revealed Cronbach coefficients alpha of 0.90 and above, all with a single component explaining 71.36% to 73.36% of the variances. Conclusions: The results supported the use of the SRMP as a reliable one- dimensional measure of cancer treatment-related memory problem. The SMRP could be used for preliminary assessment of possible underlying memory problems that might need further examinations. Studies to establish the construct validity of the SRMP are under way. Supported by NCI grant R25CA102618.

No significant financial relationships to disclose.

Extending the patient navigator research program from Harlem to the nation

6096

Background: Low-income persons face barriers when attempting to seek cancer diagnostics tests and treatment. In 1990, Harold Freeman implemented a novel patient navigator program for women with abnormal mammograms, resulting in earlier presentations and better survival. Identified barriers included lack of insurance, poor social support, coping styles, health beliefs such as fatalism, and poor health literacy skills. Single-site navigator programs have been subsequently implemented. Building on these experiences, the National Cancer Institute is supporting navigator programs at 9 sites. Methods: At 9 sites, the skill set of the navigators, community partnerships, target patient populations were reviewed for information regarding cancer type, number of patients seen, and navigator type. Common data elements include time to diagnosis and time to initiation of treatment, navigation costs, cost-effectiveness of the intervention (in order to address sustainability), and navigation satisfaction. Results: See Table . Conclusions: While programs such as the Breast and Cervical Cancer Treatment Act, the Department of Veterans Affairs, and the Indian Health Board provide financial support to pay for diagnostic/treatment services, the Patient Navigator Research Program will provide medical, social, and psychosocial services for 5,295 patients with positive breast cancer screens, 3,528 patients with positive cervical cancer screens, 5,507 patients with colorectal cancer screens, and 1,167 patients with prostate cancer screens. Diversity of sites, navigator skill sets, patient eligibility, sociodemographics, and study design in conjunction with common data elements, outcomes, and analytic plans will allow us to assess the efficacy and costs of a range of navigation programs.

[Table: see text]

No significant financial relationships to disclose.

Health promotion and cancer screening services for African refugee women

6101

Background: Previous work has shown that refugee women do not receive adequate preventive healthcare services, especially cancer screening. To identify factors that could affect the provision of cancer screening services to African Somali refugee women living in Rochester, NY, we assessed beliefs these women have about health promotion, access to care and use of preventive healthcare services. Methods: Individual in-depth interviews were conducted on a community-based sample of 34 resettled Somali-born women who were older than 18 years. Interviews were audiotaped and transcribed verbatim. A professional interpreter listened to all audiotaped interviews to check accuracy of transcription and translation. Content was analyzed by a multidisciplinary team using a grounded theory approach. Results: Median age of the women was 27 years. Length of residence in US was two months to nine years. For these women, health maintenance for acute survival took precedence over long-term prevention of disease. All women were familiar with basic health promotion practices, immunizations and routine medical examinations, and participants used both US-based and traditional techniques to prevent illness. Most women (71%, n=24), recognized the importance of maintaining good hygiene (59%, n=20) understood the need to have an adequate source of safe food and water, (74%, n=25) saw the need for access to a regular source of healthcare and (65%, n=22) acknowledged the need to function well at home. Few women understood cancer prevention services. Only three (9%) women recognized that the purpose of the Papanicalaou test was to screen for cervical cancer. Only six women (18%) recognized mammography (either the term or the procedure) and all of them were English-speaking, had lived in the US five years or longer, and had worked in the healthcare field. Conclusions: While traditional beliefs about health promotion did not appear to impede delivery of most preventive services, and participants understood prevention of infectious disease, their familiarity with cancer and cancer screening services was poor. Future health promotion programs need to increase refugee women’s knowledge about these services while building on other positive health-promoting beliefs. Supported by AHRQ 5R03HS014105 and NCI 1R25CA102618

No significant financial relationships to disclose.

Cancer patients’ reported illness and treatment related concerns, perception of availability and use of available information: The influence of socio-demographics

6077

Backgrounds: Studies that examine the roles of socio-demographics in illness perception and healthcare communication among cancer patients are relatively absent. Methods: This sample included 973 (904 whites, 69 non-whites) patients undergoing treatment for cancer at 20 geographically separate sites. Concerns over understanding the diagnosis and treatment plan were assessed on a 5-point-scale (“1=no concern” to “5=a great deal of concern”). Patients were also asked if: a) whether or not information was available to them, b) if yes, did they used it or not, and c) would more information have been helpful. χ2-analyses and ANCOVAs, were conducted to examine group differences in education, occupation, and concern over understanding the diagnosis and treatment plan. Logistic regressions were conducted to assess the independent association of race to patients’ beliefs that additional information would have been helpful. Results: χ2 analyses showed no significant difference between whites and non-whites in education and occupation (Ps > .05). Subsequent ANCOVAs showed significant group differences in concerns over understanding the diagnosis (F(1, 967) = 9.13, p = 0.003) and treatment plan (F(1, 967) = 7.95, p = 0.01), after adjusting for education, occupation, age, and gender. Additionally, χ2 showed significant group differences in beliefs that more information would have been helpful (p < .05). More non-whites (70.3%) than whites (53.1%) indicated that additional information would have been helpful to understanding the diagnosis. Similarly, more non-whites (69.4%) than whites (53.4%) indicated that additional information would have been helpful to understanding the treatment plan. Subsequent logistic regressions confirmed that race independently predicted patients’ indications that more information would have been helpful to understanding the diagnosis (OR = 1.96, 95%CI = 1.12, 3.42) and treatment plan (OR = 1.84, 95%CI = 1.05, 3.22). Conclusion: The findings underscore the need for oncology professionals to consider and integrate information about socio-demographics in their intervention and communication with racial/ethnic minority patients. Supported by NHI PHS-grant U10-CA37420

No significant financial relationships to disclose.

Racial/ethnic inequities in continuity and site of care: location, location, location

OBJECTIVE

To examine how continuity of care with the same provider varies by race/ethnicity and by site of care.

DATA SOURCES/STUDY SETTING

Secondary data analyses of the 1996-97 Community Tracking Study household survey, a representative cross-sectional sample of 34,858 U.S. adults (aged 18 to 64 years), were employed.

STUDY DESIGN

Logistic regression analyses were conducted to explore relationships between respondents' race/ethnicity and having a regular site of care, type of site, and continuity with the same provider at this site.

PRINCIPAL FINDINGS

Racial/ethnic minority group members were less likely than whites to identify a regular site of care. Among respondents who identified a regular site, minorities, particularly Spanish-speaking Hispanics, reported less continuity of care with the same provider. However, these disparities in continuity were largely explained by racial/ethnic differences in the types of places where care was obtained. Compared to those who were seen in physicians' offices, continuity with the same provider was much lower among respondents who were seen in hospital out patient departments or health centers or other clinics.

CONCLUSIONS

Racial and ethnic minority group members receive less continuity of care for reasons including lack of a regular site of care and less continuity with the same provider. Greater use of hospital clinics and community health centers by minorities also contributes to this discontinuity.

Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: a randomized controlled trial

BACKGROUND

Clinic appointments in which patients do not appear (no-show) result in loss of provider time and revenue. Previous studies have shown variable effectiveness in telephone and mailed reminders to patients.

METHODS

We conducted a randomized controlled trial of telephone reminders 1 day before the scheduled appointments in an urban family practice residency clinic. Patients with appointments were randomized to be telephoned 1 day before the scheduled visit; 479 patients were telephoned and 424 patients were not telephoned.

RESULTS

The proportions of patients not showing up for their appointments were 19% in the telephoned and 26% in the not-telephoned groups (P = .0065). Significantly more cancelations were made when telephoning patients before their visit, 17% compared with 9.9%. The opened scheduling slots were used for appointments for other patients. This additional revenue offset the cost of telephone intervention in our cost analysis.

CONCLUSION

Reminding patients by telephone calls 1 day before their appointments yields increased cancelations that can be used to schedule other patients. Telephone reminders provide substantial net revenue, but the results may be population specific.

Impact of patient socioeconomic status on physician profiles: a comparison of census-derived and individual measures

BACKGROUND

Patient education has been shown to affect physician performance profiles. It is not known whether census-derived measures of patient socioeconomic status (SES) show comparable effects.

OBJECTIVE

The objective of this study was to compare the effects on physician profiles for patient satisfaction and physical and mental health of adjustment for patient SES derived from patient addresses geocoded to the census block group level, zip codes, and patient education.

DESIGN

This was a cross-sectional survey of patients in physician practices.

SETTING

Subjects came from adult primary care practices in western New York.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician participated in the study.

MEASUREMENTS

Independent variables were census-derived (block group and zip code) patient SES and patient-reported education. The outcomes were physician ranks for patient satisfaction (Patient Satisfaction Questionnaire) and physical and mental health status (SF-12). RESULTS. In empirical Bayes models that adjusted for patient age, age squared, gender, insurance, and case mix, both the census-derived measures (block group and zip code) of SES and education had similar effects on each of the physician profiles. CONCLUSIONS. The results suggest that SES derived from either patient addresses geocoded to the census block group level or zip codes may offer a convenient alternative to individually collected SES when adjusting physician profiles for the socioeconomic characteristics of physicians' practices. The relative ease of using zip codes compared with geocoded addresses and loss of information associated with incomplete matching during geocoding suggest that zip code-derived SES may be preferable.

Racial and ethnic disparities in perceptions of physician style and trust

CONTEXT

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care

Socioeconomic and racial/ethnic disparities in health care quality have been extensively documented. Recently, the elimination of disparities in health care has become the focus of a national initiative. Yet, there is little effort to monitor and address disparities in health care through organizational quality improvement. After reviewing literature on disparities in health care, we discuss the limitations in existing quality assessment for identifying and addressing these disparities. We propose 5 principles to address these disparities through modifications in quality performance measures: disparities represent a significant quality problem; current data collection efforts are inadequate to identify and address disparities; clinical performance measures should be stratified by race/ethnicity and socioeconomic position for public reporting; population-wide monitoring should incorporate adjustment for race/ethnicity and socioeconomic position; and strategies to adjust payment for race/ethnicity and socioeconomic position should be considered to reflect the known effects of both on morbidity. JAMA. 2000;283:2579-2584

Individual income, income inequality, health, and mortality: what are the relationships?

OBJECTIVE

To examine the pathways between income inequality, self-rated health, and mortality in the United States.

DATA SOURCE

The first National Health and Nutrition Examination Survey and Epidemiologic Follow-up Study.

DESIGN

This was a longitudinal, multilevel study.

DATA COLLECTION

Baseline data were collected on county income inequality, individual income, age, sex, self-rated health, level of depressive symptoms, and severity of biomedical morbidity from physical examination. Follow-up data included self-rated health assessed in 1982 through 1984 and mortality through 1987.

PRINCIPAL FINDINGS

After adjustment for age and sex, income inequality had a modest independent effect on the level of depressive symptoms, and on baseline and follow-up self-rated health, but no independent effect on biomedical morbidity or subsequent mortality. Individual income had a larger effect on severity of biomedical morbidity, level of depressive symptoms, baseline and follow-up self-rated health, and mortality.

CONCLUSION

Income inequality appears to have a small effect on self-rated health but not mortality; the effect is mediated in part by psychological, but not biomedical pathways. Individual income has a much larger effect on all of the health pathways.

Do physicians who diagnose more mental health disorders generate lower health care costs?

BACKGROUND

Underrecognition and undertreatment of mental health disorders in primary care have been associated with poor health outcomes and increased health care costs, but little is known about the impact of the diagnoses of mental health disorders on health care expenditures or outcomes. Our goal was to examine the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of avoidable hospitalizations.

METHODS

We used cross-sectional analyses of claims data from an independent practice association-style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.

RESULTS

After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5% - 13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.

CONCLUSIONS

Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.

Vaginal douching and preterm birth: an intriguing hypothesis

The rate of preterm birth has risen in recent years and is twice as high among black women as among white women. Neither the underlying causes nor the reasons for the racial disparity are clearly understood. Further, preventable risk factors have not been identified. We hypothesize that vaginal douching plays a key role in the risk of infection-related spontaneous preterm birth. Vaginal douching is a common behavior, twice as prevalent among black women as among white women. Douching may be an important mechanism by which vaginal pathogens gain access to the upper genital tract. Douching increases the risk of acquiring bacterial vaginosis. It may also facilitate the ascent of microorganisms into the upper genital tract, resulting in a chronic bacterial colonization inside the uterus. During pregnancy, the host inflammatory response is initiated, which stimulates preterm labor and birth. Douching, a potentially preventable risk factor, may explain a substantial proportion of the black-white disparity in preterm birth.

Social determinants of (un)healthy behaviors

Medical education has historically relied on the rational choice model as a vehicle for promoting health behavior change, and has largely overlooked the powerful relationships between social class and health behaviors. The rational choice model, which assumes that people can choose to pursue behaviors that are needed for their health, has some clinical utility, especially in some circumstances, but it runs the risk of missing key sources of influence and of blaming the victim. The biopsychosocial model provides an alternative basis for teaching about health behavior change. Health behavior needs to be understood in a broad social context, in which social class is recognized as playing a large part in shaping many people's health behaviors through multiple pathways, including limited opportunities for self-fulfillment, financial constraints, health beliefs, self-efficacy, stress, and social support. In addition to highlighting the limitations of the rational choice model, we illustrate how to integrate the socio-cultural context into teaching about behavior change. Specific curricular suggestions include exercises for: (1) increasing students' awareness of their own biases regarding unhealthy behaviors and individual responsibility for change; (2) enhancing knowledge of social factors that impact health; (3) building advocacy skills; (4) learning from patients; and (5) practicing counseling skills through role-plays.

Influence of patient education on profiles of physician practices

BACKGROUND

Few data are available about the effect of patient socioeconomic status on profiles of physician practices.

OBJECTIVE

To determine the ways in which adjustment for patients' level of education (as a measure of socioeconomic status) changes profiles of physician practices.

DESIGN

Cross-sectional survey of patients in physician practices.

SETTING

Managed care organization in western New York State.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician.

MEASUREMENTS

Ranks of physicians for patient physical and mental health (Short Form 12-Item Health Survey) and satisfaction (Patient Satisfaction Questionnaire), adjusted for patient age, sex, morbidity, and education.

RESULTS

Physicians whose patients had a lower mean level of education had significantly better ranks for patient physical and mental health status after adjustment for patients' level of education level than they did before adjustment (P < 0.001); this result was not seen for patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 (95% CI, 6.6 to 9.6) for patient physical health status and by 4.9 (CI, 3.9 to 5.9) for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients.

CONCLUSIONS

Profiles of physician practices that base ratings of physician performance on patients' physical and mental health status are substantially affected by patients' level of education. However, these results do not suggest that physicians who care for less educated patients provide worse care. Physician profiling should account for differences in patients' level of education.

Patients and community together. A family medicine community-oriented primary care project in an urban private practice

BACKGROUND

There has been considerable discussion in the literature regarding the value and feasibility of community-oriented primary care (COPC), but relatively few published real-world examples.

OBJECTIVE

To examine the effect of a practice-based COPC project on rates of preventive health interventions within an inner-city family medicine practice.

METHODS

A newly created community advisory board called Patients and Community Together (PACT) and the medical director of the practice in Rochester, NY, collaborated on all phases of the COPC project. Papanicolaou smear and mammography screening, childhood immunizations, diabetes control, and smoking cessation were targeted for intervention. A practice/community awareness campaign was instituted and individual and group incentives were developed. Progress was monitored through a computerized medical record that included all active patients in the practice.

RESULTS

Rates of annual Papanicolaou smears increased from 46% to 71%; annual mammography for women older than age 50 years, from 56% to 86%; completed childhood immunizations when younger than 6 years, from 78% to 97%; and performance of semiannual glycosylated hemoglobin, from 85% to 92%. Rates of patients with glycosylated hemoglobin values under 10% improved from 56% to 77%. There were 5 smokers who successfully quit.

CONCLUSION

This project illustrates how practice-based COPC can be successfully implemented within a private practice setting. It also shows how COPC principles can be used to achieve the goals for Healthy People 2000 within inner-city practices.

Is lower income associated with greater biopsychosocial morbidity? Implications for physicians working with underserved patients

BACKGROUND

Previous studies have established a powerful relationship between socioeconomic position and health. However, there has been little attention given to the association between income, biopsychosocial morbidity, and decline in health over time among primary care patients.

METHODS

Data were collected using a survey mailed to patients receiving care at a family medicine center and through a follow-up survey mailed 2 years later. The independent association between various biopsychosocial measures and family income was assessed through stepwise linear regression. After controlling for baseline health status, the effect of family income on health status at follow-up was assessed.

RESULTS

Data were available from 922 active family medicine patients who responded to the initial survey and from 655 who responded to the follow-up survey. In bivariate analyses, lower family income was significantly associated with poorer health status, greater psychological distress, more family dysfunction, less social support, more behavioral risk factors, higher rates of obesity and uncontrolled blood pressure, poorer physical and mental health status, and more medical diagnoses. In a multivariate analysis, age, sex, marital status, race, social network, family criticism, smoking, fat consumption, and health status were independently associated with family income. After controlling for covariates, including baseline health status, family income was a significant predictor of health status at follow-up.

CONCLUSIONS

Family income is associated with biopsychosocial morbidity and health decline. Physicians who care for poorer patients will likely be confronted by challenging and complex biopsychosocial problems.

Does skepticism towards medical care predict mortality?

OBJECTIVES

Attitudes towards medical care have a strong effect on utilization and outcomes. However, there has been little attention to the impact on outcomes of doubts about the value of medical care. This study examines the impact of skepticism toward medical care on mortality using data from the 1987 National Medical Expenditure Survey (NMES).

METHODS

A nationally representative sample from the United States comprising 18,240 persons (> or = 25 years) were surveyed. Skepticism was measured through an 8-item scale. Mortality at 5-year follow-up was ascertained through the National Death Index.

RESULTS

In a proportional hazards survival analysis of 5-year mortality that controlled for age, sex, race, education, income, marital status, morbidity, and health status, skepticism toward medical care independently predicted subsequent mortality. That risk was attenuated after adjustment for health behaviors but not after adjustment for health insurance status.

CONCLUSION

Medical skepticism may be a risk factor for early death. That effect may be mediated through higher rates of unhealthy behavior among the medically skeptical. Further studies using more reliable measures are needed.

The adequacy of Papanicolaou smears as performed by family physicians and obstetrician-gynecologists

BACKGROUND

Little is known about the quality of Papanicolaou (Pap) smears performed by family physicians and obstetrician-gynecologists.

METHODS

Using hospital archival records of Pap smears performed from 1995 to 1997, we compared the quality of Pap smear sampling and the rate of detection of significant cytologic abnormalities by family physicians and obstetrician-gynecologists. Using hierarchic logistic regression, we examined the relationship between physician specialty and Pap smear reports, controlling for patient age and socioeconomic position, multiple Pap smears performed by the same clinician, and physician attending status.

RESULTS

A total of 34,916 Pap smears performed by 130 family physicians and 88 obstetrician-gynecologist residents and attending physicians were included in the analysis. There were no statistically significant differences by specialty in the rates of unsatisfactory reports (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI], 0.48 - 1.38), satisfactory but limited reports (AOR = 1.16; 95% CI, 0.93 - 1.48), or detection rates of significant cytologic abnormalities (AOR = 0.83; 95% CI, 0.66 - 1.04). However, family physicians submitted more Pap smears with an absent endocervical component (AOR = 1.50; 95% CI, 1.07 - 2.11).

CONCLUSIONS

These findings show no significant differences by specialty in Pap smear quality as measured by rates of unsatisfactory and satisfactory but limited reports, or detection of cytologic abnormalities. The finding of higher rates of absent endocervical cells, if replicated by further study, may suggest the need for improved training of family physicians in sampling the endocervix.

Association of perceived family criticism with health behaviors

BACKGROUND

Criticism from family members has been implicated in psychiatric illnesses such as schizophrenia, depression, and eating disorders. Perceived family criticism has also been linked to primary health care use. In our study, we examined the association between perceived family criticism and health behaviors, as well as the potential mediating role of negative affect.

METHODS

A questionnaire was mailed to patients receiving care at a family medicine center. Perceived family criticism was measured using the Family Emotional Involvement and Perceived Criticism Scale. Diet, regular exercise, smoking status, and levels of depression, hostility, and physical health were also assessed through self report.

RESULTS

Nine hundred twenty-two (62%) active family medicine patients responded to our questionnaire. Complete data were available for 875 patients. In univariate analysis, a high level of perceived family criticism was associated with various demographic characteristics, poorer physical health, negative affect, higher fat intake, lack of exercise, and smoking. In multivariate analysis, the association between a high level of perceived criticism and health behavior was independent of demographic characteristics and physical health, for example, high-fat diet (odds ratio [OR] = 1.47; 95% confidence interval [CI], 1.11 - 1.95), no regular exercise (OR = 1.37; 95% CI, 1.02 - 1.84) and current smoking (OR = 1.38; 95% CI, 1.00 - 1.90). None of these associations was statistically significant after controlling for depression and hostility.

CONCLUSIONS

A high level of perceived family criticism is associated with adverse health behaviors. This association appears to be explained by resultant depression and hostility.

The risk of low birth weight associated with vaginal douching

OBJECTIVE

To examine the association between vaginal douching and low birth weight (LBW) after accounting for known risk factors.

METHODS

We used cross-sectional interview data from the 1988 National Survey of Family Growth, a nationally representative sample of 4665 women of child-bearing age and 11,553 singleton live births. We compared the risk of LBW among women who reported they douched regularly with the risk among women who did not douche, after controlling for potential confounders including maternal age, race, household income, marital status, total number of pregnancies, smoking, alcohol use, drug use during the pregnancy, year of birth of each infant, geographic region, and self-reported history of pelvic inflammatory disease.

RESULTS

In multivariate analysis, regular douching was associated with an increased risk of LBW (adjusted odds ratio [OR], 1.29; 95% confidence interval [CI] 1.06, 1.57). Frequency of douching and LBW exhibited a dose-response. The adjusted OR for the association between daily douching and LBW was 2.49 (95% CI 1.23, 5.01) compared with an adjusted OR of 1.13 (95% CI 0.83, 1.55) for the association between monthly douching and LBW. There was no racial difference in the risk of LBW associated with douching.

CONCLUSION

These preliminary data suggest an association between douching and LBW risk. If these findings are replicated in future studies, douching may represent a major preventable risk factor for LBW.

Delayed first pregnancy among African-American adolescent smokers

PURPOSE

This study aimed to compare rates of adolescent pregnancy among African-American adolescents who began smoking as adolescents with those who did not.

METHODS

Cross-sectional data on 1042 primiparous African-American women enrolled in a randomized clinical trial of nurse home visitation were examined. The independent variable, adolescent smoking, was defined as a report of smoking before the age of 18 years. The outcome variable was adolescent pregnancy, defined as first pregnancy before the age of 18 years. Logistic regression was used to control for potential confounders.

RESULTS

After adjustments for drug use, use of contraception, frequency of coitus, and sexually transmitted diseases, women who smoked during adolescence had a 50% lower risk of becoming pregnant as an adolescent [odds ratio of 0.46 (95% confidence interval [CI] 0.27-0.76)]. When time to first pregnancy was examined as a continuous variable, adolescent smoking was associated with a delay in pregnancy of 22.6 months (95% CI 16.8-29.2).

CONCLUSIONS

Teen smoking appears to be associated with a significantly lower rate of adolescent pregnancy among African-Americans. Although the nature of this relationship is unclear, this finding suggests the need for linkage between smoking prevention and adolescent pregnancy prevention.

Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience

BACKGROUND

The advent of managed care has resulted in considerable debate regarding the relative effects of specialist and primary care on patient outcomes and costs. Studies on these subjects have been limited to a disease-focused orientation rather than a patient-focused orientation inherent in primary care management. We examined whether persons using a primary care physician have lower expenditures and mortality than those using a specialist as their personal physician.

METHODS

Using data on a nationally representative sample of 13,270 adult respondents tot he 1987 National Medical Expenditure Survey reporting as their personal physician either a primary care physician (general practitioner, family physician, internist, or obstetrician-gynecologist) or a specialist, we examined total annual health care expenditures and 5-year mortality experience.

RESULTS

Respondents with a primary care physician, rather than a specialist, as a personal physician were more likely to be women, white, live in rural areas, report fewer medical diagnoses and higher health perceptions and have lower annual healthcare expenditures (mean: $2029 vs $3100) and lower mortality (hazard ratio = 0.76, 95% confidence interval [CI], 0.64-0.90). After adjustment for demographics, health insurance status, reported diagnoses, health perceptions, and smoking status, respondents reporting using a primary care physician compared with those using a specialist had 33% lower annual adjusted health care expenditures and lower adjusted mortality (hazard ratio = 0.81; 95% CI, 0.66-0.98).

CONCLUSIONS

These findings provide evidence for the cost-effective role of primary care physicians in the health care system. More research is needed on how to optimally integrate primary and specialty care.

Does child abuse predict adolescent pregnancy?

OBJECTIVE

To determine whether sexual and nonsexual childhood abuse are risk factors for early adolescent sexual activity and pregnancy. DESIGN; Cross-sectional study.

SETTING

Prenatal clinic within an inner-city teaching hospital from June 1990 to August 1991.

POPULATION

One thousand twenty-six primiparous, African-American women enrolled in a randomized clinical trial of nurse home visitation.

MAIN OUTCOME MEASURES

Four measures of child abuse were used: sexual abuse, incidents of physical abuse, any major physical abuse, and emotional abuse. The outcome measures were age of first consensual coitus and age of first pregnancy.

RESULTS

After adjustments for household income, parental separation, urban residence, age of menarche, and teen smoking, sexual abuse during childhood was associated with younger age at first coitus (7.2 months; 95% confidence interval [CI], 2.6 to 11.7 months) and younger age at first pregnancy (9.7 months; 95% CI, 3.0 to 16.3 months). Incidents of physical abuse showed minimal effect on age at first coitus (1.2 days per incident; 95% CI, 0.5 to 1.9 days) and no effect on age of first pregnancy. A history of major physical abuse or emotional abuse showed no effect on age of first coitus or first pregnancy.

CONCLUSION

Child sexual abuse, but not child physical or emotional abuse, seems to be a risk factor for earlier pregnancy among African-American adolescents.

Skepticism toward medical care and health care utilization

OBJECTIVES

As health care moves toward systems that assume accountability for defined populations, there has been increasing emphasis on developing performance measures for those systems and their providers, with little attention given to patient demand or attitudinal factors. The impact of skepticism toward health care providers on health behavior and health care utilization was assessed using a cross-sectional analysis of data from the 1987 National Medical Expenditure Survey (NMES).

METHODS

A nationally representative sample from the United States comprising 18,240 persons 25 years and older was surveyed. Skepticism, defined as doubts about the ability of conventional medical care to appreciably alter one's health status, was assessed through a 4-item scale. Outcome measures included health behavior, access (health care insurance, having a regular source of care, and physician type), utilization (annual number of physician or emergency department visits and hospitalizations), total annual health care expenditures, and preventive health care behavior (having had a Pap smear within 3 years or ever having had a mammogram).

RESULTS

In multivariate analyses, skepticism was associated with younger age, white race, lower income, less education, and higher health perceptions. After adjusting for these variables, skepticism was associated with less healthy behavior, with not having health insurance, not having one's own physician, choice of a physician, fewer physician and emergency department visits, less frequent hospitalizations, lower annual health care expenditures, and less prevention compliance.

CONCLUSIONS

Medical skepticism represents a relevant patient demand factor that demonstrates significant associations with a variety of health care access and utilization measures with important policy implications.

Does psychological distress contribute to racial and socioeconomic disparities in mortality?

Being black or poor are powerful predictors of mortality. Although psychological distress has been proposed as mediating the effects of race and socioeconomic status on mortality, this hypothesis has not been previously directly tested. We used data from the National Health and Nutrition Examination I (NHANES I), a nationally representative sample from the U.S, and the NHANES I Epidemiological Follow-up Survey (NHEFS) of subsequent mortality to test this hypothesis. Both black race and lower family income were associated with significantly higher psychological distress as measured at the time of the initial survey by reports of hopelessness, depression, and life dissatisfaction. Black race and low income in addition to each of the measures of psychological distress were associated with higher mortality at follow-up. In a series of Cox proportional hazards models that controlled for the effects of age and gender, additional adjustment for hopelessness, depression, or life dissatisfaction had little effect on the relationship between either African American race or family income and subsequent all-cause mortality. We conclude that the effects of both race and income on mortality are largely independent of psychological distress. These findings do not support the hypothesis that psychological distress is a significant mediator of the effects of race or class on health.

Poverty or income inequality as predictor of mortality: longitudinal cohort study

OBJECTIVE

To determine the effect of inequality in income between communities independent of household income on individual all cause mortality in the United States.

DESIGN

Longitudinal cohort study.

SUBJECTS

A nationally representative sample of 14,407 people aged 25-74 years in the United States from the first national health and nutrition examination survey.

SETTING

Subjects were followed from initial interview in 1971-5 until 1987. Complete follow up information was available for 92.2% of the sample.

MAIN OUTCOME MEASURES

Relation between both household income and income inequality in community of residence and individual all cause mortality at follow up was examined with Cox proportional hazards survival analysis.

RESULTS

Community income inequality showed a significant association with subsequent community mortality, and with individual mortality after adjustment for age, sex, and mean income in the community of residence. After adjustment for individual household income, however, the association with mortality was lost.

CONCLUSIONS

In this nationally representative American sample, family income, but not community income inequality, independently predicts mortality. Previously reported ecological associations between income inequality and mortality may reflect confounding between individual family income and mortality.

'Being a foreigner, I may be punished if I make a small mistake': assessing transcultural experiences in caring for patients

BACKGROUND

Emotionally charged issues that arise during graduate medical education often are unrecognized and consequently not addressed by training programmes. Little attention has been given to the emotional challenges encountered by international medical graduates (IMG) in caring for patients transculturally.

OBJECTIVES

We aimed to examine the value of qualitative approaches to assessing the transcultural experiences of IMG residents during primary care training.

METHODS

Two qualitative research techniques (the critical incident and the focus group) were used to assess the transcultural challenges in caring for patients of IMG and American medical graduates (AMG) resident in a primary care residency programme. Each resident wrote a narrative describing a challenging experience and facilitators then conducted a focus group to discuss these experiences. Key themes were identified from the written narratives and from the transcript of the videotaped focus group.

RESULTS

Previously unacknowledged feelings emerged during the assessment. Themes of struggles for acceptance, fear of rejection, and fear of disappointing patients were identified from analysis of the written narrative, while themes of struggle to express caring transculturally were identified from the focus group transcript. Based on these findings, significant changes were made to the residency training curriculum.

CONCLUSIONS

Qualitative methods are useful for assessing the transcultural experiences of IMG residents and for informing curricular changes in residency training. These methods may help other training programmes to identify the particular needs of their trainees in addressing emotionally laden experiences.

Perceived family criticism and primary care utilization: psychosocial and biomedical pathways

We explored the relationship of perceived family criticism to subsequent healthcare utilization in patients attending a family medicine center. We examined: a) the relationship of perceived criticism to subsequent utilization for biomedical and psychosocial/somatic problems; b) the mediating effects of self-rated mental health and physical function; and c) the mediating effects of social support. The analyses were adjusted for age, sex, race, education, health insurance, and martial status. Higher perceived criticism predicted more psychosocial/somatic and biomedical visits. The relationship of perceived criticism with psychosocial/somatic visits was entirely mediated through self-rated mental health. The relationship of perceived criticism with biomedical visits was partly mediated through self-rated physical function and, in part, independent. Social support played no role in explaining these relationships. Further research is needed to determine whether lowering perceived family criticism lowers primary care utilization.

Family involvement in routine health care: a survey of patients' behaviors and preferences

BACKGROUND

The purpose of this study was to assess the behavior and preferences of patients regarding family involvement in their routine health care visits.

METHODS

A self-administered questionnaire was given to a convenience sample of patients visiting a family medicine center for an appointment.

RESULTS

Thirty-nine percent of patients came to the physician's office with a family member or friend. Married patients and those with higher emotional involvement scores were significantly more likely to come to the office with someone. Two thirds of accompanied patients reported that this person came into the examination room with them. One third of the accompanied patients, however, thought that their physician was unaware that someone had accompanied them to the office. The majority (55%) of patients indicated that they would prefer to have a friend or family member in the examination room with them for some of their visits. No patient indicated that they never wanted a family member or friend to come into the examination room.

CONCLUSIONS

Patients prefer direct family involvement in their health care more often than what occurs in practice. Physicians can easily address this discrepancy by asking patients whether and in what way they would like others to be involved in their health care.

Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counseling

OBJECTIVE

To determine the incremental cost-effectiveness of the transdermal nicotine patch.

DESIGN

Decision analytic model that evaluated the incremental cost-effectiveness of the addition of the nicotine patch to smoking cessation counseling. Costs were based on physician time and the retail cost of the nicotine patch, and benefits were based on quality-adjusted life years (QALYs) saved.

PATIENTS

Male and female smokers aged 25 to 69 years receiving primary care.

INTERVENTION

Addition of the nicotine patch to physician-based smoking cessation counseling.

MAIN OUTCOME MEASURE

Costs (1995 dollars) per QALYs save discounted by 3% annually.

RESULTS

The use of the patch produced 1 additional lifetime quitter at a cost of $7332. The incremental cost-effectiveness of the nicotine patch by age group ranged from $4390 to $10 943 per QALY for men and $4955 to $6983 per QALY for women. A clinical strategy involving limiting prescription renewals to patients successfully abstaining for the first 2 weeks improved the cost-effectiveness of the patch by 25%.

CONCLUSIONS

The findings provide support both for the routine use of the nicotine patch as an adjunct to physicians' smoking cessation counseling and for health insurance coverage of nicotine patch therapy.

Racial disparities in preterm births. The role of urogenital infections

OBJECTIVES

To evaluate the impact of urogenital infections on the racial gap between black and white women in preterm birth rates.

METHODS

A computer-assisted search of the medical literature was conducted through MEDLINE aided by a manual bibliographic search of published articles and relevant books. Estimates of the relative risk for preterm birth were extracted from published studies for the following infections: N. gonorrhea, syphilis, trichomoniasis, Chlamydia trachomatis, Group B streptococcal vaginal colonization, asymptomatic bacteriuria, genital mycoplasmas, and bacterial vaginosis. Estimates of the prevalence among black and white women by race for each of these infections were extracted from published studies. The attributable risk for preterm birth for selected infections was then calculated for the black and white populations and the impact on the racial gap in preterm births was estimated.

RESULTS

Only bacterial vaginosis and bacteriuria appear to be established risk factors for preterm births. Significantly higher rates of bacterial vaginosis among black women may account for nearly 30% of the racial gap in preterm births. Higher rates of bacteriuria among black women may account for roughly 5% of the gap.

CONCLUSION

Although these findings are limited by the reliability of published estimates of prevalence and relative risk for these infections, treatment of infections during pregnancy, particularly bacterial vaginosis, offers hope for reducing the racial gap in preterm births.

Race, perinatal outcome, and amniotic infection

Racial differences in rates of amniotic infection were examined through a review of the literature. Following a computerized and manual search of the literature from 1966 to 1994, studies were selected that reported the prevalence by race of presumed markers of amniotic infection. These markers included: amniotic infection syndrome, histologic chorioamnionitis, clinical chorioamnionitis, premature rupture of the membranes, and early neonatal mortality from sepsis. With the exception of overall rates of histologic chorioamnionitis, black women showed higher rates of the all the conditions examined. Insofar as amniotic infection is a risk factor for poor perinatal outcomes, the finding of higher rates of markers of amniotic infection among black women suggests that such infections may contribute to racial disparities in perinatal outcome.

Does prenatal care improve birth outcomes? A critical review

OBJECTIVE

To evaluate evidence that prenatal care improves birth outcomes.

DATA SOURCES

The MEDLINE data base was searched for appropriate studies for the years 1966-1994; a review of published studies was also conducted.

METHODS OF STUDY SELECTION

Published observational and experimental studies of prenatal care that met specified criteria were selected.

DATA EXTRACTION AND SYNTHESIS

Studies were graded based on the system used by the United States Preventive Services Task Force. Data were assessed using established criteria for the evaluation of prenatal interventions: temporal relationship, biologic plausibility, consistency, alternative explanations, dose-response, strength of association, and cessation effects. Current evidence did not satisfy the criteria.

CONCLUSION

Prenatal care has not been demonstrated to improve birth outcomes conclusively. However, policymakers deciding on funding for prenatal care must consider these findings in the context of prenatal care's overall benefits and potential cost-effectiveness. Cost-effective reductions in low birth weight deliveries may be beyond the statistical powers of detection of current studies.

Relationship of weight change to required size of vaginal diaphragm

Health care providers are instructed to counsel diaphragm users to return for a re-fitting of the device if there is a change in the patient's weight. Texts on contraception do not give a rationale for this rule. In an effort to explore the effect of weight change on the required size of diaphragm, the charts of 80 diaphragm users were reviewed. All women had at least two visits for diaphragm fitting. A table was constructed with weight and diaphragm size for each subject at each visit. The subjects ranged in age from mid-tens to early forties and all were patients at the same clinic. Chi-square analysis of the data revealed no correlation between weight change and change in diaphragm size.