Rural, urban and suburban comparisons of preventive services in family practice clinics

Numerous studies have compared health services provided in rural and urban areas, and overall they have found that utilization is lower in rural areas. A significant factor in lower utilization is that rural residents have less access to health services. Much less is known about rural and urban utilization differences once a patient has access to a service provider. This paper focuses on preventive services received when a patient is already in a clinic. Using data from an in-depth qualitative study of 16 family practice clinics in Nebraska, comparisons of physician-specific preventive service rates are made across three geographic categories: rural, urban and suburban. Results from a one-way multivariate analysis of variance show that preventive services rates for nine services examined were as high or higher in rural areas, suggesting that rural health services do not lag for patients with access.

Informed consent for pediatric leukemia research: clinician perspectives

BACKGROUND

Good, fully informed consent is critical to the ethical conduct of clinical cancer research. The authors examined clinician perspectives on informed consent for pediatric research by surveying clinicians at five major medical centers that routinely enroll patients in Children's Cancer Group studies.

METHODS

Building on a pilot study, a questionnaire was designed to elicit clinicians' general opinions, approaches, and suggestions related to informed consent in pediatric leukemia trials. Questionnaires were mailed to 132 clinicians. Eighty-nine questionnaires were returned, along with 13 nonparticipant forms notifying us of the clinician's inability to participate because of a lack of experience in pediatric informed consent. The response rate was 75%.

RESULTS

Providing information so that families can decide about study entry was ranked as the most important goal of the informed consent process, whereas parents' state of shock was rated the most significant obstacle to good informed consent. Clinicians cited high levels of parental comprehension of key aspects of clinical research studies and reported information overload and increased anxiety as effects of the informed consent process on parents. Several key items were associated with clinicians' gender, race, and professional experience. Finally, one open-ended question yielded 126 suggestions for how to improve the informed consent process that were grouped into 10 meaningful categories.

CONCLUSIONS

Clinicians report a range of approaches, opinions, concerns, and suggestions for improving the informed consent process. The article proposes that their views and suggestions be integrated with those of parents and patients in attempts to survey and improve informed consent in pediatric oncology.

Advance directives as acts of communication: a randomized controlled trial

BACKGROUND

Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions.

PARTICIPANTS AND METHODS

A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured.

RESULTS

None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation.

CONCLUSIONS

Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Continuous quality improvement and the process of writing for academic publication

OBJECTIVE

To improve their academic publication productivity by understanding the process of writing and setting long-run productivity goals.

METHODS

We used the thinking and methods of continuous quality improvement and a national survey of associate professors of Family Medicine about their level of productivity at the time of their promotion to Associate Professor.

RESULTS

Barriers to writing vary. The process from idea to publication takes well over a year on average. The average number of publications associated with successful promotion in Family Medicine ranges from 10 to 14 with substantial variation.

CONCLUSION

Knowing the time until the promotion decision, the expected level of productivity, the death rates of started papers, and the duration of time between start to publication allows one to develop a long-range plan for publication productivity.

Screening for osteoporosis in community-dwelling adults with mental retardation

Osteoporosis screening of adults ages 40 to 60 who attended community-based adult training centers was conducted utilizing dual-energy X-ray absorptiometry (DEXA) measurements of the calcaneus. Valid measurements were obtained on 107 individuals, a response rate of 94%. One fifth of the sample (21%) had osteoporosis and 34% had osteopenia. On multiple regression analysis, the most significant predictors of BMD were Down syndrome, mobility status, and race. Future studies involving larger samples of middle-age adults with mental retardation/developmental disabilities will clarify the need and optimum age for osteoporosis screening.

Substance Abuse Education for Clinical Nurses: A Controlled Study

BACKGROUND

A study was conducted to evaluate a substance abuse component of a workshop for nurses being promoted to the position of Advanced Clinical Nurse.

METHODS

We compared whether the 88 nurses who received the educational intervention increased their knowledge and enhanced their feelings of competence regarding the care of chemically dependent patients more than a control group of nurses who received the promotion workshop without the substance abuse component.

RESULTS

The nurses in the intervention group had greater increases in knowledge and competence.

CONCLUSIONS

This study points out the importance of providing hospital nurses with continuing education on substance abuse to compensate for their educational deficiencies, to provide the information they need and desire, and to help them meet the ANA's practice standards.

Comparison of preoperative characteristics of men and women undergoing coronary artery bypass grafting (the Post Coronary Artery Bypass Graft [CABG] Biobehavioral Study)

A cohort of 759 coronary artery bypass grafting (CABG) patients (269 women and 490 men) was enrolled in the prospective POST CABG Biobehavioral Study at 5 clinical centers in the United States and Canada. Sociodemographic and medical data were obtained by interview and from medical charts. Health-related quality of life and psychosocial data were ascertained preoperatively by interview and questionnaire for those patients whose condition allowed preoperative assessment and was compared among patients from hospitals enrolling both male and female patients (143 women and 267 men). Women enrolled in the Biobehavioral Study were older than men (65.4 +/- 9.0 vs 61.8 +/- 9.7 years, p < 0.001) and more likely to have a preoperative medical condition which precluded biobehavioral evaluation (47% vs 34%, p < 0.001). Women were less likely to be high school graduates (59% vs 74%, p < 0.001), were less likely to be earning > or = $25,000 per year (39% vs 69%, p < 0.001), and were married less often at the time of surgery (59% vs 85%, p < 0.001). Fewer women than men were able to perform basic self-care activities (p < 0.001) and social activities (p < 0.001). Women were also less able to perform the more demanding activities required for independent living, recreation, and maintaining a household (p < 0.001). Women were also more anxious (p = 0.01) and reported more depressive symptoms (p < 0.001) than men. These data suggest that plans for perioperative and convalescent care for women undergoing CABG should take into account their less favorable medical and psychosocial status relative to men.

Methods of recruiting and selecting residents for U.S. family practice residencies

PURPOSE

To describe the strategies used by family practice program directors to recruit and select residents.

METHOD

The residency directors of all 361 U.S. accredited nonmilitary family practice programs in 1992-93 were asked to complete three-page questionnaires regarding program descriptors, curriculum, benefits offered, interview process, and factors affecting their selection of residents. Each program was categorized into one of nine geographic regions. Variation of program characteristics across the regions was assessed using chi-square.

RESULTS

A total of 282 directors (78%) returned usable questionnaires. The programs did not differ in benefits offered except that (1) those with low fill rates in the 1992 Match of the National Resident Matching Program were more likely to have additional financial incentives and (2) the programs in areas of high competition went to extra effort and expense to market their residencies through the use of advertising materials (e.g., pens, mugs). The most important factor in selecting applicants was listed as the personal interview by 51% of the directors and performance on clinical rotations by 36%.

CONCLUSION

The residency directors' selection decisions were highly influenced by candidates' performances in interviews and on clinical rotations. The programs in the most competitive areas were characterized by greater efforts and increased expenditures of resources for recruiting. More research is needed to assess the values of the different strategies used by programs to recruit and select residents.

Physician documentation of family alcohol problems

This study was conducted to determine whether family medicine residents' documentation of patient and family alcohol problems corresponded with patients' assessments. A random sample of 180 patient charts from a university-based family practice was audited and 78% (n = 140) of these patients participated in telephone interviews. Of those who participated in the telephone interview, 40% (n = 56) reported a positive family history of drinking problems, 28% (n = 39) indicated that they were currently concerned about the alcohol use of someone in their family, and 24% (n = 34) reported that at least one family member currently had an alcohol problem. Ninety-six percent (n = 134) of the subjects indicated that they believed physicians should ask about family alcohol problems and 91% (n = 128) believed physicians could be helpful in alcohol treatment at least some of the time. The audit of the 180 medical records indicated that residents charted a positive family history on 13% (n = 23) of the records and noted impact upon the family due to a member's drinking in 2% (n = 4) of the records. The study revealed that residents frequently did not identify alcohol problems or related family difficulties and highlighted the need for training and education in this area.

Upper respiratory infection: stress, support, and the medical encounter

BACKGROUND

The purpose of this study was to examine the relationship between stress and social support to behaviors of patients and physicians during an episode of upper respiratory infection (URI).

METHODS

This was a cross-sectional study of 104 patients older than age 14 from three family practice sites; all of the patients had experienced a URI during an 8-week period. Stress scores were calculated for each patient's family using several standard instruments. Clinical and medical care utilization data were also reviewed. Data were analyzed to determine if there were relationships among stress and support scores and measures of patient and physician behaviors.

RESULTS

Measures of stress and support were related to the use of medical services, seeking additional medical care, extra phone calls, and longer perceived duration of illness. Physicians prescribed more medications, ordered more laboratory tests, and scheduled more return visits for patients with high stress or low support scores.

CONCLUSIONS

Stress and support are related to patient utilization of health services and perception of illness severity. Physicians respond to patients with high stress and low support by offering more medical services.

Categorical data analysis in primary care research: log-linear models

Primary care researchers often wish to perform multiple variable analyses using variables measured at a nominal or ordinal level. This paper provides a step-by-step description of log-linear modeling, an approach uniquely well suited to explore and describe interactions among three or more nominal or ordinal variables. The method of log-linear analysis is illustrated with the use of an example from a primary care research project in which the relationships among hypertension, diet, and sodium were examined. The advantages and disadvantages of log-linear models and logistic regression are compared and available computer software programs discussed.