Care Physicians (care + physician)

Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of Care Physicians

  • critical care physician
  • primary care physician

  • Selected Abstracts

    The Effect of Capitation on Switching Primary Care Physicians

    Melony E. S. Sorbero
    Objective To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs. Data Sources/Study Setting Administrative enrollment and claims/encounter data for 1994,1995 from four physician organizations. Study Design We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods. Data Collection/Extraction Methods Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis. Principal Findings Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs. Conclusions A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives. [source]

    An Evaluation of an Intervention to Assist Primary Care Physicians in Screening and Educating Older Patients Who Use Alcohol

    Arlene Fink PhD
    Objectives: To evaluate whether providing physicians and older patients with personalized reports of drinking risks and benefits and patient education reduces alcohol-related risks and problems. Design: Prospective comparison study. Setting: Community primary care. Participants: Twenty-three physicians and 665 patients aged 65 and older. Intervention: Combined report, in which six physicians and 212 patients received reports of patients' drinking classifications and patients also received education; patient report, in which 245 patients received reports and education, but their five physicians did not receive reports; and usual care. Measurements: Assessments at baseline and 12 months later to determine patients' nonhazardous (no known risks), hazardous (risks for problems), or harmful (presence of problems) classifications using the Computerized Alcohol-Related Problems Survey (CARPS). The CARPS contains a scanned screening measure and scoring algorithms and automatically produces patient and physician reports and patient education. Results: At baseline, 21% were harmful drinkers, and 26% were hazardous drinkers. The patient report and combined report interventions were each associated with greater odds of lower-risk drinking at follow-up than usual care (odds ratio=1.59 and 1.23, respectively, P<.05 for each). The patient report intervention significantly reduced harmful drinking at follow-up from an expected 21% in usual care to 16% and increased nonhazardous drinking from 52% expected in usual care to 58%. Patients in the combined report intervention experienced a significantly greater average decrease in quantity and frequency. Conclusion: Older primary care patients can effectively reduce their alcohol consumption and other drinking risks when given personalized information about their drinking and health. [source]

    The Rural Physician Workforce in Florida: A Survey of US- and Foreign-Born Primary Care Physicians

    Robert G. Brooks MD
    Purpose: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. Methods: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. Findings: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. Conclusions: Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs. [source]

    Using the Theory of Reasoned Action to Model Retention in Rural Primary Care Physicians

    Thomas Hugh Feeley PhD
    Purpose: The current review uses Fishbein and Ajzen's Theory of Reasoned Action (TRA) to organize the literature on the predictors and correlates of retention of rural practicing physicians. TRA suggests turnover behavior is directly predicted by one's turnover intentions, which are, in turn, predicted by one's attitudes about rural practice and perceptions of salient others' (eg, spouse's) attitudes about rural practice and rural living. Methods:Narrative literature review of scholarship in predicting and understanding predictors and correlates of rural physician retention. Findings: The TRA model provides a useful conceptual model to organize the literature on rural physician retention. Physicians' subjective norms regarding rural practice are an important source of influence in the decision to remain or leave one's position, and this relation should be more fully examined in future research [source]

    The clinical aspects of newborn screening: Importance of newborn screening follow-up

    Philip M. James
    Abstract The aim of newborn screening is to identify presymptomatic healthy infants that will develop significant metabolic or endocrine derangements if left undiagnosed and untreated. The goal of ultimately reducing or eliminating irreversible sequelae is reached by maximizing test sensitivity of the primary newborn screening that measures specific analytes by a number of methodologies. Differentiation of true from false negatives is accomplished by the test specificity. This review discusses disorders for which, in general, there are available therapies and that are detected by routine and expanded newborn screening. Recommendations are presented for evaluation by a primary care physician, with confirmation by a metabolic or endocrinology specialist. Disorders are organized in tabular format by class of pathway or analyte, with attention to typical clinical presentations, confirmatory biochemical and molecular tests, and therapies. There are numerous challenges in clinical follow-up, including diagnosis and appropriate understanding of the consequences of the disorders. The data required to meet these challenges can be acquired only by large scale longitudinal comprehensive studies of outcome in children identified by newborn screening. Only with such data can newborn screening fully serve families. © 2006 Wiley-Liss, Inc. MRDD Research Reviews 2006;12:246,254. [source]

    Referral of Emergency Department Patients for Pneumococcal Vaccination

    David E. Manthey MD
    Abstract Objectives: To determine what proportion of eligible patients, when referred to a primary care physician for pneumococcal vaccination with a prescription, actually obtain the vaccination. To ascertain the number of eligible patients who would receive the vaccination in the emergency department (ED), if available. Methods: The authors surveyed a convenience sample of patients presenting to an urban ED during a four-month period. Eligible patients were referred to specific sites with a prescription to be immunized. Data on those referred were collected by review of medical record and telephone follow-up. Results: A total of 2,299 surveys were distributed; 338 patients declined to participate, yielding an 85% response rate. The total number of patients identified as having an indication for the pneumovax was 711 (36%). Of these, 411 were not previously vaccinated; 167 of the 411 had a contraindication to vaccination. The remaining 244 qualified for referral to receive the pneumococcal vaccine. One hundred thirty-one of these accepted referral prescription. Of the patients given prescriptions, 12 followed up and received the vaccine, 81 did not follow up, and 38 were lost to follow-up. Seventy-four percent of patients would have received the pneumovax in the ED if it had been available. Conclusions: The percentage of ED patients who used prescription referral to the primary care network for pneumococcal vaccination was approximately 10%. The use of a referral by prescription method in this setting was not a reliable means of increasing the number of patients receiving the pneumococcal vaccination. [source]

    The Effect of Capitation on Switching Primary Care Physicians

    Melony E. S. Sorbero
    Objective To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs. Data Sources/Study Setting Administrative enrollment and claims/encounter data for 1994,1995 from four physician organizations. Study Design We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods. Data Collection/Extraction Methods Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis. Principal Findings Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs. Conclusions A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives. [source]

    Managing chronic headaches in the clinic

    A.J. Dowson
    Summary Chronic daily headache (CDH), which is often linked to a history of migraine, tension-type headache and the abuse of headache medications, and cluster headache are the best known of the chronic headaches. These headaches may not be well recognised or well treated in primary care. This article outlines the development of management algorithms for these headache subtypes, designed for use by the primary care physician with an interest in headache. Principles of care for chronic headaches include implementation of screening procedures, differential diagnosis, tailoring of management to the individual's needs, proactive follow-up and a team approach to care. These principles can be customised to the headache subtype by the selection of appropriate therapies. The optimal treatments for CDH include physical therapy to the neck if there is any stiffness there, withdrawal of abused medications and treatment of any subsequent withdrawal symptoms and headache prophylaxis, together with the provision of acute medications as rescue therapy. Optimal treatments for cluster headache include short- and long-term prophylaxis to prevent the headaches developing and acute medications for use as rescue. If treatment is ineffective, alternative medications can be provided at follow-up, with the possibility of referral for refractory patients. [source]

    Multiple keratoacanthomas in a young woman: report of a case emphasizing medical management and a review of the spectrum of multiple keratoacanthomas

    Ron J. Feldman MD
    A 27-year-old white woman was referred for consultation with regard to the presence of extensive multiple keratotic lesions. She began to develop these lesions at the age of 9 years, with healing of the lesions resulting in scar formation. A biopsy was performed at the age of 16 years, but the patient was unsure of the results. Since then, she had not had any treatment or biopsies, and stated that she had not suffered from any health problems during the intervening period. She was most concerned about the tumors on her heels and soles, which caused difficulty with ambulation. The family history was negative for skin diseases, including melanoma, nonmelanoma skin cancer, psoriasis, and eczema, and positive for Type II diabetes mellitus. A relative reported that the patient's grandfather had similar lesions, but the patient's parents and siblings were healthy. She was married and had one child, a 9-year-old daughter. Her child had no skin lesions. The patient's only medication was Ortho-Tricyclene birth control pills. She had no known drug allergies. Physical examination revealed the presence of multiple lesions on her body (Fig. 1). Her left superior helix contained a well-demarcated, dome-shaped nodule with a rolled, mildly erythematous border with a central hyperkeratotic plug. A similar lesion was present in the scaphoid fossa of the left ear and smaller lesions were scattered on her face. Numerous lesions were present on the arms and legs bilaterally, with the majority of lesions being located on the anterior lower legs. There were also lesions present on the palms and soles. The lesions ranged in size from 5 mm to 3 cm, the largest being a verrucous exophytic nodule on the anterior aspect of her left leg. Overall, there appeared to be two distinct types of lesion. One type appeared round, oval, and symmetric with a central keratotic plug, similar to that on the ear. The other type was larger, more exophytic, and verrucous, including the lesions on the volar surfaces. Also present were numerous, irregularly shaped atrophic scars where previous lesions had healed spontaneously. There were no oral lesions or lesions on her fingernails or toenails, and her teeth and hair were normal. Figure 1. Initial presentation of left ear and anterior legs before treatment A biopsy was obtained from an early lesion on the right dorsal forearm. Histology revealed an exo-/endophytic growth having a central crater containing keratinous material (Fig. 2). The crater was surrounded by markedly hyperplastic squamous epithelium with large squamous epithelial cells having abundant glassy cytoplasm. Some cells were dyskeratotic. Within the dermis was a dense, chiefly mononuclear inflammatory infiltrate. A buttress of epidermis surrounded the crater. The clinical and pathologic data were consistent with keratoacanthomas. Figure 2. Keratoacanthoma exhibiting an exo- and endophytic growth pattern with a central crater containing keratin (hematoxylin and eosin; original magnification, ×40) Initial laboratory screenings revealed elevated triglycerides and total cholesterol, 537 mg/dL (normal, < 150 mg/dL) and 225 mg/dL (normal, < 200 mg/dL), respectively, with all other laboratory results within normal limits. In anticipation of starting oral retinoid therapy for her multiple keratoacanthomas, she was referred to her primary care physician for control of hyperlipidemia. After her lipids had been controlled, she was placed on isotretinoin (Accutane) 40 mg/day. There was some interval improvement with regression of some lesions leaving atrophic scars. She was also started on topical application of tazarotene (Tazorac) for all nonresolving lesions. Possible side-effects from the isotretinoin occurred, including dry mouth and eyes. After 8 months of isotretinoin, the patient was switched to acitretin (Soriatane) 25 mg to determine whether it might have a more beneficial effect on the resistant lesions. Many of the larger lesions regressed leaving atrophic scars. The dose of acitretin was subsequently increased to 35 mg because the lesions on her heel and the ball of her foot persisted. Almost all of the lesions resolved, except those on her feet, which are slowly regressing. Currently, the patient is on a regimen of acitretin 25 mg once a day with tazarotene 0.1% gel applied directly to the few residual keratoacanthomas on her feet, which are slowly improving. [source]

    Practical and experimental consideration of sun protection in dermatology

    William W. Ting MD
    Much is known regarding the deleterious effects of ultraviolet radiation (UV) on the skin. As more epidemiologic and basic research continues to characterize the impact of sun exposure and other sources of UV radiation upon the development of cutaneous neoplasm and a variety of photosensitive dermatoses, it is crucial for the dermatologist to promote sun protection among his/her patients as well as the primary care physician who has a greater reach of the community than the skin specialist. Practical steps to achieve optimal sun protection include avoidance of UV radiation, avoidance of photosensitizing drugs, use of photo-protective clothing, and diligent application of broad-spectrum sunscreens. In recent years, novel agents and experimental modalities with the potential to offer enhanced protective effects against deleterious sequelae of sun exposure have been elucidated, e.g. antioxidants, alpha-MSH, polyphenol in green teas, genistein, NF-kB decoy oligodeoxynucleotides, pTpT vaccination, and IL-12. As these new photo-protective tools are being developed by scientists around the world, greater concerted effort is needed to engage public health officials and the media to promote sun protection awareness throughout the general public. [source]

    An unusual cause of dizziness in bulimia nervosa: A case report

    Randy A. Sansone MD
    Abstract Objective The current article describes the case of a 23<->year<->old female with purging<->type bulimia nervosa who was evaluated by her primary care physician for dizziness and lightheadedness. Methods After laboratory studies were performed by her primary care physician, the patient was admitted to the hospital because of severe anemia. The patient had been taking nonsteroidal antiinflammatory drugs <(>NSAIDS<)> at prescribed doses for shin splints that were secondary to jogging and developed gastric erosion. Results Endoscopic examination showed that she had diffuse gastritis with linear, streaky ulcerations throughout the body of the stomach. Discussion Lightheadedness is a common clinical symptom among individuals with eating disorders, but is typically related to dehydration, malnutrition, hypometabolism, andor combinations of these factors. Clinicians need to consider NSAID use, which may cause erosive gastritis, blood loss, and lightheadedness. © 2005 by Wiley Periodicals, Inc. [source]

    A critical review of aspirin in the secondary prevention of noncardioembolic ischaemic stroke

    Domenico Inzitari
    Both secondary prevention (such as lifestyle modifications, pharmacotherapy or surgery) and an understanding of the influence of risk factors (including the different aetiologic mechanisms of cerebral ischaemia) play a pivotal role in reducing the burden of recurrent stroke. Regarding the types of preventative treatments available, variations exist across all clinical studies, including differences in target populations (including the type of cerebral ischaemia), risk factors, length of follow-up, drop-out rates and outcomes, which makes translating the results of clinical trials to individual patients difficult. However, with such limitations in mind, this critical albeit nonsystematic review, which compared aspirin with other antiplatelets and in combination with other drugs, showed that the benefit from aspirin treatment is consistently shown in ischaemic stroke, while harms are limited. Furthermore, no definite superiority is apparent across different antiplatelet therapies. Dual antiplatelet regimens may expose to a slight but measurable higher risk of haemorrhagic complications, perhaps in selective groups of patients (i.e. those with severe small-vessel disease or in selective racial groups). Based on our analysis, the indication of aspirin as the first-line choice, also recommended by several acknowledged international or national guidelines, may be confirmed. However, the complex nature of patients at risk of recurrent ischaemic stroke necessitates a comprehensive approach, which should be driven by the primary care physician, whose role is central to successful actions for secondary stroke prevention. [source]

    Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention

    Steven R. Counsell MD
    OBJECTIVES: To provide, from the healthcare delivery system perspective, a cost analysis of the Geriatric Resources for Assessment and Care of Elders (GRACE) intervention, which is effective in improving quality of care and outcomes. DESIGN: Randomized controlled trial with physicians as the unit of randomization. SETTING: Community-based primary care health centers. PARTICIPANTS: Nine hundred fifty-one low-income seniors aged 65 and older; 474 participated in the intervention and 477 in usual care. INTERVENTION: Home-based care management for 2 years by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. MEASUREMENTS: Chronic and preventive care costs, acute care costs, and total costs in the full sample (n=951) and predefined high-risk (n=226) and low-risk (n=725) groups. RESULTS: Mean 2-year total costs for intervention patients were not significantly different from those for usual care patients in the full sample ($14,348 vs $11,834; P=.20) and high-risk group ($17,713 vs $18,776; P=.38). In the high-risk group, increases in chronic and preventive care costs were offset by reductions in acute care costs, and the intervention was cost saving during the postintervention, or third, year ($5,088 vs $6,575; P<.001). Mean 2-year total costs were higher in the low-risk group ($13,307 vs $9,654; P=.01). CONCLUSION: In patients at high risk of hospitalization, the GRACE intervention is cost neutral from the healthcare delivery system perspective. A cost-effectiveness analysis is needed to guide decisions about implementation in low-risk patients. [source]

    Vulnerable Older People in the Community: Relationship Between the Vulnerable Elders Survey and Health Service Use

    Hannah M. McGee PhD
    OBJECTIVES: The Vulnerable Elders Survey (VES), a recently developed screening tool for at-risk older people in the community, has been validated in the United States. This study evaluated its profile in older Irish people. It assessed whether those categorized as vulnerable according to the VES were likely to use health services more frequently than others. DESIGN: Nationally representative cross-sectional interviews. SETTING: Private homes in the community. PARTICIPANTS: Randomly selected older people (aged ,65) (N=2,033; 68% response). MEASUREMENTS: Interviews included the 13-item VES and questions on health service use. RESULTS: The proportion scoring as vulnerable was identical to the U.S. sample (32.1% vs 32.3%). At the community healthcare level, participants categorized as vulnerable visited their primary care physician more frequently (mean visits 6.7 vs 4.0, P<.001), had more home-based public health nurse visits (29% vs 5%, P<.001), and were more likely to have had preventive influenza vaccinations (81% vs 72%, P<.001) in the previous year. More-vulnerable older adults did not differ on assessment of blood pressure (97% vs 96%), cholesterol (82% vs 85%), or receipt of smoking advice (66% vs 52%). Vulnerable participants were more likely to have used emergency department (17% vs 8%, P<.05), inpatient (21% vs 12%, P<.05), and outpatient (28% vs 21%, P<.05) hospital services. Fourteen percent of those categorized as vulnerable had zero or one visit to their family physician in the previous year. CONCLUSION: This study provides further evidence, from a different healthcare system, of the potential of the VES to differentiate more-vulnerable older people. Prospective studies are needed to assess use of the VES as a clinical decision aid for community professionals such as family physicians and public health nurses. [source]

    Effect of Telephone Counseling on Physical Activity for Low-Active Older People in Primary Care: A Randomized, Controlled Trial

    Gregory S. Kolt PhD
    OBJECTIVES: To assess the long-term effectiveness of a telephone counseling intervention on physical activity and health-related quality of life in low-active older adults recruited through their primary care physician. DESIGN: Randomized, controlled trial. SETTING: Three primary care practices from different socioeconomic regions of Auckland, New Zealand. PARTICIPANTS: One hundred and eighty-six low-active adults (aged 65) recruited from their primary care physicians' patient databases. INTERVENTION: Eight telephone counseling sessions over 12 weeks based on increasing physical activity. Control patients received usual care. MEASUREMENTS: Change in physical activity (as measured using the Auckland Heart Study Physical Activity Questionnaire) and quality of life (as measured using the Short Form-36 Health Survey (SF-36)) over a 12-month period. RESULTS: Moderate leisure physical activity increased by 86.8 min/wk more in the intervention group than in the control group (P=.007). More participants in the intervention group reached 2.5 hours of moderate or vigorous leisure physical activity per week after 12 months (42% vs 23%, odds ratio=2.9, 95% confidence interval=1.33,6.32, P=.007). No differences on SF-36 measures were observed between the groups at 12 months. CONCLUSION: Telephone-based physical activity counseling is effective at increasing physical activity over 12 months in previously low-active older adults. [source]

    Reducing Suicidal Ideation in Depressed Older Primary Care Patients

    Jürgen Unützer MD
    OBJECTIVES: To determine the effect of a primary care,based collaborative care program for depression on suicidal ideation in older adults. DESIGN: Randomized, controlled trial. SETTING: Eighteen diverse primary care clinics. PARTICIPANTS: One thousand eight hundred one adults aged 60 and older with major depression or dysthymia. INTERVENTION: Participants randomized to collaborative care had access to a depression care manager who supported antidepressant medication management prescribed by their primary care physician and offered a course of Problem Solving Treatment in Primary Care for 12 months. Participants in the control arm received care as usual. MEASUREMENTS: Participants had independent assessments of depression and suicidal ideation at baseline and 3, 6, 12, 18, and 24 months. Depression was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Suicidal ideation was determined using the SCID and the Hopkins Symptoms Checklist. RESULTS: At baseline, 139 (15.3%) intervention subjects and 119 (13.3%) controls reported thoughts of suicide. Intervention subjects had significantly lower rates of suicidal ideation than controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and even after intervention resources were no longer available at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%). There were no completed suicides in either group. Information on suicide attempts or hospitalization for suicidal ideation was not available. CONCLUSION: Primary care,based collaborative care programs for depression represent one strategy to reduce suicidal ideation and potentially the risk of suicide in older primary care patients. [source]

    Treatment of Depression Improves Physical Functioning in Older Adults

    Christopher M. Callahan MD
    Objectives: To determine the effect of collaborative care management for depression on physical functioning in older adults. Design: Multisite randomized clinical trial. Setting: Eighteen primary care clinics from eight healthcare organizations. Participants: One thousand eight hundred one patients aged 60 and older with major depressive disorder. Intervention: Patients were randomized to the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (n=906) or to a control group receiving usual care (n=895). Control patients had access to all health services available as part of usual care. Intervention patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician. Measurements: The 12-item short form Physical Component Summary (PCS) score (range 0,100) and instrumental activities of daily living (IADLs) (range 0,7). Results: The mean patient age was 71.2, 65% were women, and 77% were white. At baseline, the mean PCS was 40.2, and the mean number of IADL dependencies was 0.7; 45% of participants rated their health as fair or poor. Intervention patients experienced significantly better physical functioning at 1 year than usual-care patients as measured using between-group differences on the PCS of 1.71 (95% confidence interval (CI)=0.96,2.46) and IADLs of ,0.15 (95% CI=,0.29 to ,0.01). Intervention patients were also less likely to rate their health as fair or poor (37.3% vs 52.4%, P<.001). Combining both study groups, patients whose depression improved were more likely to experience improvement in physical functioning. Conclusion: The IMPACT collaborative care model for late-life depression improves physical function more than usual care. [source]

    Rapid Emergency Department Intervention for Older People Reduces Risk of Functional Decline: Results of a Multicenter Randomized Trial

    DrPH, Jane McCusker MD
    OBJECTIVES: To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes. DESIGN: Controlled trial, randomized by day of ED visit, with follow-up at 1 and 4 months. SETTING: Four university-affiliated hospitals in Montreal. PARTICIPANTS: Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk (ISAR) screening tool and their primary family caregivers. One hundred seventy-eight were randomized to the intervention, 210 to usual care. INTERVENTION: The intervention consisted of disclosure of results of the ISAR screen, a brief standardized nursing assessment in the ED, notification of the primary care physician and home care providers, and other referrals as needed. The control group received usual care, without disclosure of the screening result. MEASUREMENTS: Patient outcomes assessed at 4 months after enrollment included functional decline (increased dependence on the Older American Resources and Services activities of daily living scale or death) and depressive symptoms (as assessed by the short Geriatric Depression Scale). Caregiver outcomes, also assessed at baseline and 4 months, included the physical and mental summary scales of the Medical Outcomes Study Short Form-36. Patient and caregiver satisfaction with care were assessed 1 month after enrollment. RESULTS: The intervention increased the rate of referral to the primary care physician and to home care services. The intervention was associated with a significantly reduced rate of functional decline at 4 months, in both unadjusted (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.36,0.99) and adjusted (OR = 0.53, 95% CI = 0.31,0.91) analyses. There was no intervention effect on patient depressive symptoms, caregiver outcomes, or satisfaction with care. CONCLUSION: A two-stage ED intervention, consisting of screening with the ISAR tool followed by a brief, standardized nursing assessment and referral to primary and home care services, significantly reduced the rate of subsequent functional decline. J Am Geriatr Soc 49:1272,1281, 2001. [source]

    Nurse Practitioners and Physicians: Patients' Perceived Health and Satisfaction with Care

    Jo-Allyn Pinkerton PhD
    ABSTRACT The advent of managed care has created changes in the health care environment and nurse practitioners have found a need to evaluate their care. Perceived health and patient satisfaction were measured in a multiethnic sample of 160 clinic patients, ages 18 to 89, in a managed care setting. Results of the Medical Outcomes Study SF-20 and the Nurse Practitioner Satisfaction Instrument indicated no statistically significant difference in perceived health and satisfaction with care, whether the care was given by a nurse practitioner or a primary care physician. The findings warrant further study and may mean that nurse practitioners placed in managed care environments can be expected to perform as effectively as they have in non-managed care environments. [source]

    Herpes zoster in older adults. (Duke University Medical Center, Durham, NC) Clinical Infectious Diseases.

    PAIN PRACTICE, Issue 4 2001
    1486., 2001;32:148
    Herpes zoster (HZ) strikes millions of older adults annually worldwide and disables a substantial number of them via postherpetic neuralgia (PHN). Key aged-related clinical, epidemiological, and treatment features of zoster and PHN are reviewed in this article. HZ is caused by renewed replication and spread of the varicella-zoster virus (VZV) in sensory ganglia and afferent peripheral nerves in the setting of age-related, disease-related, and drug-related decline in cellular immunity to VZV. VZV-induced neuronal destruction and inflammation causes the principal problems of pain, interference with activities in daily living, and reduced quality of life in elderly patients. Recently, attempts to reduce or eliminate HZ pain have been bolstered by the findings of clinical trials that antiviral agents and corticosteroids are effective treatment for HZ and that tricyclic antidepressants, topical lidocaine, gabapentin, and opiates are effective treatment for PHN. Although these advances have helped, PHN remains a difficult condition to prevent and treat in many elderly patients. Comment by Miles Day, M.D. This article reviews the epidemiology clinical features diagnosis and treatment of acute herpes zoster. It also describes the treatment of postherpetic neuralgia. While this is a good review for the primary care physician, the discussion for the treatment for both acute herpes zoster and postherpetic neuralgia do not mention invasive therapy. It is well documented in pain literature that sympathetic blocks with local anesthetic and steroid as well as subcutaneous infiltration of active zoster lesions not only facilitate the healing of acute herpes zoster but also prevents or helps decrease the incidence of postherpetic neuralgia. All patients who present to the primary care physician with acute herpes zoster should have an immediate referral to a pain management physician for invasive therapy. The treatment of postherpetic neuralgia is a challenging experience both for the patient and the physician. While the treatments that have been discussed in this article are important, other treatments are also available. Regional nerve blocks including intercostal nerve blocks, root sleeve injections, and sympathetic blocks have been used in the past to treat postherpetic neuralgia. If these blocks are helpful, one can proceed with doing crynourlysis of the affected nerves or also radio-frequency lesioning. Spinal cord stimulation has also been used for those patients who are refractory to noninvasive and invasive therapy. While intrathecal methylprednisolone was shown to be effective in the study quoted in this article one must be cautious not to do multiple intrathecal steroid injections in these patients. Multilple intrathecal steroid injections can lead to archnoiditis secondary to the accumulation of the steroid on the nerve roots and in turn causing worsening pain. [source]

    The management of bipolar disorder in primary care: A review of existing and emerging therapies

    MICHAEL BERK mbbch, ff (psych), franzcp, mmed (psych)
    Abstract, Recent evidence suggests that the prevalence of bipolar disorder is as much as fivefold higher than previously believed, and may amount to nearly 5% of the population, making it almost as common as unipolar major depression. It is, therefore, not unrealistic to assume that primary care or family physicians will frequently encounter bipolar patients in their practice. Such patients may present with a depressive episode, for a variety of medical reasons, for longer-term maintenance after stabilization, and even with an acute manic episode. Whatever the reason, a working knowledge of current trends in the acute and longer-term management of bipolar disorder would be helpful to the primary care physician. In addition, an understanding of important side-effects and drug interactions that occur with drugs used to treat bipolar disorder, which may be encountered in the medical setting, are paramount. This paper will attempt to review existing and emerging therapies in bipolar disorder, as well as their common drug interactions and side-effects. [source]

    National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

    Donald E. Pathman MD
    ABSTRACT:,Context: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. Purpose: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. Methods: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. Findings: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations.Conclusions: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s. [source]

    Effect of Trainees on Length of Stay in the Pediatric Emergency Department

    Catherine James MD
    Abstract Background:, Emergency departments (EDs) in teaching hospitals have competing goals of timely patient care and supervised trainee education. Previous investigations have indicated that trainees add time to the length of ED patient encounters. However, no studies have quantified the effect of trainees on pediatric ED length of stay (LOS). Objectives:, The objectives were to measure the effect of trainees on pediatric ED LOS by comparing LOS for patients managed by a pediatric emergency physician (PEP) alone to LOS for patients seen by a trainee and a precepting PEP (Trainee+PEP). A secondary objective was to identify factors other than provider type associated with LOS differences observed in teaching hospital pediatric EDs. Methods:, Data were extracted from a computerized ED tracking system in an urban tertiary care children's hospital with approximately 52,000 visits annually. All patients were seen by a PEP alone, an urgent care physician, or a trainee (a pediatric emergency medicine fellow; a pediatric, emergency medicine, or combined internal medicine/pediatrics resident; or a medical student) plus a precepting PEP. The primary comparison was the ratio of median LOS for the PEP group versus the Trainee+PEP group. Results:, There were 92,193 visits eligible for inclusion over a 2-year period. Median patient age was 5.75 years (interquartile range [IQR] = 21 months to 12.9 years). The PEP group managed 9,141 patients (10%), while the Trainee+PEP group treated 72,135 patients (78%). Overall LOS for an ED visit was 221 minutes. The median LOS was 192 minutes for PEP patients and 225 minutes for Trainee+PEP patients (difference of means = 17%, p < 0.001). Laboratory and imaging studies were associated with LOS increases of 111 and 74 minutes, respectively; both were performed more frequently in Trainee+PEP patients (44% vs. 33% for laboratory studies and 41% vs. 39% for imaging studies, both comparisons p < 0.001). When LOS was analyzed after adjusting for confounding factors including patient acuity, laboratory or radiologic testing, and trainee year, LOS for Trainee+PEP was higher by 17 minutes, or 9% (95% confidence interval [CI] = 6% to 12%, p < 0.001). When LOS was examined for four specific diagnoses (asthma, gastroenteritis, appendicitis, foot/ankle sprain), there were no significant differences in LOS between the PEP and Trainee+PEP groups. Conclusions:, In the pediatric ED of a teaching hospital, ED LOS is on average 9% higher in patients seen by trainees. In an era of increasing efforts to accelerate throughput while training future providers, these findings provide an important metric for the delivery of pediatric emergency care. [source]

    Dissecting racial disparities in the treatment of patients with locoregional pancreatic cancer

    CANCER, Issue 4 2010
    A 2-Step Process
    Abstract BACKGROUND: Previous studies have demonstrated that black patients with pancreatic cancer are less likely to undergo resection and have worse overall survival compared with white patients. The objective of this study was to determine whether these disparities occur at the point of surgical evaluation or after evaluation has taken place. METHODS: The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2002) to compare black patients and white patients with locoregional pancreatic cancer in univariate models. Logistic regression was used to determine the effect of race on surgical evaluation and on surgical resection after evaluation. Cox proportional hazards models were used to identify which factors influenced 2-year survival. RESULTS: Nine percent of 3777 patients were black. Blacks were substantially less likely than whites to undergo evaluation by a surgeon (odds ratio, 0.57; 95% confidence interval, 0.42-0.77) when the model was adjusted for demographics, tumor characteristics, surgical evaluation, socioeconomic status, and year of diagnosis. Patients who were younger and who had fewer comorbidities, abdominal imaging, and a primary care physician were more likely to undergo surgical evaluation. Once they were seen by a surgeon, blacks still were less likely than whites to undergo resection (odds ratio, 0.64; 95% confidence interval, 0.49-0.84). Although black patients had decreased survival in an unadjusted model, race no longer was significant after accounting for resection. CONCLUSIONS: Twenty-nine percent of black patients with potentially resectable pancreatic cancers never received surgical evaluation. Without surgical evaluation, patients cannot make an informed decision and will not be offered resection. Attaining higher rates of surgical evaluation in black patients would be the first step to eliminating the observed disparity in the resection rate. Cancer 2010. © 2010 American Cancer Society [source]

    Neuroticism, alexithymia, negative affect and positive affect as predictors of medically unexplained symptoms in primary care1

    V. De Gucht
    Background:, Somatization has been defined in a number of ways. Despite their differences, these definitions have one element in common, namely the presence of somatic symptoms that cannot be explained (adequately) by organic findings. Objective: The primary objectives of the dissertation were to gain a better insight into the concept of somatization, and to study (prospectively) the relationship between neuroticism and alexithymia, two personality traits that have been shown to be related to somatization, the affective state dimensions positive and negative affect (or psychological distress) and medically unexplained symptoms. Method: A selective review was conducted regarding conceptual and methodological issues related to somatization. A total number of 318 patients, presenting to their primary care physician with medically unexplained symptoms, participated in the prospective study. Both at baseline and at 6-month follow-up a number of measures were filled out with respect to somatization, neuroticism, alexithymia, negative and positive affect, anxiety and depression. Results: The concept of somatization was clarified, thereby making use of the distinction between presenting and functional somatization. The personality traits neuroticism and alexithymia were found to have an indirect influence on symptom reports. Both the cross-sectional and follow-up data pointed to the importance of positive and negative affect as determinants of (changes in) number of symptoms (over time). Negative affect, together with the alexithymia dimension measuring difficulty identifying feelings, predicted symptom persistence. Conclusions: The theoretical as well as therapeutic implications of the present paper may give an impetus to new research in the domain of somatization. [source]

    Primary care services provided to adolescents in detention: a cross-sectional study using ICPC-2

    ACTA PAEDIATRICA, Issue 7 2010
    DM Haller
    Abstract Aim:, The aim of this study was to provide a detailed description of the health problems for which primary care services are provided to adolescents in a juvenile detention facility in Europe. Methods:, We reviewed the medical files of all detainees in a juvenile detention centre in Switzerland in 2007. The health problems for which primary care services were provided were coded using the International Classification for Primary Care, version 2. Analysis was descriptive, stratified by gender. Results:, A total of 314 adolescents (18% female) aged 11,19 years were included. Most (89%) had a health assessment and 195 (62%) had consultations with a primary care physician; 80% of the latter had a physical health problem, and 60% had a mental health problem. The most commonly managed problems were skin (49.7%), respiratory (23.6%), behavioural (22.6%) and gynaecological problems (females: 23.9%); 13% females (no males) had sexually transmitted infections (STI), and 8.7% were pregnant. Substance abuse was common (tobacco: 64.6%, alcohol: 26.2%, cannabis: 31.3%). Conclusion:, In addition to health problems known to be more prevalent among young offenders, such as mental health problems and STI, these adolescent detainees required care for a range of common primary care problems. These data should inform the development of comprehensive primary care services in all juvenile detention facilities in Europe. [source]

    Advanced Heart Failure: Prognosis, Uncertainty, and Decision Making

    Jane G. Zapka ScD
    Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care. [source]

    Filicide: A comparative study of maternal versus paternal child homicide

    Marieke Liem
    Background,Filicide is the murder of a child by a parent. Historically, filicide was regarded as a female crime, but nowadays, in the West, men have become increasingly likely to be convicted of killing their child. Previous research on filicide has primarily focussed on either maternal or paternal filicide rather than comparing the two. Aim,The aim of our study is to examine and compare the socio-demographic, environmental and psychopathological factors underlying maternal and paternal filicide. Methods,Data were extracted from records in a forensic psychiatric observation hospital in Utrecht, in the Netherlands for the period 1953,2004. Results,Seventy-nine men and 82 women were detained in the hospital under criminal charges in that period, having killed (132) or attempted to kill (29) their own child(ren). Differences between men and women were found with regard to age, methods of killing and motivation underlying the filicide. Conclusions,The categories of filicide identified corresponded to those in studies from other countries, indicating that filicide follows similar patterns throughout the Western world. The fact that 25% of fathers had killed in reaction to threatened separation or divorce, and that over a third of men and more than half of the women were mentally ill at the time may suggest that increased monitoring by primary care physicians under such circumstances might have preventive value. Copyright © 2008 John Wiley & Sons, Ltd. [source]

    The targets of violence committed by young offenders with alcohol dependence, marijuana dependence and schizophrenia-spectrum disorders: findings from a birth cohort

    Louise Arseneault
    Background: Estimates of who is most at risk from violence by people with mental illness rest mainly on identified patient samples. This study, without such selection bias, examined the targets of violence committed by young adults with as-yet untreated alcohol dependence, marijuana dependence, or schizophrenia-spectrum disorders, to determine the extent to which their victims were co-residents or non-household members. Methods: In a total birth cohort of 21-year-olds (n = 956), past-year prevalence of alcohol dependence, marijuana dependence and schizophrenia-spectrum disorders were diagnosed using standardized DSM-III-R interviews. None of the people with schizophrenia-spectrum disorder has been hospitalized in the past year. Past-year violence and victim targets were measured using self-reports. Results: Compared with controls, cohort members with substance dependence or schizophrenia-spectrum disorders had higher prevalence and frequency rates of assault against co-residents, against non-household members, and also robbery and gang fights. Out of 39, five individuals with schizophrenia-spectrum disorder committed violent street crimes. Persons with substance dependence had similar proportions of violence against co-resident and non-household members, but persons with schizophrenia-spectrum disorders tended to victimize co-residents more than others. Conclusions: At the age when they are most likely to contribute to the community's violence burden, young untreated offenders with alcohol or marijuana dependence or with schizophrenia-spectrum disorders assault not only co-residents, but others as well, and commit violent street crimes. Families, schoolteachers and primary care physicians have an important potentially preventive role in early identification and treatment of the disorders. Copyright © 2002 Whurr Publishers Ltd. [source]

    Research Methods of Inquiry

    Joel Rodgers MA
    Incidents of significant consequence that create surge may require special research methods to provide reliable, generalizable results. This report was constructed through a process of literature review, expert panel discussion at the journal's consensus conference, and iterative development. Traditional clinical research methods that are well accepted in medicine are exceptionally difficult to use for surge incidents because the incidents are very difficult to reliably predict, the consequences vary widely, human behaviors are heterogeneous in response to incidents, and temporal conditions prioritize limited resources to response, rather than data collection. Current literature on surge research methods has found some degree of reliability and generalizability in case-control, postincident survey methods, and ethnographical designs. Novel methods that show promise for studying surge include carefully validated simulation experiments and survey methods that produce validated results from representative populations. Methodologists and research scientists should consider quasi-experimental designs and case-control studies in areas with recurrent high-consequence incidents (e.g., earthquakes and hurricanes). Specialists that need to be well represented in areas of research include emergency physicians and critical care physicians, simulation engineers, cost economists, sociobehavioral methodologists, and others. [source]