Screening procedures in the asymptomatic adult. Comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice

Perspective of healthy asymptomatic patients requesting general blood tests from their physicians: a qualitative study

BACKGROUND

Routine blood tests for young, healthy, asymptomatic patients have no proven value in early detection of diseases. Indeed, such tests have occasionally been found to be harmful. Although general blood tests are not recommended by evidence-based guidelines, patients frequently request referrals for these tests. A number of studies have examined the factors influencing doctors to prescribe such tests, yet little is known about patients' perspectives on this topic. The present study evaluated the knowledge, attitudes and beliefs of young, healthy asymptomatic patients requesting general blood tests from their family physician.

METHOD

Qualitative interviews with 15 healthy, asymptomatic patients aged 22-50 who requested general blood tests from their family physicians. We conducted in-depth semi-structured interviews within two weeks of their request.

RESULTS

Three main themes emerged from the interviews: 1) Patients' sense of personal responsibility and their belief that periodic blood tests are beneficial as an integral part of their health maintenance. 2) Patients' need to receive external, objective and reliable validation about what is happening inside their bodies. 3) An acquaintance's serious illness as a prompt to perform general blood tests in the belief that such tests can reveal latent conditions.

CONCLUSION

The study revealed a substantial gap between patients' attitudes and beliefs about general blood tests and current evidence-based guidelines. Implications for research and practice are discussed.

Primary care provider approaches to preventive health delivery: a qualitative study

AimThe objective of this study was to seek decision-making insights on the provider level to gain understanding of the values that shape how providers deliver preventive health in the primary care setting.

BACKGROUND

The primary care clinic is a core site for preventive health delivery. While many studies have identified barriers to preventive health, less is known regarding how primary care providers (PCPs) make preventive health decisions such as what services to provide, under what circumstances, and why they might choose one over another.

METHODS

Qualitative methods were chosen to deeply explore these issues. We conducted semi-structured, one-on-one interviews with 21 PCPs at clinics affiliated with an academic medical center. Interviews with providers were recorded and transcribed. We conducted a qualitative analysis to identify themes and develop a theoretical framework using Grounded Theory methods.FindingsThe following themes were revealed: longitudinal care with an established PCP-patient relationship is perceived as integral to preventive health; conflict and doubt accompany non-preventive visits; PCPs defer preventive health for pragmatic reasons; when preventive health is addressed, providers use multiple contextual factors to decide which interventions are discussed; and PCPs desired team-based preventive health delivery, but wish to maintain their role when shared decision-making is required. We present a conceptual framework called Pragmatic Deferral.

Screening for lung cancer

BACKGROUND

This is an updated version of the original review published in The Cochrane Library in 1999 and updated in 2004 and 2010. Population-based screening for lung cancer has not been adopted in the majority of countries. However it is not clear whether sputum examinations, chest radiography or newer methods such as computed tomography (CT) are effective in reducing mortality from lung cancer.

OBJECTIVES

To determine whether screening for lung cancer, using regular sputum examinations, chest radiography or CT scanning of the chest, reduces lung cancer mortality.

SEARCH METHODS

We searched electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5), MEDLINE (1966 to 2012), PREMEDLINE and EMBASE (to 2012) and bibliographies. We handsearched the journal Lung Cancer (to 2000) and contacted experts in the field to identify published and unpublished trials.

SELECTION CRITERIA

Controlled trials of screening for lung cancer using sputum examinations, chest radiography or chest CT.

DATA COLLECTION AND ANALYSIS

We performed an intention-to-screen analysis. Where there was significant statistical heterogeneity, we reported risk ratios (RRs) using the random-effects model. For other outcomes we used the fixed-effect model.

MAIN RESULTS

We included nine trials in the review (eight randomised controlled studies and one controlled trial) with a total of 453,965 subjects. In one large study that included both smokers and non-smokers comparing annual chest x-ray screening with usual care there was no reduction in lung cancer mortality (RR 0.99, 95% CI 0.91 to 1.07). In a meta-analysis of studies comparing different frequencies of chest x-ray screening, frequent screening with chest x-rays was associated with an 11% relative increase in mortality from lung cancer compared with less frequent screening (RR 1.11, 95% CI 1.00 to 1.23); however several of the trials included in this meta-analysis had potential methodological weaknesses. We observed a non-statistically significant trend to reduced mortality from lung cancer when screening with chest x-ray and sputum cytology was compared with chest x-ray alone (RR 0.88, 95% CI 0.74 to 1.03). There was one large methodologically rigorous trial in high-risk smokers and ex-smokers (those aged 55 to 74 years with ≥ 30 pack-years of smoking and who quit ≤ 15 years prior to entry if ex-smokers) comparing annual low-dose CT screening with annual chest x-ray screening; in this study the relative risk of death from lung cancer was significantly reduced in the low-dose CT group (RR 0.80, 95% CI 0.70 to 0.92).

AUTHORS' CONCLUSIONS

The current evidence does not support screening for lung cancer with chest radiography or sputum cytology. Annual low-dose CT screening is associated with a reduction in lung cancer mortality in high-risk smokers but further data are required on the cost effectiveness of screening and the relative harms and benefits of screening across a range of different risk groups and settings.

National trends in emergency department use of urinalysis, complete blood count, and blood culture for fever without a source among children aged 2 to 24 months in the pneumococcal conjugate vaccine 7 era

OBJECTIVES

The epidemiology of serious bacterial infections in children has changed since the introduction of the pneumococcal conjugate vaccine (PCV-7) in 2000. Whether emergency department (ED) physicians have changed diagnostic approaches to fever without a source (FWS) in response is unknown. We examine trends in rates of complete blood count (CBC), urinalysis (UA), and blood cultures among 2- to 24-month-old children with FWS since the introduction of PCV-7.

METHODS

The National Hospital Ambulatory Medical Care Survey-Emergency Department, 2001-2009, was used to identify visits to the ED by 2- to 24-month-old children with FWS. Rates of CBC, UA, neither CBC nor UA, and blood culture were tracked across time. Trends were identified using Joinpoint regression and bivariate and multivariate logistic regressions with year as the independent variables and ordering of each test as the dependent variables.

RESULTS

In bivariate and multivariate analyses, CBC orders declined between 2004 and 2009 for visits by all children 2 to 24 months, children 2 to 11 months, and boys 2 to 24 months (adjusted odds ratio [aOR], 0.88 per year [P < 0.01]; aOR, 0.88 [P < 0.05]; and aOR, 0.83 [P < 0.01], respectively). Between 2004 and 2009, ordering neither CBC nor UA increased among all children 2 to 24 months (aOR, 1.10; P < 0.05) and among boys (aOR, 1.16; P < 0.05). Orders for blood cultures declined across the time period in bivariate analysis, but not in multivariate analysis.

CONCLUSIONS

The rate of ordering a CBC for children in the 2- to 24-month age group presenting to the ED with FWS declined, a change coincident with the changing epidemiology of serious bacterial infection since the PCV-7 vaccine was introduced.

Colorectal cancer screening practices among obstetrician/gynecologists and nurse practitioners

OBJECTIVE

Obstetrician/gynecologists (Ob/Gyn) and nurse practitioners (NP) are essential providers of primary and preventive care for their female patients. Therefore, colorectal cancer (CRC) screening should be part of their routine preventive practices. The purpose of our study is to evaluate the CRC screening practices of these providers.

METHODS

A self-administered survey was mailed to a national sample of 1130 Ob/Gyns and NPs to assess providers' demographics, current CRC screening practices, and familiarity with CRC guidelines.

RESULTS

Three hundred thirty-six providers (29.7%) returned our survey (54% Ob/Gyns and 46% NPs). Three fourths of providers routinely performed screening for CRC, compared with 95% for breast and cervical cancer. Routine CRC screening was more common among Ob/Gyns (87.2%) than NPs (61.7%) (p < 0.001). Slightly over half of providers correctly identified the recommended age to begin CRC screening for the average-risk patient, with no significant difference between provider types. Overall, Ob/Gyns scored higher than NPs on a series of questions assessing CRC screening (p < 0.03). Several provider factors were found to be significantly associated with screening practices, including practicing >10 years (p < 0.01), practicing in a multispecialty group (2.62 times more likely), and having an older patient population (p < 0.001).

CONCLUSIONS

Ob/Gyns and NPs underuse CRC screening compared with breast and cervical cancer screening and lack knowledge about appropriate use of CRC screening modalities. Opportunities to further educate Ob/Gyns and NPs should be sought to improve compliance with current CRC screening guidelines.

Missed opportunities: family history and behavioral risk factors in breast cancer risk assessment among a multiethnic group of women

BACKGROUND

Clinician's knowledge of a woman's cancer family history (CFH) and counseling about health-related behaviors (HRB) is necessary for appropriate breast cancer care.

OBJECTIVE

To evaluate whether clinicians solicit CFH and counsel women on HRB; to assess relationship of well visits and patient risk perception or worry with clinician's behavior.

DESIGN

Cross-sectional population-based telephone survey.

PARTICIPANTS

Multiethnic sample; 1,700 women from San Francisco Mammography Registry with a screening mammogram in 2001-2002.

PREDICTORS

well visit in prior year, self-perception of 10-year breast cancer risk, worry scale.

OUTCOMES

Patient report of clinician asking about CFH in prior year, or ever counseling about HRB in relation to breast cancer risk. Multivariate models included age, ethnicity, education, language of interview, insurance/mammography facility, well visit, ever having a breast biopsy/follow-up mammography, Gail-Model risk, Jewish heritage, and body mass index.

RESULTS

58% reported clinicians asked about CFH; 33% reported clinicians ever discussed HRB. In multivariate analysis, regardless of actual risk, perceived risk, or level of worry, having had a well visit in prior year was associated with increased odds (OR = 2.3; 95% CI 1.6, 3.3) that a clinician asked about CFH. Regardless of actual risk of breast cancer, a higher level of worry (OR = 1.9; 95% CI 1.4, 2.6) was associated with increased odds that a clinician ever discussed HRB.

CONCLUSIONS

Clinicians are missing opportunities to elicit family cancer histories and counsel about health-related behaviors and breast cancer risk. Preventive health visits offer opportunities for clinicians to address family history, risk behaviors, and patients' worries about breast cancer.

Laboratory screening at preventive health exams: trend of testing, 1978-2004

BACKGROUND

Routine laboratory screening at preventive health exams continues to be a common practice despite expert opinion dating back to 1979 that supports only a few screening tests for apparently healthy adults. This report describes trends in such testing over a 27-year period.

METHODS

Primary care physicians were surveyed five times between 1978 and 2004 at a yearly educational meeting in Colorado. Based on case vignettes describing two apparently healthy adults, physicians indicated which laboratory tests they would routinely order.

RESULTS

Of a total of 2364 surveys collected during years 1978, 1983, 1988, 1999, and 2004, the corresponding percentage of physicians respondents who state they would order the following tests for a healthy man aged 35 years were: complete blood count (CBC) (87, 75, 73, 49, 46); urinalysis (UA) (93, 86, 79, 52, 44); chemistry panel (CHEM) (57, 48, 36, 43, 55); and electrocardiogram (ECG) (37, 27, 24, 9, 6). For a healthy woman aged 55 years, the corresponding percentages for each test were: CBC (89, 89, 86, 64, 67); UA (96, 93, 88, 62, 55); CHEM (70, 70, 66, 57, 76); ECG (63, 51, 51, 33, 29); and thyroid stimulating hormone (14, 20, 28, 42, 57).

CONCLUSIONS

Although currently practicing physicians continue to report that they order screening tests for apparently healthy people, this practice appears to have decreased over the past 27 years. This trend may reflect expert guidelines and emphasis on medical cost containment.

Promoting advance directives among African Americans: a faith-based model

BACKGROUND

Studies show that African Americans are less likely than other ethnic groups to complete advance directives. However, what influences African Americans' decisions to complete or not complete advance directives is unclear.

METHODS

Using a faith-based promotion model, 102 African Americans aged 55 years or older were recruited from local churches and community-based agencies to participate in a pilot study to promote advance care planning. Focus groups were used to collect data on participants' preferences for care, desire to make personal choices, values and attitudes, beliefs about death and dying, and advance directives. A standardized interview was used in the focus groups, and the data were organized and analyzed using NUDIST 4 software (QRS Software, Victoria, Australia).

RESULTS

Three fourths of the participants refused to complete advance directives. The following factors influenced the participants' decisions about end-of-life care and completion of an advance directive: spirituality; view of suffering, death, and dying; social support networks; barriers to utilization; and mistrust of the health care system.

CONCLUSION

The dissemination of information apprises individuals of their right to self-determine about their care, but educational efforts may not produce a significant change in behavior toward completion of advance care planning. Thus, ongoing efforts are needed to improve the trust that African Americans have in medical and health care providers.

Risk Taking and Tolerance of Uncertainty: Implications for Surgeons

BACKGROUND

Adherence to evidence-based adverse outcome prevention techniques is a critical factor in providing high-quality patient care, but many of these interventions are not used by physicians. It is unclear if surgeons' risk attitudes and reactions to uncertainty influence their use of these or other interventions.

MATERIALS AND METHODS

A systematic review of the literature was conducted to identify studies evaluating the effects of physicians' risk attitudes, reactions to uncertainty or ambiguity, and personality traits on clinical decision making.

RESULTS

A variety of instruments to assess risk attitude and reactions to uncertainty have been developed and tested among physicians involved in critical care and emergency medicine. Scoring systems distinguish risk averse and risk seeking practitioners. In many studies, these characteristics were related to clinical decision making in situations of uncertainty. For example, among patients evaluated in the emergency room for chest pain, "risk-seeking" physicians admitted significantly fewer patients who did not have acute myocardial infarction than risk-avoiding physicians (29% and 47% of patients admitted, respectively). In contrast, risk-seeking physicians were no more likely to discharge a patient who eventually was found to have an acute myocardial infarction.

CONCLUSIONS

There are very limited data on the extent to which surgical decision making is linked to risk taking behavior and "comfort with uncertainty". Understanding the behaviors, attitudes and beliefs that make up surgical "judgment" remains a challenge for those interested in influencing behavior.

Factors affecting breast cancer risk reduction practices among California physicians

BACKGROUND

Little is known about the incorporation of breast cancer risk reduction therapies into clinical practice.

METHODS

We assessed factors related to physicians' performance of breast cancer risk reduction practices through a self-administered survey. Subjects were California physicians in family medicine, internal medicine, or obstetrics/gynecology, identified through the AMA Masterfile. Physicians reported their breast cancer risk reduction practices (initiating patient counseling, referring patients for genetic evaluation, and prescribing tamoxifen or raloxifene) as well as barriers to counseling.

RESULTS

Of 1647 eligible physicians, 822 responded. Eighty-six percent reported initiating counseling, 45% referred a patient for genetic evaluation, 31% prescribed raloxifene, and 11% prescribed tamoxifen for breast cancer prevention in the past year. The leading frequent barriers to counseling were "not enough time" (40.3%) and "insufficiently informed about risk reduction options" (19.1%). Multivariate analysis showed that a training and role factors scale was negatively associated with all risk reduction practices, and number of breast cancer diagnoses per year was positively associated with referring for genetic evaluation and prescribing chemoprevention.

CONCLUSIONS

Physicians in primary care specialties report participation in several breast cancer risk reduction activities. Issues related to physician training and role in risk reduction affect the implementation of these practices.

Lifestyle Behavior Counseling for Women Patients among a Sample of California Physicians

BACKGROUND

Physical inactivity, poor diet, excessive alcohol consumption, and smoking are modifiable risk factors associated with development of chronic diseases. Although the prevalence of diseases associated with these detrimental lifestyle behaviors is high among women in the United States, they may not receive adequate counseling from physicians.

METHODS

To predict physicians' lifestyle counseling practices, we assessed personal, professional, and health behavior characteristics from responses to a self-administered survey of breast cancer risk reduction practices. Subjects were California physicians identified through AMA Masterfile, in family practice, internal medicine, or obstetrics/gynecology, who were asked to report the percentages of women patients they counseled on physical activity, diet, alcohol, and smoking.

RESULTS

Of 1647 eligible physicians, 822 (50.0%) responded. Fifty-six percent reported counseling at least 75% of patients about physical activity, 54.6% about diet, and 44.8% about alcohol. More than three quarters (78.7%) counseled at least 75% of patients about smoking. In logistic regression analyses, woman gender, family practice, and internal medicine specialties emerged as significant predictors of counseling for all lifestyle behaviors. Older age was associated with dietary and alcohol counseling. Race/ethnicity was associated only with smoking counseling, and country of medical school was associated with counseling for physical activity and smoking. Sources of new medical knowledge emerged as predictors for all types of counseling, whereas physicians' own level of physical activity only predicted counseling about physical activity.

CONCLUSIONS

Physicians' personal, professional, practice, and health behavior characteristics were associated with reported lifestyle counseling of women patients. Results reveal important directions for future physician-based interventions to improve counseling.

Physicians' attitudes and preventive care delivery: insights from the DOPC study

BACKGROUND

Interventions that modify physician attitudes to enhance preventive service delivery are common, yet other factors may be relatively more important in determining whether these services are provided. We assessed associations between physicians' attitudes and delivery of preventive care, compared with factors related to the patient, visit, or practice.

METHODS

One hundred twenty-eight primary care physicians rated the importance of five preventive services and their effectiveness at delivering them. We assessed whether their patients had received cervical smears, prostate-specific antigen (PSA) testing, smoking cessation advice, recommendation to use aspirin to prevent myocardial infarction, or weight-maintenance counseling, when appropriate. Multilevel models assessed associations between physician attitudinal characteristics and a patient's likelihood of being up to date for each service.

RESULTS

Importance of PSA screening and tobacco cessation counseling were weakly associated with patients' receipt of preventive care; no association between attitudes and other services was observed. Factors such as having a visit for well care and use of prevention flowcharts were associated with delivery of preventive services to a greater extent.

CONCLUSIONS

Physicians' attitudes toward prevention are necessary, but not sufficient in ensuring the delivery of preventive services. Future interventions should address visit- and practice-specific factors more closely associated with preventive care.

Use of a computerized guideline for glucose regulation in the intensive care unit improved both guideline adherence and glucose regulation

OBJECTIVE

To measure the impact of a computerized guideline for glucose regulation in an ICU.

DESIGN

A randomized, controlled trial with an off-on-off design.

METHODS

We implemented a glucose regulation guideline in an intensive care unit in paper form during the first study period. During the second period, the guideline was randomly applied in either paper or computerized form. In the third period, the guideline was available only in paper form.

MEASUREMENTS AND RESULTS

We analyzed data for 484 patients. During the intervention period, the control group included 54 patients and the computerized intervention group included 66 patients. The two guideline-related outcome measures consisted of compliance with: (a) glucose measurement timing recommendations and (b) insulin dose advice. We measured clinical impact as the proportion of time that glucose levels fell within target range. In the first (paper-based) study period, 29.0% of samples occurred with optimal timing; during the second period, this increased to 35.5% for paper-based and to 40.2% for computerized protocols. The third study period timeliness scores reverted to the first period rates. Late (suboptimal) sampling occurred for 66% of glucose measurements in the first study period, for 42% of paper-based and 28% of computer-based protocol samples in the second period, and for 50.0% of samples in the third study period. In the first study period, insulin-dosing guideline compliance was 56.3%; in the second period, it was 64.2% for paper-based and 77.3% for computer-based protocols, and it fell to 42.4% in the third period. For the second study period, the time that a patient's glucose values fell within target range improved for both the control (52.9%) and the computerized groups (54.2%) compared with the first study period (44.3%) and the third period (42.3%).

CONCLUSION

Implementing a computerized version of a guideline significantly improved timeliness of measurements and glucose level regulation for critically ill patients compared with implementing a paper-based version of the guideline.

Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction?

BACKGROUND

Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit.

OBJECTIVE

To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction.

DESIGN

Prospective cohort study.

SETTING

VA general medicine clinic.

PATIENTS/PARTICIPANTS

Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit.

MEASUREMENTS AND MAIN RESULTS

Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing "excellent"). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction.

CONCLUSIONS

Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Interventions fail to increase cancer screening rates in community-based primary care practices

BACKGROUND

Cancer screening in primary care offices is reaching only a modest percentage of adults 50 years and older. The objectives of this study were to determine if screening rates for breast, cervical, and colorectal cancer could be significantly increased by two simple office interventions in community-based primary care offices and then maintained over 3 years.

METHODS

Twenty-two community-based primary care practices were divided randomly into four arms: control, practice-based intervention, patient-based intervention, and both interventions combined. At baseline and annually for 3 years, medical records from approximately 100 male and 100 female patients 50 years and older were randomly selected. The outcome measures were screening rates for mammogram, Pap smear, fecal occult blood test, and flexible sigmoidoscopy or other colonic imaging.

RESULTS

Generally each study arm evidenced a significant 1-year increase in screening rates, followed by an overall decline to approximate baseline levels. The first year increases in screening were not related to either invention, alone or in combination.

CONCLUSIONS

These interventions do not have a significant impact on cancer screening rates in adults over several years. A variety of possible variables may have affected the long-term outcomes.

Cancer Prevention Services and Physician Consensus in Primary Care Group Practices

Background: We conducted a randomized clinical trial of interventions to achieve physician consensus, practice changes, and patient activation designed to help primary care group practices enhance the delivery of cancer prevention and screening services. Methods: In each of 42 primary care practices in 1991 to 1994, we studied approximately 60 patients per physician who were between the ages 53 and 64. Data sources included patient and physician questionnaires, medical record audits of consenting patients for evidence of 11 cancer prevention services during the previous 3 years, and telephone interviews with key practice personnel. Results: None of the interventions was associated with significant changes in frequency of services or procedures received or provided. Increased frequencies of services overall and of specific activities were associated with HMO membership or insurance coverage for six screening procedures. Patient reports of clinic staff recommendations to have each of six screening procedures were specifically associated with higher frequencies of services (P = 0.001). Conclusions: Demonstration of intervention impact may have been limited because the rates of prevention services were significantly higher in this study than have been reported elsewhere. These results might be explained by selection biases inherent in studying patients with a regular provider, overall practice trends for changes in provision of the studied services, and the study methods.

Gender Differences in Time Spent during Direct Observation of Doctor-Patient Encounters

BACKGROUND

Despite increasing recognition of women's health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients.

METHODS

As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men.

RESULTS

Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories.

CONCLUSIONS

Outpatient visits by women differ from those of men in ways that reflect women's unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.

Tools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery

BACKGROUND

Most research examining primary care office characteristics and preventive service delivery (PSD) has evaluated preventive service aids and equipment, while generally overlooking the complex interactions among multiple office systems where multiple factors influence the overall practice. We test a theoretical model of practice influences on PSD that accounts for Tools (preventive service aids/equipment), Teamwork (office organization), and Tenacity (prevention delivery attitudes).

METHODS

Office characteristics and 4454 patient visits were observed for 138 family physicians in northeast Ohio. Utilizing U.S. Preventive Services Task Force recommendations, age- and gender-specific PSD summary scores were computed for each patient and then averaged per physician. Multivariate analysis of variance tested office characteristic associations with PSD scores.

RESULTS

Tools were common, but most were not significantly associated with PSD scores. The Teamwork indicators of clear staff role expectations and shared vision among physician and staff existed, respectively, for 80 and 73% of physicians. A high average reported practice focus on prevention existed, despite low staff involvement in PSD (22.2%). Compared with Tools, more Teamwork and Tenacity characteristics were associated with the PSD scores.

CONCLUSION

Teamwork and Tenacity appear to be more important than Tools in delivering preventive services in primary care practices.

Primary care physicians' awareness and implementation of screening guidelines for colorectal cancer

OBJECTIVE

The objective was to determine primary care physicians' (PCPs) familiarity and implementation of screening guidelines for colorectal cancer (CRC) in central Israel.

METHODS

Fifty PCPs were interviewed and 1000 charts of their asymptomatic patients ages 50-70 were examined. All CRC patients treated at the regional Oncology Institute in 1980-1984 and in 1993-1997 were then compared, with emphasis on the event leading to diagnosis and tumor stage.

RESULTS

Almost all PCPs endorsed screening. Fecal occult blood testing (FOBT) was appropriately recommended by 40% (annually), and the use of flexible sigmoidoscopy (FS) was appropriately recommended by 12% of physicians (every 3-5 years). Only four (8%) were correct in the use of both techniques. Most PCPs estimated that >25% of their patients had been screened for CRC. In fact, 92/1,000 had FOBT (9.2%), 14/1,000 had screening FS (1.4%), and 3 patients only had both tests. Only 1.2% of CRC diagnoses in the 1980s (n = 175) and 2.6% in the 1990s (n = 343) were established as a result of screening (P > 0.25, NS). Tumor stage distribution at diagnosis was similar.

CONCLUSIONS

PCPs studied endorse CRC screening but they are not familiar with accepted guidelines and do very little about implementing them, and this has not changed much over the past decade. CRC screening has a potential to markedly decrease mortality, yet the best screening strategy is worthless without physician education and compliance.

Adherence to screening guidelines for breast and cervical cancer in postmenopausal women with coronary heart disease: an ancillary study of volunteers for hers

Postmenopausal women with coronary heart disease (CHD) who volunteered for the Heart and Estrogen/Progestin Replacement Study (HERS) randomized clinical trial had high rates of gynecological abnormalities. We examined compliance with gynecological cancer screening and factors affecting this behavior. Women who met inclusion criteria for HERS and were seen for screening by the study gynecologist were considered eligible for this study. Data were abstracted from study records, and additional information was obtained by telephone questionnaire. Adherence to mammography, breast examination, pelvic examination, and Pap smear recommendations was assessed. Provider behavior and its effect on compliance were assessed. Compliance rates were 59.1% for monthly breast self-examination (BSE), 67.2% for yearly mammography, 73% for yearly Pap smear and pelvic examination, and 75.7% for provider breast examination. Over 50% of patients had most of their screening tests done within the last year. Provider behavior was significantly related to patient screening compliance for mammography, breast examination, Pap smear, and pelvic examination. Provider gender was not significantly related to adherence. There were no significant differences in compliance rates based on the type of most recent coronary event. Compliance rates did not differ significantly between patients with and without gynecological abnormalities, except for mammography (78.3% versus 48.3%, p = 0.02). The majority of patients were compliant with gynecological screening. Among patients with gynecological abnormalities, mammography compliance was significantly lower. Provider behavior was an important factor in influencing women to obtain preventive screening. There were no significant differences in compliance based on provider gender or type of coronary event preceding HERS enrollment.

Measuring compliance with preventive care guidelines: standardized patients, clinical vignettes, and the medical record

OBJECTIVE

To determine how accurately preventive care reported in the medical record reflects actual physician practice or competence.

DESIGN

Scoring criteria based on national guidelines were developed for 7 separate items of preventive care. The preventive care provided by randomly selected physicians was measured prospectively for each of the 7 items. Three measurement methods were used for comparison: (1) the abstracted medical record from a standardized patient (SP) visit; (2) explicit reports of physician practice during those visits from the SPs, who were actors trained to present undetected as patients; and (3) physician responses to written case scenarios (vignettes) identical to the SP presentations.

SETTING

The general medicine primary care clinics of two university-afflliated VA medical centers.

PARTICIPANTS

Twenty randomly selected physicians (10 at each site) from among eligible second- and third-year general internal medicine residents and attending physicians.

MEASUREMENTS AND MAIN RESULTS

Physicians saw 160 SPs (8 cases x 20 physicians). We calculated the percentage of visits in which each prevention item was recorded in the chart, determined the marginal percentage improvement of SP checklists and vignettes over chart abstraction alone, and compared the three methods using an analysis-of-variance model. We found that chart abstraction underestimated overall prevention compliance by 16% (P < .01) compared with SP checklists. Chart abstraction scores were lower than SP checklists for all seven items and lower than vignettes for four items. The marginal percentage improvement of SP checklists and vignettes to performance as measured by chart abstraction was significant for all seven prevention items and raised the overall prevention scores from 46% to 72% (P < .0001).

CONCLUSIONS

These data indicate that physicians perform more preventive care than they report in the medical record. Thus, benchmarks of preventive care by individual physicians and institutions that rely solely on the medical record may be misleading, at best.

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

OBJECTIVES

Although nurse practitioners and physician assistants form a large and growing portion of the primary care workforce, little is known about their colorectal cancer screening practices. The aim of this study was to assess the colorectal cancer screening practices, training, and attitudes of nurse practitioners and physician assistants practicing primary care medicine.

METHODS

All nurse practitioners (827) and physician assistants (1178) licensed by the Medical Board of the State of North Carolina were surveyed by mail. Both groups were further divided into primary care versus non-primary care by self-described roles. Self-reported practices, training, and attitudes with respect to colorectal cancer screening were elicited.

RESULTS

Response rates were 71.4% and 61.2%, for nurse practitioners and physician assistants respectively. A total of 51.3% of nurse practitioners and 50.3% of physician assistants described themselves as adult primary care providers. No primary care nurse practitioners and only 3.8% of primary care physician assistants performed screening flexible sigmoidoscopy. However, 76% of primary care physician assistants and 69% of primary care nurse practitioners reported recommending screening flexible sigmoidoscopy. A total of 95% primary care physician assistants and 92% of primary care nurse practitioners reported performing fecal occult blood testing. Only 9.4% of physician assistants and 2.8% of nurse practitioners received any formal instruction in flexible sigmoidoscopy while in their training. Additionally, 41.4% of primary care physician assistants and 27.7% of primary care nurse practitioners reported that they would be interested in obtaining formal training in flexible sigmoidoscopy.

CONCLUSIONS

Physician assistants and nurse practitioners are motivated, willing and underutilized groups with respect to CRC screening. Efforts to increase education and training of these professionals may improve the availability of CRC screening modalities.

Put prevention into practice: a controlled evaluation

OBJECTIVES

The purpose of this study was to evaluate whether Put Prevention Into Practice (PPIP) materials affected the delivery of 8 clinical preventive services.

METHODS

Program materials were provided to a family medicine practice serving a diverse, low-income population. Appropriate use of clinical preventive services was assessed via medical record reviews at baseline, 6 months, 18 months, and 30 months at both intervention and control sites.

RESULTS

The delivery rates of 7 clinical preventive services were higher in the intervention site at 6 months. These rates had flattened or decreased by 30 months.

CONCLUSIONS

Use of PPIP materials modestly improved delivery of certain clinical preventive services. Sustained improvement will require substantial system changes and ongoing support.

Principles of screening

Preventive medicine is an increasingly important area of clinical practice. Conceptually, preventive medicine involves three tasks of the clinician: screening, counseling, and immunization/prophylaxis. This opening article reviews some of the basic tenets underlying screening including basic epidemiologic principles, characteristics of a good screening situation, barriers to screening, and some of the potential hazards of screening.

The effects of information framing on the practices of physicians

OBJECTIVE

The presentation format of clinical trial results, or the "frame," may influence perceptions about the worth of a treatment. The extent and consistency of that influence are unclear. We undertook a systematic review of the published literature on the effects of information framing on the practices of physicians.

DESIGN

Relevant articles were retrieved using bibliographic and electronic searches. Information was extracted from each in relation to study design, frame type, parameter assessed, assessment scale, clinical setting, intervention, results, and factors modifying the frame effect.

MAIN RESULTS

Twelve articles reported randomized trials investigating the effect of framing on doctors' opinions or intended practices. Methodological shortcomings were numerous. Seven papers investigated the effect of presenting clinical trial results in terms of relative risk reduction, or absolute risk reductions or the number needing to be treated; gain/loss (positive/negative) terms were used in four papers; verbal/numeric terms in one. In simple clinical scenarios, results expressed in relative risk reduction or gain terms were viewed most positively by doctors. Factors that reduced the impact of framing included the risk of causing harm, preexisting prejudices about treatments, the type of decision, the therapeutic yield, clinical experience, and costs. No study investigated the effect of framing on actual clinical practice.

CONCLUSIONS

While a framing effect may exist, particularly when results are presented in terms of proportional or absolute measures of gain or loss, it appears highly susceptible to modification, and even neutralization, by other factors that influence doctors' decision making. Its effects on actual clinical practice are unknown.

Variation in recommendations for cancer screening among primary care physicians in New Mexico

The acceptance of age-appropriate cancer screening as an integral part of primary care has grown among physicians over the past decade. We conducted a mailed survey of all primary care physicians in New Mexico in order to better understand their current cancer screening practices. We found a high rate of self-reported screening, particularly for prostate and colorectal cancer. The screening rates were influenced only slightly by the introduction of evidence-based guidelines, with younger physicians and those with university affiliations more likely to follow recommendations. Female physicians and obstetrician-gynecologists endorsed breast and cervical cancer screening among all age groups and were less likely to follow recommendations for less frequent screening in women as they age. Since a physician's practice beliefs influence his/her attitude toward testing, tailoring education by physician specialty may be more effective than using generic messages in encouraging compliance with the most recent evidence-based guidelines.

Barriers and facilitators to providing common preventive screening services in managed care settings

Despite increasing emphasis on disease prevention and health promotion, and ample evidence demonstrating the effectiveness of preventive services, such services are underutilized in the United States. The current trend of health care toward health maintenance organizations and other managed care systems opens the door, perhaps to more effective control of heart disease, cancers and other chronic diseases through preventive care. This warrants attention to the barriers/facilitators to the provision/utilization of preventive screening services in such settings. Overall goal of this study was to assess barriers/facilitators to the provision/utilization of preventive services in managed care organizations (MCOs). This was accomplished by a) identifying barriers/facilitators to the provision/utilization of three common preventive screening services (cholesterol screenings, mammograms, and Pap smears); and b) profiling typical MCO recipients of these three preventive screening services. A self-administered, mail questionnaire was used to obtain information from a national sample of 1,200 Directors of MCOs associated with preventive care. A total of 175 usable responses were received resulting in a 17.3 percent net response rate. The strongest barrier to the provision of all three screening services is the inability of them to generate short term savings for the MCO. Other barriers include high disenrollment rates, conflicting recommendations about effectiveness (for mammograms and cholesterol screenings), and patients' fears of getting a positive result (for mammograms and Pap smears). The improved health status as a result of early intervention, high consumer awareness (for mammograms and Pap smears), and long term savings are important facilitators to the provision/utilization of these screening services. Comparing barriers and facilitators across the three services shows the stronger barriers affecting the provision/utilization of mammograms. For all three screening services, typical managed care recipients are those in the high income groups with greater education levels. However, with the increasing enrollment of Medicaid beneficiaries into managed care, MCOs may find themselves selectively targeting these high risk low income and less educated individuals to receive the preventive screening services. Study findings should be useful to health planners, policymakers and researchers at all levels in their efforts to encourage and promote healthier lifestyle choices among U.S. residents. Future studies should address receipt of preventive services by Medicaid and Medicare beneficiaries in managed care settings.

CaDet, a computer-based clinical decision support system for early cancer detection

Cancer risk evaluation and early detection are subject to serious limitations mainly related to human factors and to characteristics of the data involved. To help overcome these problems, a computer-based system was designed to provide the physician with a clearer clinical picture and aid in directing patients to appropriate measures. Clinical and epidemiological data related to early cancer detection and to cancer risk factors was collected from the literature and incorporated in a database, together with heuristic rules for evaluating this data. Individual data obtained from patients through a questionnaire are input into CaDet, a computerized clinical decision support system. A report summarizing patient data and cancer hypotheses, with a scoring system that reflects degrees of alarm, is generated. The CaDet system, as well as some preliminary results of the clinical experience accumulated in its use, are described. These preliminary results suggest that the approach may be useful in improving cancer risk assessment and screening in primary care setups.

How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits

OBJECTIVES

This study was designed to determine the optimal nonobservational method of measuring the delivery of outpatient medical services.

METHODS

As part of a multimethod study of the content of primary care practice, research nurses directly observed consecutive patient visits to 138 practicing family physicians. Data on services delivered were collected using a direct observation checklist, medical record review, and patient exit questionnaires. For each medical service, the sensitivity, specificity, and Kappa statistic were calculated for medical record review and patient exit questionnaires compared with direct observation. Interrater reliability among eight research nurses was calculated using the Kappa statistic for a separate sample of videotaped visits and medical records.

RESULTS

Visits by 4,454 patients were observed. Exit questionnaires were returned by 74% of patients. Research nurse interrater reliabilities were generally high. The specificity of both the medical record and the patient exit questionnaire was high for most services. The sensitivity of the medical record was low for measuring health habit counseling and moderate for physical examination, laboratory testing, and immunization. The patient exit questionnaire showed moderate to high sensitivity for health habit counseling and immunization and variable sensitivity for physical examination and laboratory services.

CONCLUSIONS

The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.

Screening for hypercholesterolaemia in primary care: randomised controlled trial of postal questionnaire appraising risk of coronary heart disease

OBJECTIVES

To validate a self administered postal questionnaire appraising risk of coronary heart disease. To determine whether use of this questionnaire increased the percentage of people at high risk of coronary heart disease and decreased the percentage of people at low risk who had their cholesterol concentration measured.

DESIGN

Validation was by review of medical records and clinical assessment. The questionnaire appraising risk of coronary heart disease encouraged those meeting criteria for cholesterol measurement to have a cholesterol test and was tested in a randomised controlled trial. The intervention group was sent the risk appraisal questionnaire with a health questionnaire that determined risk of coronary heart disease without identifying the risk factors as related to coronary heart disease; the control group was sent the health questionnaire alone.

SETTING

One capitation funded primary care practice in Canada with an enrolled patient population of about 12 000.

SUBJECTS

Random sample of 100 participants in the intervention and control groups were included in the validation exercise. 5686 contactable patients aged 20 to 69 years who on the basis of practice records had not had a cholesterol test performed during the preceding 5 years were included in the randomised controlled trial. 2837 were in the intervention group and 2849 were in the control group.

MAIN OUTCOME MEASURES

Sensitivity and specificity of assessment of risk of coronary heart disease with risk appraisal questionnaire. Rate of cholesterol testing during three months of follow up.

RESULTS

Sensitivity of questionnaire appraising coronary risk was 87.5% (95% confidence interval 73.2% to 95.8%) and specificity 91.7% (81.6% to 97.2%). Of the patients without pre-existing coronary heart disease who met predefined screening criteria based on risk, 45 out of 421 in the intervention group (10.7%) and 9 out of 504 in the control group (1.8%) had a cholesterol test performed during follow up (P<0.0001). Of the patients without a history of coronary heart disease who did not meet criteria for cholesterol testing, 30 out of 1128 in the intervention group (2.7%) and 18 out of 1099 in the control group (1.6%) had a cholesterol test (P=0.175). Of the patients with pre-existing coronary heart disease, 1 out of 15 in the intervention group (6.7%) and 1 out of 23 in the control group (4.3%) were tested during follow up (P=0.851, one tailed Fisher's exact test).

CONCLUSIONS

Although the questionnaire appraising coronary risk increased the percentage of people at high risk who obtained cholesterol testing, the effect was small. Most patients at risk who received the questionnaire did not respond by having a test.

Primary care physicians and coronary heart disease prevention: a practice model

Primary care physicians have an important role in coronary heart disease prevention. This paper discusses the results of a qualitative study conducted with Nova Scotian physicians to explore the following: physicians' expectations about their role in prevention; obstacles to providing preventive care; and, mechanisms by which preventive care occurs. The second part of the paper presents a practice model which is intended as a framework by which physicians may more effectively educate and counsel their patients about health issues, such as coronary heart disease.

Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care

A considerable body of knowledge noe exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of "competing demands" derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated "domains," representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of "face validity" for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.

HIV risk screening in the primary care setting. Assessment of physicians skills

OBJECTIVE

To assess the content and extent of HIV risk assessment by primary care physicians across a diverse panel of patients with unidentified HIV risk behaviors.

DESIGN

Standardized patient examination to assess primary care physicians' skills at identifying and managing HIV infection and overall clinical skills. In a day of testing, physicians saw 13-16 standardized patients (SPs) with diverse case presentations. In analyses presented here, physician performance was examined with nine SPs who had unidentified risks for HIV, which they offered if asked.

SETTING

An academic clinic.

PARTICIPANTS

We randomly selected 134 paid volunteers (general internists and family/general practitioners) after stratifying by specialty, experience caring for patients with HIV infection, and year of medical school graduation.

MEASUREMENTS AND MAIN RESULTS

Performance at initiating HIV risk screening and identifying patients' HIV risk behaviors were the main outcome measures. Physicians performed variably at HIV risk screening with different patients and across different HIV risk screening topics. Although physicians initiated screening with 60% of patients, they identified only 49% of risk behaviors and included HIV in the differential diagnosis for less than half of at-risk patients. Physicians performed better with cases in which there was a higher probability of HIV infection based on symptoms, but often did not screen at-risk patients without obvious symptoms suggestive of HIV. Board-certified general internists initiated screening and identified risk behaviors with more patients than board-certified family practitioners. Medical school graduation year also influenced performance.

CONCLUSIONS

Our data suggest that primary care physicians do not routinely perform HIV risk assessments with patients who have risk behaviors for HIV infection. Methods are needed to develop, standardize, and disseminate better screening techniques to identify patients with or at risk of developing HIV infection, such as written HIV risk screening questions for use in medical intake forms.

Physician preventive care philosophy and the five year durability of a preventive services office system

A group of 30 community physicians who practiced in northeastern United States and who participated in the Cancer Prevention in Community Practice project in 1988 were interviewed five years later. The aim of the interviews was to assess the long-term impact of the preventive services office system which had been introduced by the project. The qualitative analysis of interviews revealed three distinct physician philosophies about the provision of preventive services: a Request Only focus, responding to specific patient inquiries about prevention but taking no initiative to recommend indicated services; a Health Maintenance Visit focus, providing indicated services only during visits specifically scheduled for preventive care; and an Opportunistic Prevention focus, providing indicated preventive services at every chance. Physicians demonstrated these philosophies in their overall view of disease prevention, perceived obstacles to delivery of preventive care, as well as in their continued use of flow sheets and their impression of the value of the Cancer Prevention in Community Practice project. The long-term impact of the office system was the most apparent in the Opportunistic Prevention group. We conclude that the durability of a preventive services office system is influenced by a physician's preventive care philosophy.

Quality improvement among primary care practitioners: an overall appraisal of results of the Ambulatory Care Medical Audit Demonstration Project

OBJECTIVES

The authors appraised the overall conclusions of a randomized, controlled trial of quality assurance in 16 primary care group practices, addressing the relevance of findings to health maintenance organizations in the 1990s.

METHODS

The framework was the analogy of opening the "black box" of quality assurance interventions to examine circumstances in which interventions worked.

RESULTS

External pressures for quality improvement were weak during the study and knowledge of continuous quality improvement principles lacking. Correspondingly, within study practices, pre-existing mechanisms lacked the rigorous data-driven approach and system focus of the quality assurance cycles conducted. Additional barriers to demonstrating an effect of quality assurance included pre-existing good performance, high variability in performance measurements, and lack of time within the study for radical re-design of systems. Improvement in performance for one guideline was impeded by change of practice recommendations during the study. Nevertheless, clinically and statistically significant improvements in quality were obtained in five of the seven remaining guidelines, with effects peaking after feedback of performance results. A sixth guideline showed improvement in practices in which the physician leader influenced colleagues to improve. The seventh guideline showed improvement that did not reach statistical significance, in part because of lack of statistical power.

CONCLUSIONS

This study demonstrated the effectiveness of cycles of quality measurement and improvement. The findings provide guidance for health-care practitioners and managers of the 1990s, for whom quality measurement and improvement has become a priority.

The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations

OBJECTIVES

This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times.

METHODS

Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states.

RESULTS

The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations.

CONCLUSIONS

These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.

Most nephrologists are primary care providers for chronic dialysis patients: results of a national survey

The medical care of end-stage renal disease (ESRD) patients includes not only dialysis-related medical care but preventive and general medical care as well as the care of minor acute illnesses. There is little information about nephrologists' interpretation of their potential role as a primary health care provider for the general medical needs of chronic dialysis patients. To characterize nephrologists' primary care practice patterns related to the care of chronic dialysis patients, we surveyed a randomly selected group of practicing nephrologists and asked questions about preventive medicine guidelines followed, treatment of minor acute illnesses, and management of chronic medical problems in ESRD patients. The results of 233 questionnaires (46% response rate) were analyzed. Most of the responding nephrologists were men (91%), were board certified in internal medicine (96%) and nephrology (83%), were out of nephrology practice for a mean of 16 years, had a mean age of 48 +/- 7 years, and were in private practice (65%). The average percentage of time spent with chronic dialysis patients was reported as 30%; 38% of that time was devoted to the general medical care of those patients. Ninety percent of nephrologists reported that they provided primary care to their dialysis patients, and only 21% said a nurse practitioner or physician assistant worked with them. Age and number of years in practice were the only demographic factors increasing the likelihood of nephrologist-provided primary care, with older, more experienced practitioners more likely to be providing primary care to dialysis patients. Most nephrologists reported that they managed minor acute illnesses and comorbid conditions (diabetes mellitus, cardiac disease, and gastrointestinal disease) in their dialysis patients. Nephrology fellowship training programs and recertification programs may need to address issues of primary general health care of ESRD patients. Plans under development for health care programs and reimbursement criteria also need to recognize and consider the primary medical care role practiced by nephrologists caring for ESRD patients.

Longitudinal in-shoe foot pressure relief achieved by specially designed footwear in high risk diabetic patients

Specially designed Thor-Lo footwear has been shown to reduce the in-shoe foot pressures in diabetic patients at risk of foot ulceration when compared to their own footwear. Fifty at high risk patients 32 (64%) males, 17 (34%) type 1 diabetes) have been provided with this foot wear and have been followed up for 6 months. Mean age was 57.6 (range, 34-78) years, duration of diabetes 22.4 (range, 4-50) years, Neuropathy Symptom Score 3.36 +/- 2.96 (mean +/- S.D.), Neuropathy Disability Score 16.8 +/- 6.83, VPT 43.4 +/- 11.8 Volts while 43 (86%) could not feel a 5.07 or smaller Semmes-Weinstein monofilament. Forty-two (84%) patients were re-examined at an interim visit 3 months after baseline, while 37 (74%) completed the study. In-shoe peak forces and pressures were measured using the F-Scan system. No difference was found among the peak force among baseline (95.5 +/- 26 kg), interim (96.5 +/- 33) and final visit (97.7 +/- 25.2, P + NS). There was no difference in peak pressures at the baseline (3.98 +/- 1.42 kg.cm-2), second visit (4.13 +/- 2.30) and the final visit (4.25 +/- 1.51). Nine (18%) patients developed foot problems and one died during the study. We conclude that no changes in foot pressures were found over a period of 6 months of continuous usage of the specially designed footwear in a group of diabetic patients at risk of foot ulceration. Further prospective studies are required to evaluate the impact of specially designed footwear in reducing the rate of foot ulceration.

Barriers to cancer screening

Many barriers to cancer screening have been summarized and discussed. Barriers have been documented in all patient populations, but some groups such as ethnic minorities and the elderly face unique barriers. The barriers to cancer screening, are multifactorial, but much of the responsibility for change must lie with health care providers and the health care delivery industry. This is not to free the patient of all responsibility, but some significant barriers are beyond their direct control. Take, for example, socioeconomic status, disease knowledge, and culturally related perceptions and myths about cancer detection and treatment. The health care industry must do a better job identifying and overcoming these barriers. The significant effects of provider counseling and advice must not be underestimated. Patients must first be advised, and then further actions must be taken if they reject the screening advice. Did they refuse adherence to recommendations because they do not view themselves as susceptible, because of overwhelming personal barriers, or because of a fatalistic attitude toward cancer detection and treatment? If that is the case, physicians and health care institutions must attempt to change perceptions, educate, and personalize the message so that patients accept their disease susceptibility [table: see text]. Multiple patient and provider risk factors have been identified that can be used to target patients particularly at high risk for inadequate cancer screening and providers at high risk for performing inadequate screening. Research has clearly demonstrated the effectiveness of interventions to improve tracking of patient and physician compliance with screening recommendations. Further research is needed to show the impact of managed-care penetration and payer status on screening efforts, and incentive schemes need to be tested that reward institutions and third-party payers who develop uniform standards and procedures for cancer screening. The greatest responsibility lies with medical and health care institutions and those who determine the priorities of these institutions. Patient and physician barriers to mass cancer screening can be addressed by institutional support. If the quality of care delivered by providers, group practices, managed-care organizations, and HMOs is assessed with priority given to the regularity and consistency with which basic screening procedures are performed, cancer screening will undoubtedly receive greater attention in the clinic. Medical institutions must collaborate to develop standards for cancer screening with attention to the cost-effectiveness of various screening techniques to determine how limited resources can best be spent in cancer control. Such efforts should keep in mind "that a very small change implemented over a broad population may have a greater effect in absolute numbers than a large level of change applied in a small segment of the population."

Breast cancer screening and compliance and evaluation of lesions

It appears that screening mammography certainly is of value in women over age 50, and although controversy exists regarding screening of women under 50 years of age for breast cancer, the authors believe that this strategy is the most reasonable one for women 40 to 64 years of age at this time. Additionally, it is important for physicians to remember to encourage their patients to undergo cancer screening evaluation. Encouragement by physicians is an important factor in increasing cancer screening rates.

Principles of cancer screening

Screening for cancer is an important aspect of cancer prevention and treatment. The science of screening is based on epidemiologic principles that are central to understanding the potential risks and benefits of a screening program. Screening is best applied to those conditions that are relatively common and have an important impact on quality of life and for which acceptable tests and treatments are available and affordable.

Bridges between health care research evidence and clinical practice

Research is producing increasing amounts of important new evidence for health care, but there is a large gap between what this evidence shows can be done and the care that most patients actually receive. An important reason for this gap is the extensive processing that evidence requires before application. This article discusses a three-step model for bridging research evidence to management of clinical problems: getting the evidence straight, formulating evidence-based clinical policies, and applying evidence-based clinical policies at the right place and time. This model is purposely broad in scope and provides a framework for coordinating efforts to support evidence-based medical care. The authors' purpose is to represent the roles of health informatics in the context of the roles of all the key players, including health care researchers and practitioners, health care organizations, and the public. Health informatics has already made important contributions to bridging evidence to practice, including improving evidence retrieval, evaluation, and synthesis; new evidence-based information products; and computerized aids for facilitating the use of these products during clinical decision making. However, much more innovation and coordination are needed. The authors call for health informaticians to pay balanced attention to 1) the quality of evidence embodied in information innovations, 2) the performance of technologies and systems that retrieve, prepare, disseminate, and apply evidence, and 3) the fit of information tools to the specific clinical circumstances in which evidence is to be applied. Effective interdisciplinary teams that include health services researchers and other evidence experts, clinical practitioners, informaticians, and health care managers are needed to achieve success. Informaticians can make increasingly important contributions to the transfer of health care research by joining such teams.

Radiotherapy planning for lung cancer: can we do better?

Modern radiotherapy planning and treatment techniques allow the delivery of treatment with considerable geographic and dosimetric precision. Uncertainties and variability in the radiotherapy process prior to this stage, that is, localization of the target volume, has received little systematic study. The results of a planning study in non-small cell carcinoma of the lung are presented to highlight the possible variability in the planning process, both at an inter-clinician and intra-clinician level. The implications of this survey, both in terms of treatment outcome and training issues, are discussed.

Factors associated with the use of screening mammography in a primary care setting

Despite consensus recommendations the use of screening mammography remains low. We examined physician and patient related variables associated with requests to undergo screening mammography in a primary care setting, in order to assess current barriers to screening mammography at the level of the physician-patient interaction. A sample of 261 women over the age of 50, whose primary care was provided by resident physicians in a large, urban, academic medical center were examined. Data concerning patients and physicians demographic and clinical characteristics were abstracted. The data were analyzed by Chi-square and stepwise logistic regression. Forty-five percent of the patients were offered screening mammography within the study year and 53% were offered mammography over the preceding two years. Variables significantly associated with a request for screening included a previous history of breast disease (p < .001) and the severity of the patient's overall medical condition. Patients with an overall medical condition rated as mild were more likely to be requested to undergo screening than patients rated as moderately or severely ill (p < .01). Patients with higher educational levels were also more likely to be offered screening (P = .06). First year postgraduate (PGY 1) physicians requested more mammograms than PGY 2 or PGY 3 physicians (P < .05). A multivariable model utilizing logistic regression confirmed the association of the significant variables above with screening requests. Physicians were more likely to request mammography in patients at higher risk for developing breast cancer and less likely to request it in patients who had co-morbid illness. Increasing physician understanding of the importance and benefits of mammography and further investigation of strategies to ensure physician compliance with mammography recommendations are necessary to increase utilization.

Put prevention into practice: implementing preventive care. U.S. Department of Health and Human Services

Delivery rates for many preventive services are low in the U.S., often falling below 50%. Many factors contribute to this shortcoming, a number of which are within the control of the practicing clinician. This section discusses two important aspects of the delivery of clinical preventive services--establishing a preventive care protocol and implementing it in practice--and reviews basic principles of screening, immunization, and counseling. The references serve as a basic bibliography on the implementation of preventive services in primary care settings.

The potential of computers in patient education

Typical computer programs for patient education are didactic and fail to tailor information to an individual's specific needs. New technology greatly enhances the potential of computers in patient education. Computer-assisted instruction programs can now elicit information from users before leading them through problem-solving exercises. New authoring systems enable health professionals to develop their own programs. The capacity to elicit and report back information about factors that influence patients' health behaviors give the newest computer programs one of the strengths of face-to-face patient counseling: the ability to tailor an educational message for an individual patient. These programs are not intended to replace but rather to enhance personal interaction between providers and patients. This article describes the advantages of using computers for individualizing patient education and assessing trends across groups of patients. Innovative programs and features to look for in programs and equipment selection are also described.

Cervical cancer screening in hospitals: the efficacy of legislation in Maryland

OBJECTIVES

The purpose of the study was to examine the efficacy of a Maryland law requiring Pap testing to be offered during hospital admissions. "In-reach" strategies emphasize cancer screening within existing health care contacts (such as inpatient stays) rather than additional visits solely for screening.

METHODS

Data from a 1986 telephone survey of Maryland women were used to examine the effect of hospitalization on self-reported Pap testing in a 3-year period. The effect of hospitalization on screening was examined by age and income to assess whether inpatient screening was more prevalent among certain subgroups of women.

RESULTS

For the group as a whole, the odds of Pap screening did not vary with hospitalization. However, among women aged 45 to 54 years with annual household incomes over $20,000, hospitalized women were more likely than nonhospitalized women to report recent Pap tests. For low-income women aged 75 years and older, hospitalization actually decreased the likelihood of reporting Pap tests.

CONCLUSIONS

Despite legislation, inpatient cervical cancer screening appears to mirror outpatient patterns, leaving elderly and low-income women unscreened. Methods for increasing inpatient Pap testing for underscreened women are discussed.

Promoting preventive care with patient-held minirecords: a review

Although patient involvement is essential for the success of all types of preventive care, patient involvement in clinical prevention has been limited. Patient-held minirecords have recently received support from public health authorities, providers and the public as a means to improve patient involvement in preventive care for adults. This paper reviews the history and current developments in patient-held minirecord use for preventive care.

METHODS

A literature review was performed using sources obtained from electronically searching the Medline database from 1966 to the present and using reference lists to obtain secondary sources. The author's collection of privately and governmentally produced minirecords was also utilized.

FINDINGS

Patient-held minirecords have been widely and successfully employed to improve preventive care for children, particularly with regard to immunizations. They have not been widely used to promote adult preventive care. Several clinical trials have found that their use can lead to improved preventive care for the general adult population. Potential advantages of patient-held minirecords include: improved performance rates of preventive care, improved continuity of preventive care, low cost and improved practice promotion for prevention-oriented providers. Potential barriers to the use of patient-held minirecords include: the traditional power relationship of physicians and patients, physicians' reticence to share records with patients and time and effort costs. The optimal characteristics of a patient-held minirecord for adult preventive care remain to be delineated by research and evaluation.

SIGNIFICANCE

A patient-held minirecord is an inexpensive, practical intervention that can help build patient involvement and improve the quality of preventive care for adults as well as children.