Controlling antibiotic resistance: will we someday see limited prescribing autonomy?
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Anti-Bacterial Agents↗
Biomedical subjects
A G Mainous
Publications and source records attributed to A G Mainous.
Do rural and urban children have comparable asthma care utilization?
This study compares asthma-related health care visits and drug therapy for rural and nonrural Kentucky children with Medicaid health insurance in 1995. The 8,634 children with asthma had a mean age of 5.7 years. Ninety-two percent made at least one asthma office visit, and 13 percent were hospitalized. The urban and rural patterns of care for childhood asthma varied in some potentially important ways. Urban children were twice as likely as rural children to see an asthma specialist (5 percent vs. 2.5 percent, P < 0.05), 2.7 times as likely to receive asthma care in an emergency department (19 percent vs. 7 percent, P < 0.01) and 1.4 times as likely to receive oral steroids (16 percent vs. 12 percent, P = 0.04). If given inhaled anti-inflammatory medication, rural children were more likely to receive inhaled steroids while urban children were more likely to receive cromoglycates.
Adolescent↗
The relationship between attendance at religious services and cardiovascular inflammatory markers.
OBJECTIVE: Previous studies have shown an association between attendance at religious services and health, particularly cardiovascular morbidity and mortality. Little research has focused on religious attendance and physiological markers of cardiovascular risk. The purpose of this study was to explore the relationship between religious attendance and inflammatory markers of cardiovascular risk. METHOD: Nationally representative sample of non-institutionalized United States adults aged 40 and over derived from the National Health and Nutrition Examination Survey III 1988-1994 (n = 10,059). The main outcome measures were the inflammatory system markers C-reactive protein, fibrinogen, and white blood cell count. RESULTS: 40.8 percent of the population attended religious services 40 or more times in the previous year while 22.4 percent attended services less than 40 times and 36.8 percent attended no religious services at all. Non-attenders of religious services were more likely than attenders to have elevated white blood cell counts (p = .001), highly elevated C-reactive protein (p = .02), and elevated fibrinogen (p = .05). After adjusting for demographic variables, health status, and BMI, the association between religious attendance and cardiovascular markers remained. Once current smoking was added to the model the independent effect of religious attendance dropped below conventional confidence limits. CONCLUSIONS: These findings suggest that people who have attended religious services in the previous year are less likely to have elevated levels of certain inflammatory markers, however, current smoking has significant shared variance with religious attendance.
Adult↗
Continuity of care and trust in one's physician: evidence from primary care in the United States and the United Kingdom.
BACKGROUND AND OBJECTIVES: Patients' trust in their physician to act in their best interest contributes to the effectiveness of medical care and may be related to the structure of the health care system. This study explored the relationship between continuity of care and trust in one's physician, particularly in terms of differences between the United States and the United Kingdom (UK). METHODS: We conducted a cross-sectional survey of adult patients (n = 418 in the United States and n = 650 in the UK) who presented in outpatient primary care settings in the United States (Charleston, SC, and Lexington, Ky) and in the UK (Leicester and Exeter). RESULTS: A high percentage of both groups of patients reported having a usual place of care and doctor. A total of 69.8% of UK patients and 8.0% of US patients have had their regular physician for > or = 6 years. US patients (92.4%) are more likely than UK patients (70.8%) to value continuity with a doctor. Both groups had high levels of trust in their regular doctor. Trust was related to one continuity measure (length of time for the relationship) but not to another (usual provider continuity index more than 1 year). In a multivariate model, country of residence had no independent relationship with trust, but continuity of care was significantly related. CONCLUSIONS: Higher continuity is associated with a higher level of trust between a patient and a physician. Efforts to improve the relationship between patients and physicians may improve the quality and outcomes of care.
Adult↗
The lack of screening for diabetic nephropathy: evidence from a privately insured population.
BACKGROUND: We examined the performance of screening tests for diabetic nephropathy in a population of privately insured individuals. METHODS: Administrative data from a large private health plan were analyzed. Continuously insured persons with diabetes (ages 30-62) with > or = one office visit during the study year (July 1995 to June 1996) were included (n = 4,758). Outcome variables included a urinalysis for protein and a test for microalbuminuria. The likelihood of test performance according to age, gender, insurance plan type, total office visits, diabetes office visits, and specialty of predominant physician was examined both in bivariate analyses and a logistic regression. RESULTS: Among the 4,623 patients without evidence of nephropathy, only 16.5% had a urinalysis test conducted sometime in the year. All individuals (2.1% of sample) who received a microalbuminuria test also received a urinalysis. Individuals with indemnity or PPO plans were more likely to be screened than individuals in point-of-service plans. Patients with more visits and more diabetes visits were more likely to be screened. In the regression with family practice as the reference category, general internists were the only physician specialty more likely to have screened patients. CONCLUSIONS: The majority of patients with diabetes mellitus do not receive annual screening for microalbuminuria or urinary protein.
Adult↗
Family medicine faculty development fellowships and the medically underserved.
OBJECTIVE: This study measured the prevalence of service in federally designated medically underserved communities (FD-MUC) by Title VII-funded, full-time faculty development fellowship alumni. METHODS: A two-stage survey of alumni of full-time, family medicine faculty development fellowships was completed. Alumni were dichotomized as serving in an FD-MUC or not. RESULTS: Of the 105 fellowship alumni identified, 81% (n = 85) responded; 42% (n = 36) were serving in an FD-MUC. Of alumni serving in an FD-MUC, the mean full-time equivalent service time was 73%. Of the demographic variables measured, only race was significantly associated with FD-MUC service, and minorities were more likely to practice in an FD-MUC. Respondents serving in FD-MUCs were more satisfied with their relationships with nonphysician health professionals, salary and income, and their role in making organizational and administrative decisions than those not serving in FD-MUCs. CONCLUSIONS: Title VII has the broad policy objective of increasing access to medical care by improving the supply and distribution of physicians and recruitment of minority health professionals. Alumni of faculty development programs have a high service rate in FD-MUCs, and minority alumni are significantly more likely to practice in these sites.
Adult↗
The financial status of departments of family medicine at US medical schools.
BACKGROUND: This report examined the financial health of departments of family medicine in US allopathic medical schools. METHODS: We conducted a survey of departments of family medicine at US medical schools, using academic year 1997-1998 as the index year. A total of 52 (46%) of medical schools that have a department of family medicine responded to the survey. The survey examined sources of revenue and categories of expenditures. Analysis assessed the overall financial status of departments at that period of time. RESULTS: Responding departments of family medicine received 32% of their funding from state or university sources and an additional 32% of funding from clinical services. Grants and hospital support comprised another 17% each. Departments in public institutions received higher levels of support from hospitals (22% of revenue versus 8% for private schools). The overall balance sheets for departments of family medicine showed that 56% of departments have financial reserves, while 19% had no reserves but no debt. Twenty-five percent of all departments were in debt, including 2% with debt exceeding $1 million. CONCLUSIONS: The majority of departments of family medicine remain fiscally healthy, but these departments are dependent on funds from state and medical school sources. A substantial proportion of departments are in debt. Lower levels of grant support and the difficulty in increasing clinical revenue may create future funding problems for primary care faculty as medical schools increase dependence on these sources of income.
Family Practice↗
Female and underrepresented minority faculty in academic departments of family medicine: are women and minorities better off in family medicine?
BACKGROUND: Several studies have shown that the percentage of women represented in senior academic positions at US medical schools is lower than the percentage of men in senior positions. Similarly, the percentage of minority faculty members represented in senior academic positions is lower than that of their majority counterparts. This study assessed whether these findings were also present in departments of family medicine and identified any factors related to the institution or department that favored academic success for women and minorities. METHODS: Data regarding faculty workforce composition, including faculty rank and rank for women and underrepresented minorities, were extracted from a comprehensive survey of departments of family medicine at US allopathic medical schools. The data are based on faculty workforce in 1997 and include responses from 58 (51%) of all schools with a department of family medicine. RESULTS: Faculty in departments of family medicine were more likely to be female (41% versus 25%) and an underrepresented minority (9% versus 4%), compared with all academic medicine disciplines. However, women in full-time positions were less likely than men, and minorities were less likely than nonminorities, to be either an associate or full professor. We could find no institutional or departmental characteristics that were associated with academic success for women or minority faculty members. CONCLUSIONS: While women and underrepresented minorities are more common to the faculty workforce in family medicine, members of both of these groups are not well represented in senior faculty ranks.
Academic Medical Centers↗
Use of microalbuminuria testing in persons with type 2 diabetes: are the right patients being tested?
OBJECTIVE: Our goal was to determine whether adult patients with type 2 diabetes who had gross proteinuria or were already taking angiotensin-blocking drugs were screened for microalbuminuria. STUDY DESIGN: This was a retrospective cross-sectional study. POPULATION: We included a total of 278 adult patients with type 2 diabetes seen during 1998 and 1999 at the family medicine practices of the Medical University of South Carolina. OUTCOMES MEASURED: The outcomes were microalbuminuria testing during either 1998 or 1999 and the initiation of medication if the screening test result was positive. RESULTS: We found that patients who could derive the greatest benefit from testing (ie, those without preexisting proteinuria or who were not receiving an angiotensin-blocking drug) were no more likely to be screened for microalbuminuria than those with existing proteinuria (16% vs 18%, P=.84) or those who were already being treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (16% vs 16%, P=.83). Also, when the microalbuminuria test result was positive, only 40% of the patients were placed on angiotensin-blocking drugs. CONCLUSIONS: Physician use of microalbuminuria screening does not follow established guidelines. The test appears to be used for many patients who might not need to be screened, and it is not always used for patients who should be screened. Consideration should be given to other strategies to prevent nephropathy in persons with type 2 diabetes.
Albuminuria↗
Disease management for diabetes among family physicians and general internists: opportunism or planned care?
BACKGROUND AND OBJECTIVES: Diabetes requires substantial ongoing medical management and use of monitoring tests. However, physicians' performance of these tests is often suboptimal. This study explored primary care physicians' management of diabetes in the context of both planned diabetes visits and acute visits for conditions unrelated to diabetes. METHODS: Semi-structured depth interviews were conducted with 12 primary care physicians in 9 family practice and internal medicine practices distributed throughout the state of South Carolina. All interviews were tape recorded and transcribed. Themes, divergences, and trends were identified and discussed by the investigators. RESULTS: Although all participants reported a preference toward planned diabetes management, because most patients fail to adhere to scheduled care, opportunistic disease management tended to be the default mode of diabetes care. Participants reported performing appropriate tests during scheduled visits but acknowledged that when confined to acute visits, diabetes care was difficult to perform. Reasons included time constraints and patient agenda. Participants reported that inadequate tracking of completion of diabetes standards of care influenced their adherence to guidelines. CONCLUSIONS: The current system of delivering diabetes care opportunistically in the context of non-diabetes acute visits may need to be more closely examined in an effort to improve the delivery of services.
Attitude of Health Personnel↗
Serum vitamin C levels and use of health care resources for wheezing episodes.
BACKGROUND: Evidence suggests that the antioxidant vitamin C may play a role in lung function and wheezing, although the data are limited to laboratory evaluation of pulmonary function. OBJECTIVE: To examine the relationship among serum vitamin C levels, wheezing episodes, and use of health care services. METHODS: Analysis of adult subjects (aged > or = 17 years) surveyed in the third National Health and Nutrition Examination Survey (1988-1994) (n = 19,760), including measurements of serum vitamin C levels and self-reports of wheezing episodes, ambulatory health care visits, and overnight hospitalizations for wheezing. RESULTS: A large proportion of individuals (2377/19,760 [12.0%]) have received a diagnosis of asthma, chronic bronchitis, or emphysema. Among 874 individuals having an ambulatory visit for wheezing, 408 (46.7%) did not have a diagnosed respiratory conditions. Similarly, among 159 individuals hospitalized for wheezing, 61 (38.4%) did not have a diagnosed respiratory condition. Serum vitamin C level had no significant relationship with reported diagnosis of respiratory conditions, episodes of wheezing, or use of health care services for wheezing. In a model computed only with individuals with low or high serum vitamin C levels, after adjustment for potential confounders, no statistically significant relationship was found between serum vitamin C levels and ambulatory care (odds ratio, 0.78; 95% confidence interval, 0.58-1.05) or hospitalization for wheezing episodes (odds ratio, 1.21; 95% confidence interval, 0.67-2.21). CONCLUSIONS: Serum vitamin C levels do not appear to be a marker for use of health care services for wheezing. Future investigations of the role of antioxidants in managing respiratory conditions should focus on the clinically important outcomes of health care use.
Adult↗
The effect of continuity of care on emergency department use.
OBJECTIVE: To examine whether continuity of care with an individual health care provider is associated with the number of hospital emergency department (ED) visits in a statewide Medicaid population. DESIGN: A cross-sectional study based on a 100% sample of Delaware Medicaid claims for 1 year (July 1, 1993, to June 30, 1994). Continuity with a single provider during the year was computed for each participant. SETTING: The state of Delaware. PARTICIPANTS: Continuously enrolled Medicaid clients aged 0 to 64 years who had made at least 3 physician office visits during the study year (N = 11,474). INTERVENTION: None. MAIN OUTCOME MEASURES: Likelihood of making a single ED visit or multiple ED visits during the study year. RESULTS: In multivariate analysis, continuity is associated with a significantly lower likelihood of making a single ED visit (odds ratio, 0.82; 95% confidence interval, 0.70-0.95), and is even more strongly associated with a lower likelihood of making multiple ED visits (odds ratio, 0.65; 95% confidence interval, 0.56-0.76). CONCLUSIONS: This study demonstrates that high provider continuity is associated with lower ED use for the Medicaid population. This suggests that strategies to improve continuity of care may result in lower ED use and possibly reduced health care costs. Such strategies may be more acceptable than current managed care policies that attempt to control costs by denying access to emergency care.
Adolescent↗
Fragmentation of patient care between chiropractors and family physicians.
BACKGROUND: Most patients using alternative practitioners also receive care from physicians. It is unclear, however, how well alternative practitioners and physicians communicate and coordinate the care of shared patients. OBJECTIVE: To describe the communication and coordination of care for shared patients between chiropractors and family physicians as well as potential barriers to effectively sharing care. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional national random sample survey of 400 chiropractors and 400 family physicians. MAIN OUTCOME MEASURES: Reports on shared patients including information on adverse events, treatment, and health status. Attitudes toward perceived expertise as well as perceived liability and economic competition involved in sharing care were also assessed. RESULTS: Surveys were completed by 360 (49%) of the 736 eligible practitioners, including 227 chiropractors and 133 family physicians. Although a high degree of interaction occurs between the practitioners, family physicians received information from chiropractors on 26.5% of referred patients while chiropractors received information from family physicians in 25.0% of cases (P = .73). Both groups believed that they did not receive enough information on adverse health outcomes or treatment plans for shared patients. Although neither group was particularly oriented toward wanting to share care, family physicians were much less likely than chiropractors to feel comfortable sharing care (P<.001). CONCLUSIONS: These findings indicate that care is fragmented between chiropractors and the general medical sector, with little information communicated between health care providers on issues with critical importance to quality of care. Further study is needed to identify ways to improve communication and coordination of care.
Chiropractic↗
Predicting cost-benefits before programs are started: looking at conjugate vaccine for invasive pneumococcal infections.
This analysis uses existing data to examine how an analysis to predict the net financial impact for an emerging medical program, namely a conjugate vaccine against Streptococcus pneumoniae, and to identify which key variables will have the greatest impact on the program's costs and benefits. Using data available on the prevalence and case fatality rates for invasive diseases caused by S pneumoniae, we examined the theoretical economic impact of vaccinating all newborns versus not vaccinating. Effectiveness estimates for conjugated pneumococcal vaccines and disease incidence and fatality rates were obtained from published sources. Because of scanty or inconclusive data for otitis media and pneumonia, the analysis was limited to cases of meningitis and bacteremia due to S pneumoniae. Based on these two diseases alone, immunization with conjugate pneumococcal vaccine could save an estimated 222 lives per million children vaccinated per year. Analysis of direct costs (projected immunization costs minus savings from reduced illness) show that a pneumococcal vaccine program will result in net direct costs between $0.08 and $2.42 per child. When indirect costs are included in the analysis, the vaccine is cost savings for all cases except when the two year incidence of disease and death rates are lowest and the cost of the vaccine series is $150. Further research should focus on these key issues as the vaccine is introduced into use, as expected in the next few years.
Bacterial Vaccines↗
Antibiotics and return visits for respiratory illness: a comparison of pooled versus hierarchical statistical methods.
BACKGROUND: Antibiotic prescribing for respiratory illness has been associated with small reductions in return visits in an analysis of a large practice-based network. In this study, we apply hierarchical analytical methods that account for the clustering of patients by practices to identify whether antibiotic prescribing by primary care physicians reduces subsequent visits for 6 acute respiratory illnesses-upper respiratory infection, pharyngitis, bronchitis, otitis media, sinusitis, and cough. METHODS: The study data came from 318 family physicians and internists in 45 practices in the Practice Partner Research Network from January 1995 through December 1996, with 255,564 active patients. Patients treated with antibiotics were compared with those who were not on the frequency of revisit within the next 14 days. A simple pooling model and 3 hierarchical statistical models (fixed-effects, random-effects, and Bayesian) were used to compare the odds-ratios for return visits. RESULTS: Statistically significant results were found only for bronchitis and sinusitis by the hierarchical models, but the simple pooling model produced statistically significant results for all study conditions. CONCLUSION: We conclude that antibiotics may reduce return visits for patients with bronchitis and sinusitis, but not for patients with other respiratory illness (upper respiratory infection, pharyngitis, otitis media, or cough). Studies of large clinical databases should use methods of analysis that account for the grouping of patients by practice to avoid false positive associations (type I errors.)
Academic Medical Centers↗
Medical students' abilities to take an occupational history: use of the WHACS mnemonic.
This study examined medical students' use of the WHACS mnemonic during an occupational history objective structured clinical examination station. Students' performance on the 10 content-specific station items was calculated. Factor analysis of the items was conducted, and student demographic and academic characteristics associated with performance on the station were examined. A total of 205 students completed the station. The mean number of correct responses was 5 (SD, 1.6). Students performed well on some items and less well on others. Factor analysis supported the WHACS framework. There were no significant associations with student demographic or academic characteristics. Students were aware of the particular features of an occupational history but were deficient in other areas; this awareness was not related to demographic or academic characteristics. The WHACS mnemonic could be an effective tool to teach occupational history-taking skills.
Adult↗
Hospitalists for the NHS?
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Hospitalists↗
The pharmacist's role in promoting optimal antimicrobial use.
Optimal use of antimicrobials is essential in the face of escalating antibiotic resistance, and requires cooperation from all sectors of the health care system. Although antibiotic-restriction policies in the hospital setting are important in altering microbial susceptibility patterns, an overall reduction in antibiotic prescriptions in the outpatient setting is more likely to significantly impact antibiotic resistance. Education of providers, application of clinical practice guidelines, audit and feedback activities, and multifaceted interventions all have had an effect in altering antibiotic prescribing in a research setting. Clinicians must alter antibiotic prescribing for the treatment of infectious diseases, and patients must change their perception of the need for these drugs. Pharmacists can play a major role through clinician education and focused clinical services. With cooperation of health care teams, the effectiveness of available antibiotics may be sustained and the threat of resistance minimized.
Anti-Bacterial Agents↗