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Biomedical subjects

B F Crabtree

Publications and source records attributed to B F Crabtree.

At least 37 records · Page 2Linked to original sources
PubMed1998

The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice.

BACKGROUND: Primary care physicians are expected to identify mental health problems. Currently, it is unclear how a recent experience of emotional distress affects the physician-patient encounter and the diagnostic process. METHODS: Using the Davis Observation Code, we studied 1269 encounters between family physicians and adult patients who completed brief questionnaires after the visit. Patients were separated into three groups using self-report and billing data: those denying recent emotional distress, those reporting recent emotional distress but not receiving a mental health diagnosis, and those reporting recent emotional distress and receiving a diagnosis of anxiety or depression. RESULTS: Nineteen percent of patients reported significant emotional distress during the previous 4 weeks; 18% of these patients received a billing diagnosis of depression or anxiety. Patients not reporting emotional distress had the shortest visits (10.0 minutes); recent emotional distress was associated with significantly longer visits: 11.5 minutes for those without a diagnosis of depression or anxiety and 12.8 minutes for those with a diagnosis of depression or anxiety. The visits of patients with a diagnosis of depression or anxiety included more counseling, history-taking, and discussions of family information and substance use, and less time providing physical examination and evaluation feedback. Fewer preventive services and less chatting occurred when patients reported recent distress, regardless of diagnosis. CONCLUSIONS: Recent patient emotional distress has a powerful impact on the structure of the family practice visit, with important implications for efforts to enhance diagnosis and treatment of mental health issues. The challenge for the family physician is to recognize and treat a patient's emotional distress while continuing to fulfill competing medical demands.

Anxiety Disorders↗
PubMed1998

Making time for tobacco cessation counseling.

BACKGROUND: The objective of this study was to examine the incidence, targeting, and time demands of tobacco cessation advice by community family physicians. METHODS: Research nurses directly observed 2 days of outpatient visits to 138 family physicians in northeast Ohio. Smoking status was identified by patient questionnaire. Visit characteristics were determined from direct observation and billing data. Visits by smokers with and without smoking cessation advice were compared. RESULTS: The incidence of tobacco cessation advice was highest during wellness visits (55% vs 22% for illness visits; P < .001). Smokers seen for a tobacco-related chronic illness were more likely to receive advice than those seen for a chronic problem not related to tobacco (32% vs 17%; P = .05). The average duration of advice was less than 1 1/2 minutes. There were no significant differences in the duration of advice across different types of visits. CONCLUSIONS: Physicians are providing brief, targeted interventions for smoking cessation in family practices. The findings support the feasibility of implementing a brief intervention with all smokers seen during office visits.

Counseling↗
PubMed1997

Mortality experience of Navajos with type 2 diabetes mellitus.

OBJECTIVES: We sought to determine the contribution of type 2 diabetes mellitus to mortality in a Navajo population, and to assess the impact of pre-existing coronary heart disease on this relationship. METHODS: A cohort of 77 Navajos with type 2 diabetes mellitus and 77 non-diabetic controls matched on age, gender and community of residence were followed for an 18-year period, from 1974 to 1992. RESULTS: The vital status of 152 of the 154 study subjects was ascertained at 18-year follow-up. There were 30 deaths (39%) in the type 2 diabetes group and 13 (17%) in the control group during the 18-year period which was significantly different in bivariate matched pairs analysis (risk ratio = 3.12, McNemar's chi 2 = 7.76, p < 0.01). Multivariate conditional logistic response models (risk ratio = 3.02, 95% CI 1.21, 7.53) and stratification analysis (McNemar's Summary chi 2 = 8.05, 2 df, p < 0.05), confirmed that survival was significantly different for the two groups, even when controlling for baseline cardiovascular comorbidity and hypertension. CONCLUSION: These data describe the mortality impact of the epidemic of type 2 diabetes and cardiovascular disease now accelerating among the Navajo. The significant mortality differences between the diabetes and non-diabetes groups and the continuing rise in prevalence of type 2 diabetes underscore the need for an effective community-based approach to diabetes prevention among the Navajo.

Arizona↗
PubMed1997

Meeting the challenges of workload and building a practice: the perspectives of 10 rural physicians.

This qualitative study used in-depth interviews to identify and describe factors regarding the retention of rural physicians. A purposeful sample of 10 established rural physicians from counties of fewer than 10,000 people participated in the study. Analysis of the interview transcripts identified the increased workload involved in building a rural practice to be a major concern of the physicians. The physicians expressed this difficulty in the form of two challenging dilemmas: (1) Towns with only a few physicians presented excellent opportunities for a building practice, but the lack of physicians resulted in more difficult working conditions; and (2) building a practice was described as primarily competitive, but staying in rural practice involved working cooperatively with various competitors. The demands of family, practice, and community interact in a complex fashion. The smallest health systems, those in counties with populations of fewer than 10,000, one hospital, and fewer than five physicians, may represent situations where it is difficult to find a workable solution.

Economic Competition↗
PubMed1997

Current trends in tobacco prevention and cessation in Nebraska physicians' offices.

BACKGROUND: Despite years of intervention, few studies describe the extent to which recommended tobacco use prevention and cessation activities occur in community-based family practices. This study was designed to discover current practice patterns in these areas and to describe physician outcome and efficacy expectations. METHODS: An exploratory comparative case study of 11 family practices used direct observation of practices and clinical encounters, chart reviews, and in-depth interviews. Qualitative and quantitative information was gathered on (1) intensity of tobacco use prevention and cessation; (2) physicians' attitudes and beliefs regarding outcome expectations; and (3) physicians' perceptions of their ability to counsel. Qualitative content analysis and descriptive statistics were used to construct case studies for comparisons. RESULTS: Themes common to most practices included the "provision of little prevention" and "a lack of perceived need to address smokeless tobacco." Responsibility for tobacco activities fell almost solely to physicians. Although physicians felt confident in their counseling skills, the skills they identified were fairly basic. Most physicians were pessimistic about the positive effects of these activities. None of the practices was using any specifically developed "package," and pharmaceutical companies provided almost all patient education material. There was considerable variation in intensity of activities because of differences in attitudes, expectation, and background. CONCLUSIONS: To increase tobacco control activities, practice systems need to be individually evaluated to identify what is needed, how it will fit within the practice culture, and how it can best be implemented in this specific practice. One-size-fits-all interventions probably will not be widely implemented.

Adolescent↗
PubMed1997

Differences between diabetic patients who do and do not respond to a diabetes care intervention: a qualitative analysis.

BACKGROUND AND OBJECTIVES: We designed a qualitative case study to ascertain whether attitudes and views of diabetes differ between patients with diabetes who do and do not respond well to a diabetes care intervention. METHODS: Prospective epidemiological data were used to classify and sample graduates from an outpatient diabetes care program into one of two groups: 1) positive responders (n = 18) who had a 20% or greater improvement in glycemic control 6 months after the care program and 2) negative responders (n = 16) who had less than a 20% improvement in glycemic control 6 months after the care program. We collected data using depth interviews and focus groups. Transcriptions were summarized and analyzed using an editing approach. The themes from these two groups were summarized and compared to ascertain similarities and differences in attitudes and views of diabetes. RESULTS: Four major themes emerged from the analysis. Positive and negative responders differed a) in their views of diabetes and its treatment, b) on how they incorporated diabetes care into their daily routines, c) in "conversion experiences" in which some patients became suddenly much more aware of the serious threat of diabetes to their health, and d) in their views of their medical care providers. CONCLUSIONS: The conversion experiences observed in many of these subjects are not consistent with stage-of-change models of health-related behavior change. These data advance our understanding of patients' diabetes-related attitudes and behaviors and may be used by clinicians to monitor change in patients' attitudes and expectations over time and by researchers to develop and target novel patient-centered clinical interventions to improve patient satisfaction and clinical outcomes.

Adult↗
PubMed1997

Evaluating family practice residencies: a new method for qualitative assessment.

BACKGROUND AND OBJECTIVES: This study reports on a novel qualitative method for evaluating family practice training programs. Previous evaluation techniques have generally been quantitative in nature and have limited their scope to a few isolated elements of residency education. METHODS: A guest faculty, working in conjunction with local faculty, conducted a site analysis of an East Coast and a West Coast family practice residency. Multiple qualitative techniques were used, including participant observation, focus groups, long interviews, and analysis of key texts. Program strengths and weaknesses were analyzed, and a discrepancy model was used to compare program goals and ideals to the actual training realities. The analysis used a process of immersion/crystallization, and triangulation of the multiple data sources was achieved through repeated comparisons. RESULTS: This report focuses on the process of the evaluations, rather than on their content. In general, the sites have achieved most of their objectives, but notable limitations are present at both programs. This is particularly apparent in terms of multiple demands on faculty, the lack of a shared vision, and program isolation. CONCLUSIONS: Significant lessons were learned from these initial assessments, which can be used to further refine the method. Comprehensive qualitative reviews may provide unexpected insights and identify program limitations and strengths.

Data Collection↗
PubMed1996

An ounce of prevention? Evaluation of the 'Put Prevention into Practice' program.

BACKGROUND: The "Put Prevention into Practice" (PPIP) program was designed to enhance the capacity of health care providers to deliver clinical preventive services. This study was designed to evaluate the program's effectiveness when applied to family physicians in private practice settings. METHODS: Eight Midwestern practices that had purchased PPIP kits were identified and agreed to participate in the study. A comparative case study approach encompassing a variety of data collection techniques was used. These techniques included participant observation of clinic operations and patient encounters, semistructured and key informant interviews with physicians and staff members, chart reviews, and structured postpatient encounter and office environment checklists. Content analysis of the qualitative data and construction of the individual cases were done by consensus of the research team. RESULTS: PPIP materials are not being used, even by the clinics that ordered them. Physicians already providing quality preventive services prefer their existing materials to those in the PPIP kit. Sites that are underutilizing preventive services are unable or unwilling to independently implement the PPIP program. CONCLUSIONS: Development of technical support may facilitate implementation of PPIP materials into those practices most deficient in providing preventive services. Given the diversity of practice environments it is unlikely that a "one size fits all" approach will ever be able to address the needs of all providers.

Delivery of Health Care↗
PubMed1995

Depression in rural family practice. Easy to recognize, difficult to diagnose.

OBJECTIVE: To explore rural family physicians' decision-making processes when they encounter depression. DESIGN: Exploratory qualitative "field study" using individual in-depth interviews and participant observation. Interviews were audiotaped, transcribed, and analyzed by an editing approach. SETTING: Rural Nebraska family physicians' offices. PARTICIPANTS: A purposeful sample of six rural Nebraska family physicians, including five men and one woman, aged 35 to 65 years; two in solo practice, three in two-person practices, and one in a group practice; in communities with populations ranging from 600 to 6500. MAIN OUTCOME MEASURES: Themes common to all interviews. RESULTS: Themes included the following: depression is easy to recognize but difficult to diagnose; depression is readily treatable but requires negotiation to manage; and depression is important but time and resources are limited. The inadequate diagnosis and treatment of depression appeared to be partly artifactual and must be understood against a background of perceived stigma, high prevalence of depressive symptoms, structural barriers to care, and context of rural practice. CONCLUSIONS: Rural family physicians may have a more deliberate, organized, and rational approach to depressive disorders than previously reported. Depression is commonly recognized by rural family physicians; however, they hesitate to diagnose this condition because of diagnostic uncertainty, perceived stigma, the desire to preserve the physician-patient relationship, time and financial pressures, and a lack of supporting resources.

Adult↗
PubMed1994

Clinical risk factors for methicillin-resistant Staphylococcus aureus bacteriuria in a skilled-care nursing home.

OBJECTIVE: To establish the risk factors for methicillin-resistant Staphylococcus aureus (MRSA) bacteriuria in a nursing home population. DESIGN, SETTING, AND SUBJECTS: A case-control study was conducted in a 360-bed skilled-care nursing facility in the northeastern United States that was experiencing an outbreak of MRSA. Fifteen residents were identified as having had MRSA isolated from their urine over an 18-month period and were compared with 40 controls who were randomly selected from all nursing facility residents. RESULTS: In bivariate analysis, MRSA bacteriuria was associated with the presence of an indwelling urinary catheter (odds ratio [OR], 36; 95% confidence interval [CI], 7.0 to 184.2), antibiotic use in the prior 6 months (OR, 2.9; 95% CI, 1.5 to 5.5), and impaired physical function (OR, 5.8; 95% CI, 1.3 to 26.6). Urinary catheter use and antibiotic use remained significantly associated with MRSA bacteriuria even when controlling for impaired physical function. CONCLUSIONS: Methicillin-resistant S aureus is being isolated with increasing frequency in nursing homes, and MRSA bacteriuria may prove to be an important reservoir for the spread of organisms in long-term-care settings. Conservative use of indwelling urinary catheters and of broad-spectrum antibiotics should be investigated as potential control measures to reduce the spread of MRSA in nursing homes.

Bacteriuria↗
PubMed1994

Qualitative analysis: how to begin making sense.

The clinical process used to make sense of patient concerns closely parallels the analysis process of qualitative research. This partly explains why qualitative research methods are appropriate for many family practice research questions. Unfortunately, the language used by qualitative researchers, especially with regards to analysis, is often obscure. This impedes family physicians from implementing qualitative research. This paper overviews qualitative analysis and introduces a language and means by which family physicians can begin to make sense of qualitative data. The concepts, "reflexivity," "iteration," "data saturation," and "text," are defined. Three core steps of qualitative analysis are identified and compared to the diagnostic process. They consist of choosing an organizing system, reducing the data, and making connections. Four idealized ways for conducting these steps, editing, template, quasistatistical, and immersion/crystallization, are presented and compared to four ways of approaching patient concerns. Finally, the process of creating an appropriate qualitative analysis strategy is described for a hypothetical research study and some pitfalls and principles of qualitative analysis are reviewed.

Family Practice↗
PubMed1994

Patients, family physicians, and pain: visions from interview narratives.

BACKGROUND: Family physicians reportedly underestimate their patients' pain severity. Explanations for this remain unexamined. This study explores the understanding family physicians and their patients have of the common experience of pain. METHODS: We studied six culturally homogeneous private practice family physician-patient pairs from Connecticut using a qualitative, cross-sectional long interview design. Interviews were taped in the office or home and analyzed by the research team using an editing style derived from the constant comparative method. RESULTS: The patients described pain as spiritually awakening, experienced in the body, and part of everyday life with conceptual, behavioral, functional, and spiritual dimensions. The patients all claimed that physicians don't listen. The family physicians expressed a personal understanding of pain similar to the patient and a professional one which was more biomedical, concerned about addiction, and related to control of and connection with patients. Patients and physicians described the role of the doctor as a four-stage process of listening, knowing, responding, and taking time, but they meant different things. CONCLUSIONS: This study reveals family physicians and their patients struggling to communicate about pain. The role of family physician socialization, strategies for listening and sharing power in the clinical encounter, and a new four-dimensional classification of pain are briefly discussed.

Adult↗
PubMed1994

Geographic variation in exercise testing by family physicians.

BACKGROUND: The purposes of this study were to determine the extent to which exercise stress testing is performed by family physicians; whether rural physicians are more likely to utilize exercise stress testing than their urban counterparts; and what factors influence their decisions. METHODS: A random sample of 211 practicing members of the Nebraska Academy of Family Physicians was surveyed. Responses were received from 163 (77%). To ensure independence, if two or more subjects were members of the same group practice, one was randomly assigned to the study, for a total of 125 respondents available for analysis. Questionnaire items included performance of exercise stress tests, population base, and distance to the nearest specialist who performed the test. Respondents were classified as urban, rural, or frontier, based on population per square mile in their county. RESULTS: Seventy-three of the 125 respondents (58%) reported that they perform exercise stress testing. Physicians in rural or frontier counties were twice as likely to perform the test as urban physicians (P < .001). Similar results were found for distance to the closest specialist who performs exercise stress tests (P < .001) and reported population base (P < .01). Of those performing the procedure, 42 (58%) indicated they had learned it during residency, whereas 15 (21%) were self-taught or had learned from a colleague. CONCLUSIONS: Family physicians in rural Nebraska are significantly more likely to perform exercise stress testing than those in urban areas and much more likely to do stress testing than previous national studies indicate. National guidelines should acknowledge the need for family physicians to perform exercise tests and promote training in this procedure.

Adult↗
PubMed1992

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

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

Humans↗
PubMed1992

Smokeless tobacco use and oral pathology in a professional baseball organization.

BACKGROUND: Smokeless tobacco has been implicated as a risk factor for numerous oral conditions. Since baseball players are known to have a high incidence of smokeless tobacco use, they are an excellent group in which to study the effects of smokeless tobacco on the oral cavity. We report our findings in 206 of 220 eligible men during spring training of a professional baseball organization. Major and minor league ballplayers, coaches, and management personnel were included. METHODS: Participants completed a 2-page, 23-item questionnaire on smokeless tobacco use. This was followed by a detailed examination for oral leukoplakia, periodontal disease, and dental caries performed by a physician who was blinded to the results of the questionnaire. Oral leukoplakia was graded I, II, or III according to severity. RESULTS: Eighty-eight of 206 participants (42.7%) reported current use of smokeless tobacco; 62 of these men used smokeless tobacco year round, while 26 used smokeless tobacco only during the baseball season. The 88 smokeless tobacco users often used more than one form of tobacco. Moist snuff was the most common form (73.9% of users) followed by loose leaf tobacco (53.4%) and plug tobacco (9.1%). Oral leukoplakia was found in 25 of 88 current users (28.4%). Only the year-round users, however, had an incidence rate (37.1%) that was significantly different from all others (odds ratio = 9.35, 95% CI = 3.46 to 26.21). Year-round users were also more likely to have a higher grade of oral leukoplakia. Periodontal disease and dental caries were no more prevalent among smokeless tobacco users than nonusers. CONCLUSIONS: We conclude that the use of smokeless tobacco products is a significant risk factor for the development of oral leukoplakia, and that this risk is greatest in those individuals who use smokeless tobacco continuously throughout the year.

Adolescent↗