The pharmaceutical industry and continuing education.
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Conflict of Interest↗
Biomedical subjects
D J Madlon-Kay
Publications and source records attributed to D J Madlon-Kay.
Home health nurse clinical assessment of neonatal jaundice: comparison of 3 methods.
OBJECTIVE: To compare 3 methods of clinical assessment of jaundice in newborns by home health nurses. DESIGN: Prospective clinical trial. SETTING: Homes of newborns living within 10 miles of a 340-bed community hospital where they were delivered. PARTICIPANTS: Home health nurses and newborn patients (< or =2 weeks old). INTERVENTIONS: The nurses examined the newborns and documented whether they detected jaundice. In newborns thought to have jaundice, the nurses estimated bilirubin levels, documented the extent of caudal progression of the jaundice, and determined the Ingram (Cascade Health Care Products, Salem, Ore) icterometer readings from the newborns' noses. Total serum bilirubin tests were obtained from all newborns studied. OUTCOME MEASURES: Nurse assessment of the presence of jaundice and its caudal progression, nurse estimates of bilirubin levels, icterometer readings, and bilirubin levels. RESULTS: The nurses determined that 82 (50%) of the 164 newborns had jaundice. Their estimates of bilirubin levels were most highly correlated with serum bilirubin levels (Pearson correlation, 0.61). All 3 newborns with bilirubin levels greater than or equal to 291 micromol/L (> or =17 mg/dL) were recognized by the nurses as having jaundice. These newborns had icterometer readings greater than or equal to 3.5 and had estimated bilirubin levels of greater than or equal to 274 micromol/L (> or =16 mg/dL). CONCLUSIONS: The method of evaluation that each nurse was accustomed to using was the most accurate in determining the severity of newborn jaundice. These results suggest that postpartum home health nurses can effectively evaluate newborns for the presence and severity of jaundice.
Bilirubin↗
Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment.
OBJECTIVE: To examine differences by physician gender in the identification and treatment of childhood psychosocial problems. DESIGN: Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample. SUBJECTS: Children ages 4 to 15 years seen consecutively for nonemergent care. MEASURES: Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms. RESULTS: Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems. CONCLUSIONS: Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.
Adolescent↗
Liquid medication dosing errors.
BACKGROUND: Our goal was to examine the following issues relevant to the use of liquid medications: (1) which liquid medication dosing devices are commonly owned and used; (2) the ability of potential patients to accurately measure liquids using 3 different dosing devices; (3) their ability to correctly interpret a variety of dosing instructions; and (4) their ability to correctly interpret a pediatric dosing chart. METHODS: One hundred thirty volunteers from the waiting areas of 3 primary care clinics in the St. Paul, Minnesota, area were interviewed. Participants were shown 7 liquid dosing devices and were asked which they had in their homes and which they had ever used. The participants were tested and scored on their ability to measure liquid medicines and interpret dosing instructions accurately. The total performance score was determined, with a maximum obtainable score of 11. RESULTS: A household teaspoon was the device most frequently used for measuring liquid medication. Women and participants with more education had higher total performance scores. Common errors included misinterpreting instructions, confusing teaspoons and tablespoons on a medicine cup, and misreading a dosage chart when weight and age were discordant. CONCLUSIONS: Clinicians need to be aware that many people continue to use inaccurate devices for measuring liquid medication, such as household spoons. They should encourage the use of more accurate devices, particularly the oral dosing syringe. Clinicians should always consider the possibility of a medication dosing error when faced with an apparent treatment failure.
Administration, Oral↗
Choosing a family physician. What do patients want to know?
What type of information do patients find valuable when choosing a family physician? At a suburban Midwestern clinic, 221 adults rated the value of 12 demographic items and eight attributes pertaining to physicians. Of the demographic information, board certification was most valued by respondents; all personal attributes listed were rated very highly. Although 44% of women preferred a female physician, 93% of women agreed that, in general, male and female family physicians are equally competent. In summary, a physician's personal attributes and characteristics are of most importance to consumers when choosing a family physician. With the exception of board certification status, information about a physician's training or demographics is of much less value to patients. In addition, the information identified as most important in the survey is not typically provided by managed care organizations.
Adult↗
Evaluation and management of newborn jaundice by midwest family physicians.
BACKGROUND: Recognition and management of newborn jaundice is controversial and even more challenging with the early discharge of newborns. The purpose of this study was to describe the jaundice management patterns of family physicians in Minnesota and Wisconsin and compare them with American Academy of Pediatrics recommendations. METHODS: Forty-two members of the Practice-Based Research Group of the Wisconsin Research Network and of the Minnesota Academy of Family Physicians Research Network recorded information on study cards about the care they provided to healthy full-term newborns for 6 months. RESULTS: Data was collected on 335 infants, 30% of whom were jaundiced. Physicians ordered limited laboratory testing on selected jaundiced infants. Infants with jaundice were more frequently breast-fed, and had longer hospital stays. Jaundice was commonly managed by phototherapy (17%), home sunlight (28%), and increased breast-feeding (44%). Twenty-six percent of the physicians used a formal phototherapy guideline. The timing of the first follow-up visit did not differ for infants discharged before or after 48 hours of age. CONCLUSIONS: Family physicians identified and managed newborn jaundice relatively infrequently in our study. Their practice patterns were consistent with most aspects of the American Academy of Pediatrics jaundice guideline, although few of them used it to guide phototherapy use. The study physicians did not generally follow recommendations for follow-up of infants discharged early. Until a large-scale clinical trial of newborn jaundice management is performed, a variety of practices should continue to be acceptable.
Aftercare↗
Accreditation and certification.
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Certification↗
A clinic system to improve preschool vaccinations in a low socioeconomic status population.
OBJECTIVE: To determine if a clinic system to assess and vaccinate preschool-age children at every clinic visit can improve vaccination rates. DESIGN: A nonequivalent control group design contrasting an intervention clinic with a comparison clinic. SETTING: Two urban St Paul, Minn, clinics. The intervention clinic is a family practice residency clinic, and the comparison, clinic is a community health center clinic. PATIENTS: Primarily a low socioeconomic status white population. INTERVENTIONS: A clinic-wide system to identify and vaccinate children at all clinic visits. Appointment personnel, medical assistants, and physicians all had roles in the intervention protocol. MAIN OUTCOME MEASURES: Percentage of children at the 2 clinics who were up-to-date for a primary vaccine series at age 24 months and also at the end of the study collection periods, preintervention and postintervention. RESULTS: The intervention clinic improved the percentage of children up-to-date for a primary vaccine series at age 24 months from 42% to 56% (P = .02), while the percentage at the comparison clinic did not change significantly (P = .81). Similarly, the intervention clinic improved the percentage of children up-to-date for age at the end of the study periods from 49% preintervention to 63% postintervention (P = .02), while the percentage at the comparison clinic did not improve significantly (P = .45). The system was especially useful for children with few visits to the intervention clinic. CONCLUSIONS: Although the intervention clinic resulted in a substantial improvement in vaccination rates for preschool-age children, rates remained well below national goals. A combination of clinic, community, and national initiatives may be needed to ensure appropriate vaccination rates for this challenging patient population.
Child Welfare↗
Recognition of the presence and severity of newborn jaundice by parents, nurses, physicians, and icterometer.
OBJECTIVE: To determine how well parents, nurses, physicians, and an Ingram icterometer can detect the presence and the severity of jaundice in newborns. SETTING: Normal newborn nursery in a 340-bed teaching hospital. PATIENTS OR OTHER PARTICIPANTS: Nurses and physicians caring for nursery infants and parents of the infants. INTERVENTIONS: Physicians and nurses examining newborns documented whether they detected jaundice in the infants and, if so, the estimated bilirubin level and the extent of cephalocaudal progression of the jaundice. An assistant taught the parents how to examine the infants for jaundice and determine its cephalocaudal progression. The assistant also obtained icterometer readings. Bilirubin testing was performed according to usual clinical practice. OUTCOME MEASURES: Nurse and physician estimates of bilirubin levels; parent, nurse, and physician assessment of the presence of jaundice and its cephalocaudal progression; icterometer readings; bilirubin levels. RESULTS: There was moderate agreement about the presence of jaundice in the infants (pairwise kappa, 0.48) However, all infants with bilirubin levels >12 mg/dL were correctly identified as jaundiced by all examiners. The parents' assessment of cephalocaudal progression and the icterometer readings were most highly correlated with serum bilirubin levels (adjusted Pearson correlations, 0.71 and 0.57, respectively). CONCLUSIONS: Many parents can be taught to accurately assess cephalocaudal progression of jaundice in the hospital. The icterometer is a useful tool for assessing jaundice severity. Both parent assessment and the icterometer were more highly correlated with bilirubin levels than physician and nurse estimates in this study. Additional research is needed to determine how accurate these methods of clinical assessment are at the higher bilirubin levels that typically occur after hospital discharge.
Bilirubin↗
The effectiveness of a mail reminder system for depot medroxyprogesterone injections.
To determine if a mail reminder system leads to an increase in the percentage of depot medroxyprogesterone acetate (Depo-Provera) injections administered on time, the charts of 184 women were reviewed. The reminder postcard included the due dates of both the next medroxyprogesterone injection and the next Papanicolaou test. Timeliness of injections improved with the reminder system from 64% administered on time to 76% (P < .02). Injections given late despite the reminders were late a mean of 8 days. Injections given late before the reminder system began were late a mean of 20 days (P < .05). If injections given during the injection's 14-day "grace" period are included, the on-time rate improved from 87% to 96% with the reminder system (P < .005). The reminder system was not effective in ensuring annual Papanicolaou testing. Vigilance is needed to ensure that women receiving medroxyprogesterone injections also receive timely Papanicolaou testing.
Adult↗
Use of a 'Health Habits Questionnaire' to improve health promotion counseling.
A 10-item patient "Health Habits Questionnaire" was developed that included counseling topics recommended by the US Preventive Services Task Force. Patient education brochures for each of these topics were designed and displayed in examination rooms. The questionnaires were to be given to every adult presenting to a family medicine residency clinic for a physical examination. Charts of patients receiving physical examinations were audited. Of 368 visits, 206 questionnaires were completed. Patients who completed the questionnaires were significantly more likely to have chart documentation of counseling about seat-belt use, exercise, stress, alcohol and other drug use, and dental health. The topic areas that had no significant improvement in documentation had higher counseling documentation rates than those that improved. The Health Habits Questionnaire appears to be a useful tool to improve counseling documentation, particularly for those habits that may otherwise receive little counseling.
Adult↗
Too many shots? Parent, nurse, and physician attitudes toward multiple simultaneous childhood vaccinations.
OBJECTIVE: To learn about parent, nurse, and family physician attitudes toward multiple simultaneous childhood vaccinations. DESIGN: Survey. SETTING: Thirty-two family practice clinics in Minnesota. PATIENTS/PARTICIPANTS: Forty-six volunteer Minnesota Academy of Family Physicians Research Network members, 42 of their nurses, and 342 parents of their patients aged less than 6 years who have had at least one injection. MAIN OUTCOME MEASURES: Number of injections believed to be too many for a child to receive simultaneously and comfort level associated with children's receiving three simultaneous injectable vaccinations. RESULTS: Most parents, nurses, and physicians (71%, 76%, and 59%, respectively) think that three injections are too many for a child to receive at one visit. Similar percentages of parents, nurses, and physicians are uncomfortable with a child's receiving three injections at one visit. Sixty-seven percent of the physicians who do not offer universal newborn hepatitis B vaccinations cite the number of required simultaneous injections as a factor in that decision. Only 15% of physicians order all three recommended injections for most of their 15-month-old patients. CONCLUSIONS: Most parents, nurses, and physicians are uncomfortable with three simultaneous injections for children. This discomfort may be a significant barrier to the adoption of the new immunization recommendations. The development of effective combination vaccines should be a research priority.
Adult↗
Adolescent measles vaccination. Response rates to mailings addressed to patients vs parents.
OBJECTIVE: To determine the measles vaccination rate in adolescents that could be achieved with a mailed notification of the recommendation, and to determine if the response rate differed if the mailing was addressed to the parents or to the adolescents. DESIGN: Randomized trial. SETTING: A family medicine residency training clinic serving a low-socioeconomic population. PATIENTS OR OTHER PARTICIPANTS: Four hundred forty-nine adolescents aged 12 through 18 years who were seen in the clinic within the previous 21 months without receiving a documented second dose of measles vaccine were randomized into two groups. INTERVENTION: A letter recommending measles revaccination was sent to the parents in one group (parent group) and to the adolescents themselves in the second group (adolescent group). The content of both letters was basically the same, but they differed in style and reading level. MAIN OUTCOME MEASURE: Measles vaccinations administered to adolescents during the 2-month period following mailing of the letters. RESULTS: Twenty-eight patients were excluded after randomization. Fifty-six letters were undeliverable after two mailing attempts. Eleven (6.3%) of 176 adolescents in the parent group and five (2.6%) of 189 adolescents in the adolescent group received the measles vaccination (P > .05). CONCLUSIONS: Although the adolescents whose parents received the letter were twice as likely to be vaccinated, the response rate was poor in both groups. The letter campaign was not an effective method to reach adolescents for measles revaccination.
Adolescent↗
Health promotion counseling in residency training.
This report describes health promotion counseling attitudes and practices in a family medicine residency that attempted to encourage such counseling. A patient "Health Habits Questionnaire" and matching patient education booklets were developed and distributed. Six grand rounds presentations on counseling were given. On three occasions, residency physicians completed questionnaires about counseling. Despite good personal health habits and positive attitudes toward counseling, the residency physicians had only moderate confidence in their counseling ability and infrequently documented counseling. The residents reported significant improvement in their ability to counsel patients about smoking cessation. Overall, the curriculum appeared to have a limited effect on health promotion.
Adult↗
The clinical significance of ABO blood group incompatibility.
OBJECTIVE: To compare incidence, severity, and treatment of jaundice in ABO-compatible and -incompatible infants. DESIGN: Retrospective chart review. SETTING: A 340-bed acute-care public and teaching hospital. PATIENTS OR OTHER PARTICIPANTS: All infants with blood groups A or B delivered in 1990 by Rh-positive mothers with blood group O. On direct antiglobulin testing 65 infants had positive and 78 had negative results. The control group comprised 78 infants with blood group O born to mothers of blood group O. INTERVENTION: None. RESULTS: Infants who were ABO-incompatible and showed positive results to the direct antiglobulin test had the highest incidence of jaundice and underwent more tests and phototherapy. Infants who showed negative results to the direct antiglobulin test had jaundice incidence rates between those seen for control infants and infants who tested positive. Mean peak bilirubin levels did not differ significantly among the groups. CONCLUSION: Incompatibility of ABO blood group is associated with an increased incidence of jaundice and higher phototherapy rates. Clinicians should continue to be concerned about possible ABO incompatibility in infants with jaundice born to mothers with blood group O.
ABO Blood-Group System↗
Striae gravidarum. Folklore and fact.
OBJECTIVE: To study the factors associated with the formation of striae gravidarum and the measures used by women to prevent them. DESIGN: Retrospective cohort study. SETTING: One private and one teaching hospital in St Paul, Minn. PARTICIPANTS: Forty-eight nulliparous women at 34 to 36 weeks' estimated gestational age attending prenatal classes or tours of the labor and delivery departments. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Presence of abdominal striae. RESULTS: Women with abdominal striae were significantly younger, more likely to receive state medical assistance, more likely to have hip striae, and had a greater total weight gain than women without abdominal striae. Results of diabetes screening tests and glycosylated hemoglobin levels were similar in women with and without striae. Although most women attempted to prevent striae formation, women who used oils or creams formed striae as frequently as those who did not. CONCLUSIONS: A previously reported association between increased striae and glucose intolerance, which led to the theory of adrenal cortical hyperactivity as a cause of striae gravidarum, was not confirmed by this study. Many women use creams or oils in an attempt to prevent striae formation despite their ineffectiveness.
Abdomen↗
The tyranny of the throwaways.
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Periodicals as Topic↗
Clinical evaluation of ankle inversion injuries in family practice offices.
BACKGROUND: The use of radiography in evaluating inversion ankle injuries remains high despite several studies suggesting that x-ray examination should be limited to patients meeting certain clinical criteria. These studies were all done in emergency departments. The present study examined detection of ankle fractures by clinical evaluation alone in private family practice offices. METHODS: Twelve physicians in three family practice offices participated. Check-off forms were developed to record clinical data. The physicians all attended a session to standardize terminology. The physicians then evaluated 94 consecutive patients with inversion ankle injuries. RESULTS: Eight fractures were detected by radiography, five of which had not been suspected on clinical examination (5.9% false-negative rate). Only one fracture required treatment different from that for a sprain. Tenderness on the dorsum of the foot, impaired weight-bearing ability, recentness of injury (less than 12 hours earlier), and presence of additional injuries were significantly associated with a fracture. Unlike several previous studies, swelling was not associated with fractures. If radiography had been limited to patients presenting with inability to bear weight fully or tenderness on the dorsum of the foot, none of the fractures would have been missed, and the use of radiography would have been reduced from 90% to 61%. CONCLUSIONS: The fracture rate in these family practice offices is lower than that reported in most emergency department studies. It is important that family physicians order radiographs judiciously rather than routinely for patients with inversion ankle injuries. The clinical criteria reported here are likely to reduce unnecessary ordering of radiographs and are compatible with recently published, prospectively validated rules for acute ankle injury in an emergency department setting.
Adult↗