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Biomedical subjects

G E Fryer

Publications and source records attributed to G E Fryer.

At least 37 records · Page 2Linked to original sources
PubMed2002

A preliminary taxonomy of medical errors in family practice.

OBJECTIVE: To develop a preliminary taxonomy of primary care medical errors. DESIGN: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. SETTING: The National Network for Family Practice and Primary Care Research. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Medical error category, context, and consequence. RESULTS: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. CONCLUSIONS: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Adult↗
PubMed2001

Uncoordinated growth of the primary care work force.

Family physicians, nurse practitioners and physician assistants are distinctly different in their clinical training, yet they function interdependently. Together, they represent a significant portion of the primary care work force. Training capacity for these professions has increased rapidly over the physician assistant decade, but almost no collaborative work force planning has occurred.

Family Practice↗
PubMed2001

Direct graduate medical education payments to teaching hospitals by Medicare: unexplained variation and public policy contradictions.

PURPOSE: To comprehensively examine both inter- and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services. METHOD: Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria for moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined from the Area Resource FILE: RESULTS: Variations in inter- and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAS: CONCLUSION: Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to U.S. physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Hispanic versus white, non-Hispanic physician medical practices in Colorado.

The purpose of the study was to extend the scope of earlier research on minority physicians attending to the needs of the poor and their own ethnicity by contrasting practice characteristics of Hispanic doctors in Colorado with those of their white, non-Hispanic counterparts. It was found that Hispanic physicians spent more hours per week in direct patient care, were more likely to have a primary care specialty, and were less often specialty board certified than white, non-Hispanic doctors. Hispanic generalists established practices in areas in which the percentages of the population that were (1) below poverty level, (2) Hispanic, (3) Hispanic and below poverty level, and (4) white, non-Hispanic, and below poverty level were greater than in areas in which white, non-Hispanic primary care physicians practiced. These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs.

Adult↗
PubMed2001

Shortchanging adolescents: room for improvement in preventive care by physicians.

BACKGROUND AND OBJECTIVES: Behaviors developed in adolescence influence health later in life. Adolescents seldom visit physicians to discuss health-related behaviors. Instead, physicians must incorporate health counseling into the exams for which the adolescents do come. We studied the frequency and duration of adolescents' consultations with family physicians and pediatricians involving counseling about diet and nutrition, exercise, weight reduction, cholesterol reduction, HIV transmission, injury prevention, and tobacco use. METHODS: Data were analyzed from the National Ambulatory Medical Care Survey for the 3-year period from 1995 through 1997. This survey uses a multistage national probability sample of patient visits to nonfederal, office-based physicians. We described patterns of counseling provided to adolescents and compared patterns for family physicians/general practitioners and pediatricians. RESULTS: Of 91,395 physician-reported visits analyzed, 4,242 (4.6%) were by adolescents ages 12-19. Visits to family physicians and pediatricians accounted for 1,846 (43.5%) of these visits. Counseling about any of the seven areas studied was included in 15.8% of family physician visits and 21.6% of pediatrician visits. The length of consultation increased from 13.8 to 17.6 minutes if counseling was included. CONCLUSIONS: Adolescents visits physicians infrequently. When they do, few receive counseling on critical adolescent health issues. Both family physicians and pediatricians have room for improvement.

Adolescent↗
PubMed2000

Educating doctors to provide counseling and preventive care: turning 20th century professional values head over heels.

Internationally, 20th century medical education concentrated on equipping new graduates with technical skills and pushing the frontiers of technological sciences to extend and enhance life in ways unimaginable in previous decades. In the 21st century, health services are expected to be characterized not by the "fix-up-when-things-go-wrong" type of care that 20th century physicians have become so good at, but by preventive care that can obviate much of the need for these fix-up services. Enabling doctors to deal with the different health care needs of future patients will require a values shift in medical education. The United States leads the world in per capita health care expenditure yet trails in many important measures of health status. It epitomizes many elements of both the good and the bad in current medical education that may be less obvious in other countries that are less wealthy, less technologically oriented, and less committed to individual freedoms. In this paper we use the US as a case study to argue the need for a fundamental shift in values away from the 20th century emphasis on disease, specialization and treatment, and towards health, generalization and prevention. We draw on data from the National Ambulatory Medical Care Survey to compare roles of primary care physicians and other office-based medical specialties in delivering preventive health care. We also estimate the cost of providing preventive care in terms of physician time. Finally, we contemplate how medical education values must change in the US and other countries if 21st century physicians are to be prepared to meet the health care needs of their communities.

Journal Article↗
PubMed1999

Multi-method assessment of access to primary medical care in rural Colorado.

The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Colorado↗
PubMed1999

The development and goals of the AAFP center for policy studies in family practice and primary care. American Academy of Family Physicians.

In this article we describe the creation and role of the Center for Policy Studies in Family Practice and Primary Care established by the American Academy of Family Physicians in Washington, DC, this year. We recount the events leading to the decision to implement the Center, list its guiding assumptions, and explain its initial structure and function. We also identify the 3 themes that will guide the early work of the Center: sustaining the functional domain of family practice and primary care; investing in key infrastructures; and securing universal health coverage.

District of Columbia↗
PubMed1998

A randomized trial of nortriptyline for smoking cessation.

BACKGROUND: Smoking cessation rates with current therapy are suboptimal. One class of drugs that may improve cessation is the tricyclics. OBJECTIVE: To add nortriptyline hydrochloride to a behavioral smoking cessation program to enhance cessation rates and reduce withdrawal symptoms. SUBJECTS AND METHODS: We conducted a randomized, double-blind, placebo-controlled trial at an affiliated Department of Veterans Affairs Medical Center and an Army Medical Center. Subjects were aged 18 through 70 years, smoked 10 or more cigarettes per day, and were without current major depression. Nortriptyline hydrochloride or matched placebo was started at 25 mg before bed 10 days prior to quit day and titrated to 75 mg/d or to the maximal tolerated dose. The behavioral intervention consisted of 2 group sessions and 12 individual follow-up visits. Withdrawal symptoms were measured using a daily diary, and smoking cessation was defined as self-reported abstinence, expired carbon monoxide of 9 ppm or less, and a 6-month urine cotinine level of less than 50 ng/mL. RESULTS: A total of 214 patients were randomized (108 to nortriptyline and 106 to placebo). There was a significant reduction in several withdrawal symptoms including anxious/tense, anger/irritability, difficulty concentrating, restlessness, and impatience by day 8 after quit day in the nortriptyline group. The cessation rate at 6 months was 15 (14%) of 108 and 3 (3%) of 106, respectively (P = .003; absolute difference, 11%; 95% confidence interval, -18% to -4%). Nortriptyline caused frequent adverse effects, including dry mouth (64%) and dysgeusia (20%). CONCLUSIONS: We conclude that nortriptyline led to an increased short-term cessation rate compared with placebo. In addition, there were significant, but relatively small, reductions in withdrawal symptoms. Nortriptyline may represent a new therapeutic approach to smoking cessation.

Adrenergic Uptake Inhibitors↗
PubMed1997

Selection bias in an inpatient outcomes monitoring project.

Managed care organizations increasingly tout clinical outcomes assessment as the mechanism by which we will ensure quality and compare providers. The authors report on their experience with a multisite inpatient outcomes monitoring project by comparing patients who accepted (N = 51), refused (N = 36), or were not asked (N = 110) to participate in the project. The patients who were asked to participate had significantly longer inpatient stays compared with the unasked group (11.2 vs 6.9 days). Patients who agreed to participate in the project were more likely to have a bipolar (43.1% vs 19.2%) or any affective disorder (94.1% vs 79.5%), and less likely to have a schizophrenic disorder (2.0% vs 11.6%) than the refused and unasked groups. The project participants also had higher 90-day readmit rates (27.5% vs 9.6%), more readmissions (0.51 vs 0.16), and more education (14.59 vs 13.51 years) than nonparticipating patients. In this preliminary study, patient-related variables were found to influence who the staff asked and who consented to participate in this clinical outcomes monitoring project. The authors distinguish clinical outcomes monitoring from treatment effectiveness research and discuss the need to develop methodologies that deal with nonrepresentative patient sampling and intersite variability in recruitment practices.

Adolescent↗
PubMed1997

Impact of shorter lengths of stay on status at discharge in bipolar mania.

UNLABELLED: This study assesses the impact of shortening the inpatient length of stay on status at discharge in patients with mania. METHODS: The authors performed a chart review on 131 patients with discharge diagnoses of bipolar disorder, current episode manic type, admitted to the private attending service at Colorado Psychiatric Hospital between 1985 and 1995. In 1990, a new program (the alternatives program) that provides a continuum of acute care services and shorter inpatient lengths of stay was instituted. Retrospectively assessed GAF, CGI, treatment outcome rating scores, and length of stay (LOS) were compared for the prealternatives (1985-1989), early alternatives (1990-1992), and recent alternatives (1993-1995) program treatment eras. A progressive decrease in inpatient LOS, duration of the acute care episodes, and total service utilization was seen across eras. Despite the more recent shortening in LOS, no significant differences were seen in GAF and treatment outcome rating scores at discharge. GAF and treatment outcome rating scores on hospital days 3 and 7, however, suggested that patients were improving more rapidly in the more recent eras. Inpatient LOS and duration of the acute care episodes have significantly decreased over the last 10 years, but patients appear no more ill at discharge. The authors postulate that changes in psychopharmacologic practice and the inpatient treatment model may have facilitated the more rapid clinical improvement seen in the more recent eras. The authors caution that we need prospective studies that include postdischarge follow-up to assess further the impact of shorter inpatient stays on the posthospital course of manic patients.

Analysis of Variance↗
PubMed1997

The effects of physician in-migration to rural Colorado (1992 to 1995).

This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in-migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three-year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from nonmetropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants.

American Medical Association↗
PubMed1997

Considering school health program screening services as a cost offset: a comparison of existing reimbursements in one state.

This paper reports results of an analysis of the approximate costs of Colorado school health program screening activities during the 1993/94 school year had they been conducted elsewhere in the public or private sectors. School nurses and health aides performed 1,161,779 screening procedures during the year, an average of 1.93 per child enrolled in school districts throughout the state. Charges for Current Procedures Terminology (CPT) codes, which correspond to school health program screening activities, were used to approximate market value. Conservative assumptions were made regarding provider skill and time requirements as well as student service utilization profiles. The general dimension of the contribution of school health screening activities was found to be impressive.

Colorado↗