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Biomedical subjects

J M Gill

Publications and source records attributed to J M Gill.

At least 19 recordsLinked to original sources
PubMed2001

Moderate exercise, postprandial lipaemia and triacylglycerol clearance.

Moderate intensity exercise reduces postprandial triacylglycerol (TG) concentrations. We tested whether this reflects increased TG clearance. Eight normotriglyceridaemic men, aged 48.3 +/- 7.3 years (mean +/- SD), performed two oral fat tolerance tests (blood samples taken in the fasted state and for six hours after a high-fat meal containing 1.00 g fat, 0.97 g carbohydrate, 58 kJ energy kg-1 fat-free body mass) and two intravenous fat tolerance tests (blood samples in the fasted state and after a bolus injection of Intralipid, 0.1 g fat kg-1 body mass). The afternoon before one oral and one intravenous test, subjects walked briskly for 90 min; no exercise was performed before the control tests. Prior exercise reduced fasting TG concentration similarly in the oral (16 +/- 7 %) (mean +/- SEM) and intravenous (18 +/- 7 %) tests, and reduced postprandial TG concentrations in the oral test by 18 +/- 6 % (all P < 0.05). However, prior exercise did not increase Intralipid clearance (disappearance curve slopes: control, 4.69 +/- 0.49 % min-1; exercise, 4.85 +/- 0.40 % min-1). These data suggest that mechanisms other than increased TG clearance mediate the lower postprandial TG concentrations seen after moderate exercise.

Administration, Oral↗
PubMed2001

The impact of referral to a primary physician on cervical cancer screening.

OBJECTIVES: The purpose of this study was to determine whether referral to a primary physician led to an increase in screening for cervical cancer among women enrolled in Delaware Medicaid. METHODS: Medicaid claims data were used to compare annual Papanicolaou (Pap) test rates for women referred to a primary care physician or obstetrician (n = 365) with rates for age-matched comparison women who were not referred (n = 1799). RESULTS: Thirty-eight percent of referred women and 27% of comparison women underwent Pap tests (adjusted odds ratio = 1.71; 95% confidence interval = 1.33, 2.20). CONCLUSIONS: Referral to a primary physician had a positive impact on cervical cancer screening among the study participants.

Adolescent↗
PubMed2001

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↗
PubMed2001

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↗
PubMed2001

Effects of prior moderate exercise on exogenous and endogenous lipid metabolism and plasma factor VII activity.

Moderate exercise reduces postprandial triacylglycerol concentrations, which are a risk marker for coronary heart disease. The present study sought to determine the qualitative nature of exercise-induced changes in lipid metabolism and their association (if any) with changes in factor VII activation. Eleven normotriglyceridaemic men, aged 51.7+/-6.1 years (mean+/-S.D.), participated in two oral fat tolerance tests after different pre-conditions: control (no exercise), and exercise (90 min of brisk walking the day before). Venous blood samples were obtained in the fasted state and for 8 h after ingestion of a high-fat meal (1.32 g of fat, 1.36 g of carbohydrate, 0.30 g of protein and 10 mg of [1,1,1-(13)C] tripalmitin x kg(-1) body mass). Prior exercise reduced postprandial plasma triacylglycerol concentrations by 25+/-3% (mean+/-S.E.M.), with lower concentrations in the Svedberg flotation rate (Sf) 20--400 (very-low-density lipoprotein) fraction accounting for 79+/-10% of this reduction. There was no effect on plasma factor VII coagulant activity or on the concentration of the active form of factor VIIa. Prior exercise increased postprandial serum 3-hydroxybutyrate and plasma fatty acid concentrations, decreased serum postprandial insulin concentrations and increased exogenous (8 h (13)C breath excretion of 15.1+/-0.9% of ingested dose compared with 11.9+/-0.8%; P=0.00001) and endogenous postprandial fat oxidation. These data raise the possibility that reduced hepatic secretion of very-low-density lipoprotein plays a role in the attenuation of plasma triacylglycerol concentrations seen after exercise, although it is possible that increased triacylglycerol clearance also contributes to this effect.

Aged↗
PubMed2001

Impact of an electronic medical record on quality of care in a primary care office.

OBJECTIVE: To determine whether or not implementation of an electronic medical record (EMR) in a primary care office is associated with an increase in completion of preventive care for a general population of adults and children, and for adults with diabetes mellitus. DESIGN: Observational cohort study that compared the change in completion rate of recommended interventions from before to one year after implementation of an EMR. The EMR was designed for direct interaction by providers and included guidelines for preventive care as well as automated prompts for when interventions were due. MEASUREMENTS: Patients were selected from a family medicine teaching practice in Delaware that implemented an EMR in July of 1998. We examined completion of recommended interventions for adults (influenza and pneumococcal immunizations, mammograms and cholesterol screening), children (hepatitis B and varicella immunizations) and adults with diabetes mellitus (monitoring for glycosylated hemoglobin and cholesterol, influenza and pneumococcal immunizations). Completion rates were compared from before to one year after EMR implementation. RESULTS: The number of persons analyzed ranged from 117 for diabetes interventions to 1148 for cholesterol screening. Completion rates increased from before to after EMR implementation for all outcomes studied. The largest increases were seen for mammograms (28.7 percent to 52.5 percent), varicella immunizations (29.6 percent to 55.9 percent), glycosylated hemoglobin (53.0 percent to 80.3 percent) and influenza immunization for persons with diabetes (29.7 percent to 55.1 percent). CONCLUSION: Implementation of a primary care EMR was associated with a substantial increase in completion of recommended preventive care across a broad spectrum of interventions and populations.

Delaware↗
PubMed2000

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↗
PubMed2000

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↗
PubMed2000

Postprandial lipemia: effects of exercise and restriction of energy intake compared.

BACKGROUND: The mitigating effect of exercise on postprandial lipemia may be attributable to the energy deficit incurred. OBJECTIVE: We aimed to compare the effects of prior exercise and an equivalent energy intake deficit on postprandial lipemia. DESIGN: Eleven postmenopausal women participated in 3 oral-fat-tolerance tests after undergoing different treatments on the preceding day: control (subjects refrained from exercise and consumed a prescribed diet), exercise (subjects consumed the same diet but walked briskly for 90 min), and intake restriction (subjects' food intake was restricted to induce the same energy deficit, relative to control, as brought about by the 90-min walk). Venous blood samples were obtained after subjects fasted overnight, 30 min after they ate a mixed, high-fat meal (1.70 g fat, 1.65 g carbohydrate, and 99 kJ/kg fat-free body mass), and hourly for the next 6 h. RESULTS: In the exercise trial, the mean fasting triacylglycerol concentration was 19% and 17% lower than the control and intake restriction values, respectively (P < 0.05 for both). Compared with the control trial, exercise reduced postprandial lipemia by a mean of 20% (P < 0.05), whereas intake restriction reduced it by 7% (NS). In the exercise trial, fasting and postprandial fatty acid concentrations were higher than control values (P < 0.05). Exercise, but not intake restriction, reduced postprandial insulin concentrations. CONCLUSIONS: The results suggest that the effect of exercise on postprandial lipid metabolism was greater than and different from that attributable to the energy deficit incurred.

Blood Glucose↗
PubMed2000

The impact of a computerized physician reminder and a mailed patient reminder on influenza immunizations for older patients.

PURPOSE: To examine the impact of a computerized physician reminder in combination with a mailed patient reminder on the rate of influenza immunizations for older adults in a large family medicine office in Delaware. METHODS: In July of 1998, the Christiana Care Foulk Road Family Medicine Center (FMC) implemented an electronic patient record which included automated physician reminders for when influenza immunizations and other preventive interventions were due. In addition, FMC patients ages 65 years and older were sent a mailing urging them to receive an influenza immunization in 1998. Medical records were reviewed for active FMC patients ages 65 and older. Rates of receipt of influenza immunization were compared for the year before (1997) and after (1998) these two interventions were implemented. A secondary analysis compared influenza immunization rates for three different age groups (65-74 years, 75-85 years, over 85 years). RESULTS: For the 344 patients in the main study population, influenza immunization rates increased from 50.4 percent in 1997 to 61.6 percent in 1998 (p < 0.001). Immunization rates were lowest for persons over age 85 years, and rates increased significantly in the two younger groups but not in those over age 85 years. CONCLUSIONS: This study indicates that the use of a computerized physician reminder and a mailed patient reminder had a positive impact on influenza immunizations for older adults in a large family practice office. This combination strategy resulted in immunization rates that exceed published national goals, although there is still room for improvement, particularly for the oldest age group. These results support the notion that electronic patient records (EPRs) and other computerized reminder systems can significantly improve quality of care in office based settings.

Aged↗
PubMed1999

Using mailed patient reminders to increase influenza immunization rates among older adults in a primary care office.

PURPOSE: To examine the impact of mailed patient reminders on the rate of influenza immunizations for older adults in a large family medicine office in Delaware. METHODS: In October 1996, all patients ages 65 years and older who were established patients of the Christiana Care Foulk Road Family Medicine Center were sent a mailing urging them to receive an influenza immunization. Medical records were abstracted for each patient to determine receipt of an influenza immunization in 1995, 1996 and 1997. The proportion of patients who received an influenza immunization in the year prior to the reminder (1995) was compared to the proportion who received an immunization the year the reminder was sent (1996). A secondary analysis examined influenza immunization rates in the subsequent year (1997), when no reminder was sent. RESULTS: Of the 289 patients in the main study population, 41.8 percent received an influenza immunization in 1995, while 55.4 percent received an immunization in 1996 (p < 0.0001). Immunization rates in 1997 did not change significantly from 1996, and continued to be significantly higher than in 1995. Rates were somewhat lower for persons ages 85 years and older compared to younger groups. CONCLUSIONS: This study indicates that a mailed patient reminder had a positive impact on influenza immunizations for older adults in a large family practice office. This is a relatively simple strategy that, if widely used, could have a major impact on the health of older adults in Delaware.

Adult↗
PubMed1998

Postprandial lipemia: effects of intermittent versus continuous exercise.

PURPOSE: The purpose of this study was to assess whether exercise performed in continuous and discontinuous formats reduced postprandial lipemia to a similar degree. METHODS: Fifteen normolipidemic and three borderline hyperlipidemic healthy males (ages 30.6 +/- 9.0 (mean +/- SD) yr, BMI 23.1 +/- 1.4 kg.m-2) participated in three trials, each conducted over 2 d. Subjects refrained from exercise for the 2 d preceding each trial. On day one, subjects rested (control trial), or ran at 60% of maximal oxygen uptake in either one 90-min session (continuous exercise trial), or three 30-min sessions (intermittent exercise trial). On day two, subjects ingested a high-fat test breakfast (1.2 g fat, 1.2 g carbohydrate, 70 kJ energy per kilogram body mass). Blood samples were obtained in the fasted state and at intervals for 6 h postprandially. RESULTS: Fasting plasma triacylglycerol (TAG) concentrations did not differ between trials. Areas under the TAG versus time curves were 18.1 +/- 6.7% (mean +/- SEM) and 17.7 +/- 7.6% (both P < 0.05) lower than control in the continuous exercise and intermittent exercise trials, respectively. Plasma glucose responses to the test meal did not differ between trials, but the serum insulin response was lower in the intermittent exercise trial compared with that in the control. CONCLUSION: The results suggest that both intermittent and continuous exercise can reduce postprandial lipemia.

Adult↗
PubMed1998

The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician?

OBJECTIVES: This study examined the effect of continuity with clinicians and health care sites on likelihood of future hospitalization. METHODS: Delaware Medicaid patient data were analyzed. Logistic regression models supplied adjusted effects of continuity on hospitalization. RESULTS: Patients in the high clinician continuity group had lower odds of hospitalization than patients in the high site/low clinician continuity group (odds ratio [OR] = 0.75, 95% confidence interval [CI] = 0.66, 0.87). The latter group did not differ from the low site/low clinician continuity group (OR = 0.93, 95% CI = 0.80, 1.08). CONCLUSIONS: A location providing health care without clinician continuity may not be sufficient to ensure cost-effective care.

Adolescent↗
PubMed1998

Improving preventive care for women: impact of a performance improvement program in a family practice office.

PURPOSE: In 1993, the Family Medicine Center (FMC) at the Medical Center of Delaware (MCD) implemented a performance improvement (PI) program to increase rates of adult preventive care. This program included adoption of evidence-based preventive care guidelines, education of physicians and nurses regarding these guidelines, development of a flow sheet for tracking preventive care on office charts, and adoption of a policy of nurse review to alert physicians of which preventive services are due. The purpose of this study was to determine whether this PI program had a positive impact on the delivery of preventive care to female patients of the FMC. METHODS: A retrospective chart review was conducted for 280 female patients of the FMC ages 40-75. We determined the percentage of women who had received appropriate screening for breast and cervical cancer as well as appropriate immunizations, according to the guidelines of the US Preventive Services Task Force. These percentages were compared for the three year time periods before and after the PI program was implemented (July, 1990-June, 1993 and July, 1993-June, 1996). RESULTS: Prior to implementation of the PI program, PAP smears were completed in 65.3 percent of women, mammograms in 70.3 percent, breast exams in 44.2 percent, flu shots in 29.6 percent and tetanus shots in 15.5 percent. After the program, these percentages increased for all preventive services, especially PAP smears which increased by 12 percent and tetanus shots which tripled. After the program, the rate of flu shots was still low at 37 percent. CONCLUSIONS: After implementation of a PI program at the FMC, performance of preventive care for female patients improved for both cancer screening and immunizations. This improvement suggests that an office-based strategy can improve performance of preventive care, especially if it incorporates the active involvement of nursing staff. However, there is still room for further improvement, notably with completion of flu shots. These improvements will likely require additional strategies, such as computerized tracking systems and preventive care reminders to patients.

Adult↗
PubMed1997

Improving childhood immunizations in a family practice office.

PURPOSE: In the fall of 1993, the Family Medicine Center (FMC) of the Medical Center of Delaware instituted an office-based program designed to improve preventive care for children. This study examined whether the "Pediatric Prevention Program" (PPP) resulted in an improvement in childhood immunization rates for FMC patients. METHODS: Using chart review, we compared the percentage of two-year-old FMC patients who had completed appropriate immunizations before and after the PPP. We examined completion rates for the primary series of each immunization, for booster immunizations and for the combined total immunization series (four DPTs, three OPVs, one MMR, four HIBs). We also determined whether immunization rates were affected by patient demographics, pattern of office visits, and physician level of experience. RESULTS: After implementation of the program, the percentage of 2-year-old children who had completed the appropriate immunizations increased for all types of immunizations. The increase was greatest for HIBs (6 percent for the primary HIB series and 7 percent increase for the HIB booster) and for the combined total series (10 percent increase). Children who made few office visits were the least likely to have completed immunizations, but also saw the greatest benefit from the PPP. CONCLUSIONS: This study shows the positive impact of an office-based intervention for improving childhood immunizations. However, the improvements are relatively small and not sufficient to achieve optimal immunization rates throughout the community. In order to achieve these goals, additional interventions are needed which target high risk children, especially those who change physicians or who visit their physician infrequently. Targeting such children will likely require better data systems to track immunizations both in the office and across the community. These efforts should be given a high priority in Delaware.

Child, Preschool↗