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Biomedical subjects

J M Gill

Publications and source records attributed to J M Gill.

At least 37 records · Page 2Linked to original sources
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

A presumed inherited spongiform leucoencephalomyelopathy of Romney lambs in New Zealand.

This paper records a unique ovine encephalomyelopathy seen on several farms in the Otago Region of New Zealand. It occurred in 2-3 month-old Romney lambs as a rapidly progressive posterior paresis leading to flaccid paralysis. Pathologically, it was characterised by severe spongy vacuolation of white matter in both brain and spinal cord. It is suspected that the condition is inherited.

Journal Article↗
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↗
PubMed1997

Can hospitalizations be avoided by having a regular source of care?

BACKGROUND AND OBJECTIVES: This study sought to determine whether Medicaid patients with a regular source of care (RSOC) are less likely to be hospitalized, either for all conditions or for ambulatory care sensitive conditions (ACSCs), than those without an RSOC. METHODS: This population-based survey study examined Delaware Medicaid patients ages 0-64 over a 1-year period from September 1992 to August 1993 (n = 22,862). Patients who had made more than 50% of their physician office visits to the same provider group were considered to have an RSOC. The probability of hospitalization for all conditions and for ACSCs was compared for persons with and without an RSOC. RESULTS: Eighty-one percent of Medicaid clients had an RSOC, 75% of whom were primary care physicians. Persons with an RSOC were not less likely than those without an RSOC to be hospitalized for any condition (15% versus 14.6%) or for ACSCs (3.4% versus 3.2%). The results were not substantially different for persons who used primary care physicians as their RSOC. CONCLUSIONS: Having an RSOC is not associated with a lower likelihood of hospitalization for the Medicaid population, either for all conditions or for ACSCs. While providing access to care may have other positive benefits, simply providing Medicaid patients with an RSOC is unlikely to result in a short-term reduction in hospital admissions.

Adolescent↗
PubMed1996

Disagreement among health care professionals about the urgent care needs of emergency department patients.

STUDY OBJECTIVE: To assess agreement among health professionals with regard to the need for urgent care among emergency department patients. METHODS: We conducted a chart review of 266 ED patients in an urban teaching hospital. Eight health professionals (four emergency nurses, two emergency physicians, two family physicians) used identical criteria to retrospectively rate urgency. Agreement was measured for all reviewers, as well as among health professionals of the same specialty. Agreement was also measured between one ED nurse's retrospective assessment and the prospective assessments of the triage nurses who had seen the patients on presentation. RESULTS: The percentage of patients rated as needing urgent care by the retrospective reviewers ranged from 11% to 63%. Agreement among the retrospective reviewers was fair (kappa = .38; 95% confidence interval, .30 to .46) and was no better among reviewers of the same specialty. We found only slight agreement between the nurse reviewer's retrospective assessment and the triage nurses' prospective assessments (kappa = 19; 95% confidence interval, .07 to .31). CONCLUSION: Even when using the same criteria, health professionals frequently disagree about the urgency of care in ED patients. When retrospective reviewers disagree with a prospective assessment of urgency, the potential exists for denial of payment or even lawsuits. Because the subjectivity of urgency definitions may increase disagreement, the development of more objective and uniform definitions may help improve agreement.

Adolescent↗
PubMed1996

A mathematical model for analysis of pharmacologically induced changes in the kinetics of cardiac muscle.

A mathematical model of the isometric contraction of cardiac muscle is developed and utilized to characterize the inotropic and lusitropic effects of cardioactive compounds in isolated guinea pig left atria. In contrast to metrics that are based on minima and maxima of an isometric twitch and its derivative function, the entire time course of the twitch is used to quantify the kinetics of the contraction-relaxation cycle. The model relates observed tension to a time-dependent activation function that describes generation of internal force and a coupling function that determines mechanical response to the activation function. The model is structured so that it is suitable for nonlinear curve fitting to observed data. Results obtained using the model for fitting experimental data from tissues treated with different classes of cardioactive compounds agree with more qualitative results presented by other authors. Experiments using the model to fit data over an extended (90 min) time course revealed differences in the kinetic profiles of milrinone and forskolin. Computer simulations that demonstrate the effect of each model parameter on twitch kinetics are presented, and the relationships between the model and other theoretical and empirical models of cardiac muscle are discussed. The mathematical model is useful to enable a more quantitative understanding of the kinetics of cardiac muscle contraction and relaxation and identify compounds that may be selective for inotropic or lusitropic effects.

Animals↗
PubMed1996

Nonurgent use of hospital emergency departments: urgency from the patient's perspective.

BACKGROUND: Patients often seek care from hospital emergency departments (EDs) for conditions medical personnel perceive as nonurgent. The purpose of this study was to examine ED patients' perceptions of urgency, and to determine whether patients with no regular source of medical care are more likely to use the ED for problems they perceive as nonurgent. METHODS: We surveyed 268 patients in an urban ED waiting area who were considered nonurgent by the ED triage nurse. Using structured interviews, we determined patients' perceptions, about the urgency of their medical condition, whether they had a regular source of medical care, and their reasons for choosing the ED for care. After controlling for other variables, we determined whether having non regular source of care was associated with patient-rated nonurgent ED utilization. RESULTS: Eighty-two percent of patients rated their condition as urgent. Patient-rated urgency was not associated with having a regular source of care. The most common reason for seeking care in the ED was expediency. CONCLUSIONS: A large majority of ED patients perceive the problems for which they seek care from an ED as urgent, even when they are assessed as nonurgent by a health professional. Lack of a regular source of care has no significant impact on ED utilization for problems that patients perceive as nonurgent. Simply providing patients with a regular source of care is unlikely to have a significant impact on nonurgent ED utilization without efforts to manage utilization and ensure adequate access to primary care.

Adolescent↗
PubMed1996

Physician performance of preventive care for women.

BACKGROUND: The purpose of this study was to examine whether academic primary care physicians recommended appropriate preventive care to their female patients, whether recommendations differed for different types of physicians, and how often these recommendations led to completion of the preventive service. METHODS: A retrospective chart review was conducted in the family medicine and internal medicine outpatient practices at the Medical Center of Delaware (MCD). A total of 324 women ages 40 and over were selected from the patient panels of nine faculty and 14 residents. Physician recommendation of PAP smears, mammograms, breast exams, and influenza immunizations were measured against the guidelines of the U.S. Preventive Service Task Force. Specifically examined was whether rates of recommendation differed by specialty, gender and faculty/resident status of the physician. Also measured was completion of each preventive service and whether rates of completion differed from rates of physician recommendation. RESULTS: Physicians recommended appropriate PAPs in 72 percent of patients, mammograms in 83 percent of patients, breast exams in 46 percent of patients and influenza immunizations in 30 percent of patients. Family physicians were more likely to recommend PAP smears (odds ratio 5.53, 95 percent confidence interval 2.26-12.98), but not more likely to recommend other services; female physicians were more likely to recommend breast exams (odds ratio 3.48, 95 percent confidence interval 2.05-5.89), but not other services. There were no significant differences between faculty and residents. Preventive services were completed in 48 percent of patients for PAPs, 68 percent for mammograms, 42 percent for breast exams, and 27 percent for flu shots. CONCLUSIONS: In academic primary care practices at MCD, physicians perform well in recommending PAPs and mammograms, but not in recommending breast exams or influenza immunizations. There were few differences in performance among different types of physicians. Because many women did not follow through with their physicians' recommendations for preventive care, physician performance is more accurately measured according to their recommendations rather than completion of services. Efforts to improve preventive care in women should differ depending on whether the problem lies in physician performance or patient behavior.

Adult↗
PubMed1996

Effect of primary care referral on emergency department use: evaluation of a statewide Medicaid program.

BACKGROUND AND OBJECTIVES: Medicaid recipients without a regular source of care frequently use hospital emergency departments (EDs) for minor problems. This study examined whether referring Medicaid patients to primary care physicians and obstetricians results in a decrease in ED use and an increase in physician office visits. METHODS: The statewide Voluntary Initiative Program (VIP), which referred Medicaid patients to primary care physicians and obstetricians without any managed care component, was examined. Claims data were reviewed for Medicaid clients 0-64 years old who obtained VIP referrals during the first five months of the program. The change in rate of visits to hospital EDs and physician offices was compared for the study group (n = 444) and for the state's overall Medicaid population (n = 40,860). RESULTS: After referral, ED use decreased 24 percent for the VIP group and 4 percent for the Medicaid population. During the same period, physician office visits increased 50 percent for the VIP group but decreased 13 percent for the Medicaid population. CONCLUSIONS: Even in the absence of managed care, referral to primary care physicians and obstetricians resulted in fewer ED visits and more physician office visits. These findings confirm the importance of primary care in improving the efficiency of health care delivery for the Medicaid population.

Adolescent↗
PubMed1996

Effect of primary care referral on emergency department use: evaluation of a statewide Medicaid program.

BACKGROUND AND OBJECTIVES: Medicaid recipients without a regular source of care frequently use hospital emergency departments (EDs) for minor problems. This study examined whether referring Medicaid patients to primary care physicians and obstetricians results in a decrease in ED use and an increase in physician office visits. METHODS: The statewide Voluntary Initiative Program (VIP), which referred Medicaid patients to primary care physicians and obstetricians without any managed care component, was examined. Claims data were reviewed for Medicaid clients 0-64 years old who obtained VIP referrals during the first 5 months of the program. The change in rate of visits to hospital EDs and physician offices was compared for the study group (n = 444) and for the state's overall Medicaid population (n = 40,860). RESULTS: After referral, ED use decreased 24% for the VIP group and 4% for the Medicaid population. During the same period, physician office visits increased 50% for the VIP group but decreased 13% for the Medicaid population. CONCLUSIONS: Even in the absence of managed care, referral to primary care physicians and obstetricians resulted in fewer ED visits and more physician office visits. These findings confirm the importance of primary care in improving the efficiency of health care delivery for the Medicaid population.

Adolescent↗
PubMed1995

The generation of anchoring fibrils by epidermal keratinocytes: a quantitative long-term study.

Anchoring fibrils (AFs) are derived from basal keratinocytes, but the kinetics of their formation is unknown. In this study, de novo generation of AFs by cultured human keratinocyte autografts was assessed from 1 week to 6 years postgrafting. Within 2 weeks, AF population densities were equal to those of normal controls and remained normal thereafter. However, AF diameters were narrow compared to controls (P < 0.05) until 3 years postgrafting. The depth of extension of AF-anchoring plaque lattices into the subjacent stroma was normal by 3 weeks but, after 1 month, was typically 1.5-to 2-fold greater than normal. The findings indicate that: (1) basal keratinocytes immediately re-establish a full complement of AFs; (2) once reformed, AF populations remain normal in density over time; (3) nascent AFs are thin and require several years to reach full maturity; and (4) abnormally thick AF lattices may form over time in healed wounds.

Basement Membrane↗
PubMed1994

Nonurgent use of the emergency department: appropriate or not?

People often assume that the use of hospital emergency departments for nonurgent problems is inappropriate. To test this assumption, several questions must be answered. These include, "How do we determine what is appropriate use of an ED?"; "How can we measure urgency in the ED?"; "Is care for nonurgent problems less effective in an ED than in a primary care facility?"; and "Is nonurgent care more costly in an ED than in a primary care facility?" These four questions are addressed, and suggestions for future research that would help answer these questions are made.

Efficiency, Organizational↗
PubMed1993

Deaths in yellow-eyed penguins (Megadyptes antipodes) on the Otago Peninsula during the summer of 1990.

About 150 rare, adult, yellow-eyed penguins died over a short period during the summer of 1989-1990 on the Otago Peninsula. These were from a total mainland population estimated at 240 breeding pairs. Penguin chicks and non-breeding birds were not affected, but there were indications of shortages in feed supply for birds that bred successfully. Thirteen dead penguins were examined. In ten birds, the cause of death was not established. Although it was commonly found that adult birds had little or no food in their gut, none were considered to have starved to death. No consistent pathological lesions were found, nor were any viruses, Chlamydia or significant bacteria recovered from selected tissues. Toxicology tests ruled out poisoning by copper, zinc, iron, lead, arsenic, selenium, cadmium, mercury, organophosphates, organochlorines, polychlorinated biphenyls, hexachlorobenzene or the toxins of Clostridium perfringens, Clostridium botulinum and dinoflagellates. The problem did not recur during the following summer.

Journal Article↗