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Biomedical subjects

J Melnikow

Publications and source records attributed to J Melnikow.

30 records · Page 2Linked to original sources
PubMed1993

Adequacy of prenatal care among inner-city women.

BACKGROUND: Lack of prenatal care is a well-recognized risk factor for infant mortality and low birthweight. This study was conducted to identify factors that facilitate or inhibit access to prenatal care among low-income inner-city women. METHODS: A case-control interview study was conducted with women during their postpartum hospitalization at a midwestern inner-city hospital. Fifty-eight women who had received no prenatal care and 71 women who had received markedly inadequate prenatal care were compared with 123 controls who had received intermediate or adequate prenatal care. RESULTS: The majority of subjects were minorities, single, had low incomes, and were in the Medicaid program. Subjects' median age was 23 years and median parity 2, and the majority had not completed high school. Inadequate prenatal care was independently associated with the following variables (adjusted odds ratios): lack of any insurance, including Medicaid (5.3), being a smoker (3.8), being homeless (2.7), being black (2.5), not being worried what the physician or nurse might say (2.4), not using contraception (2.1), having a household income of less than $400 a month (1.8), being ashamed or afraid of the pregnancy or the physician (1.4), having transportation problems (1.3), and level of education (0.8). CONCLUSIONS: Practical factors related to poverty are substantial barriers to obtaining prenatal care. Comprehensive approaches to prenatal services that address these barriers may be more effective in facilitating adequate prenatal care among low-income women.

Adolescent↗
PubMed1993

Asthma health status. Ongoing measurement in the context of continuous quality improvement.

There are no widely accepted measures of health status for asthmatic patients, and these must be developed. Criteria for good health status measures are described. Their intended use determines their form. The concepts of continuous quality improvement (CQI) are used here to define a new perspective about asthma health status measures. In the context of CQI, a patient-centered continuous measurement can be used to understand and reduce variance in health status. Ongoing health status measures can be applied to groups of patients or individuals. Medical students collected data about the health status of their asthmatic patients as part of a project to introduce them to CQI. These results are presented as an example of this new direction.

Asthma↗
PubMed1992

Promoting successful breast-feeding skills.

Breast milk provides ideal nutrition for the newborn infant. More than half of mothers intend to breast-feed, yet many are unsuccessful at sustaining breast feeding beyond the first few weeks postpartum. Preparation for breast feeding should begin during prenatal care. Breast feeding early and often in the postpartum period promotes establishment of the milk supply. Attention to proper positioning is essential to successful nursing. The family physician can be especially helpful in the early postpartum weeks, when many mothers become discouraged and discontinue breast feeding. Formula supplements should be avoided in the early postpartum period. Most problems, such as sore nipples, engorgement and pain with latch-on, subside after several weeks; symptomatic relief and emotional support from the family physician during this period are crucial.

Breast Feeding↗
PubMed1992

Physician agreement with US Preventive Services Task Force recommendations.

BACKGROUND: No large-scale work has yet assessed the reactions of physicians to the report of the US Preventive Services Task Force (USPSTF), despite its potential for fostering a consensus among practitioners. This study undertook a survey of family physicians to assess their agreement with the recommendations of the Task Force. METHODS: A survey containing the verbatim summary recommendations of the USPSTF was mailed to all 1784 active members of the Ohio Academy of Family Physicians. RESULTS: No evidence of selection bias was found among the 898 responding physicians. The average physician agreed with 88% of the recommendations. For a number of recommendations, however, particularly those in which the Task Force differed with the American Cancer Society, there was a high level of disagreement. Physician disagreement with the recommendations was associated with older age, not having completed a residency, male sex, less prior exposure to the USPSTF guidelines, and greater perception of the impracticality of applying them. CONCLUSIONS: The high level of agreement with most USPSTF recommendations implies that they represent an emerging consensus about which preventive services should be delivered. Attempts at USPSTF guideline dissemination should focus on recommendations with high agreement. Additional research is needed to assess the reasons for disagreement.

Age Factors↗
PubMed1991

Introducing quality improvement thinking to medical students: the Cleveland asthma project.

This article describes a medical school's effort to introduce quality improvement (QI) concepts and methods through experiential learning to students as part of a required eight-week primary care clerkship. Each student describes a patient with asthma, investigates the cost of care, and assesses the outcome through an interview with the patient. These patients are considered together as recipients of an areawide process of care. The statistical tools of QI were adapted in a workbook to help students understand care as a process and their role as physicians in improving it.

Algorithms↗
PubMed1991

Characteristics of inner-city women giving birth with little or no prenatal care: a case-control study.

Lack of prenatal care has been identified as an important risk factor for poor perinatal outcomes. A case-control study was conducted to identify risk factors for inadequate prenatal care. Records of women giving birth at an inner-city hospital who had fewer than three prenatal visits (cases) were compared with those of women giving birth at the same hospital who had more adequate prenatal care (controls). The final sample contained 120 women in each group. Women in the case group were more likely to be multiparous, to be less educated, and to have no telephone in the home. Tobacco and drug abuse were recorded significantly more often among these women. There was no difference in racial distribution between the case and control groups. Infants of women with minimal or no prenatal care had a lower mean birthweight and a higher frequency of prematurity. In logistic regression analysis, higher parity, age less than 30 years, single status, smoking, drug abuse, and residence in one of two statistical planning areas in the city were independently associated with increased odds of not receiving prenatal care. To be effective, prenatal outreach programs for inner-city women must be based on knowledge of the characteristics and needs of this population.

Adult↗
PubMedDate not supplied

Do follow-up recommendations for abnormal Papanicolaou smears influence patient adherence?

OBJECTIVE: To compare adherence to follow-up recommendations for colposcopy or repeated Papanicolaou (Pap) smears for women with previously abnormal Pap smear results. DESIGN: Retrospective cohort study. SETTING: Three northern California family planning clinics. PATIENTS: All women with abnormal Pap smear results referred for initial colposcopy and a random sample of those referred for repeated Pap smear. Medical records were located and reviewed for 90 of 107 women referred for colposcopy and 153 of 225 women referred for repeated Pap smears. INTERVENTION: Routine clinic protocols for follow-up--telephone call, letter, or certified letter--were applied without regard to the type of abnormality seen on a Pap smear or recommended examination. MAIN OUTCOME MEASURES: Documented adherence to follow-up within 8 months of an abnormal result. Attempts to contact the patients for follow-up, adherence to follow-up recommendations, and patient characteristics were abstracted from medical records. The probability of adherence to follow-up vs the number of follow-up attempts was modeled with survival analysis. Cox proportional hazards models were used to examine multivariate relationships related to adherence. RESULTS: The rate of overall adherence to follow-up recommendations was 56.0% (136/243). Adherence to a second colposcopy was not significantly different from that to a repeated Pap smear (odds ratio, 1.40; 95% confidence interval, 0.80-2.46). The use of as many as 3 patient reminders substantially improved adherence to follow-up. Women without insurance and women attending 1 of the 3 clinics were less likely to adhere to any follow-up recommendation (hazard ratio for no insurance, 0.43 [95% confidence interval, 0.20-0.93], and for clinic, 0.35 [95% confidence interval, 0.15-0.73]). CONCLUSIONS: Adherence to follow-up was low in this family planning clinic population, no matter what type of follow-up was advised. Adherence was improved by the use of up to 3 reminders. Allocating resources to effective methods for improving adherence to follow-up of abnormal results may be more important than which follow-up procedure is recommended.

Adolescent↗
PubMedDate not supplied

Cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis.

BACKGROUND: The new Centers for Disease Control and Prevention treatment guidelines for Chlamydia trachomatis include two recently available drugs, azithromycin and ofloxacin. The best choice for initial therapy remains controversial. OBJECTIVES: We wanted to perform a cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis. METHODS: Using information gathered from a MEDLINE search of the English language literature from 1966 to 1994, employing the key words "cervicitis," "C. trachomatis," "erythromycin," "tetracycline," "doxycycline," "ofloxacin," and "azithromycin," we developed a decision analysis model specific for a nonpregnant woman with uncomplicated Chlamydia trachomatis cervicitis. Options in this model included an initially cured infection, a failed initial cure resulting in persistent cervicitis, or pelvic inflammatory disease treated either on an inpatient or outpatient basis. Probability estimates for each option were derived from previously published reports. A cost-effectiveness analysis was performed for three end points: cost per cure with initial therapy, cost per case of pelvic inflammatory disease averted, and cost per hospitalization averted. Sensitivity analyses were done by varying the cure rates for each antibiotic and the complication rates for failed therapy. The costs incurred for treatment were also varied. RESULTS: Using the high estimate for initial cure rates, doxycycline and tetracycline were the most cost-effective agents. Azithromycin was the next most cost-effective agent, followed by ofloxacin and erythromycin. To achieve an equivalent final cost, the probability of initial cure with azithromycin must exceed that of doxycycline by 3 percentage points. As the cost of azithromycin decreases, the difference in initial cure rates between the two drugs to achieve an equivalent final cost becomes smaller. CONCLUSIONS: Doxycycline remains the drug of choice in the treatment of Chlamydia trachomatis cervicitis. The results favor the use of azithromycin rather than doxycycline when there is concern for compliance to the standard doxycycline regimen. A lower cost for azithromycin could favor its use as the drug of choice.

Anti-Bacterial Agents↗
PubMedDate not supplied

Is cervicography a useful diagnostic test? A systematic overview of the literature.

BACKGROUND: The appropriate approach to women with mild dyskaryotic changes on Papanicolaou smear is subject to controversy. Our aim was to assess the usefulness of cervicography as a diagnostic test in detecting cervical cancer or its precursors. METHODS: We undertook an extensive literature search looking for pertinent studies of cervicography published between 1966 and 1996. Eligible studies included those in which the reference standard (colposcopy) was done on all patients. The following information was calculated: sensitivity, specificity, positive predictive value, negative predictive value, disease prevalence, and likelihood ratios. RESULTS: Cervicography has a high false-positive rate. This rate ranged from 8.2 to 61.0 percent (median 42.1 percent) for any dysplasia and 9.8 to 63.4 percent (median 50.6 percent) for high-grade cervical lesions. Likelihood ratios for a positive test result ranged from 1.0 to 10.6. Likelihood ratios for a negative result ranged from 0.02 to 1.0. CONCLUSIONS: The usefulness of cervicography is heavily dependent on the approach used to evaluate abnormal findings on a Papanicolaou smear. If a provider typically offers colposcopy to all patients with low-grade cytologic findings on a Papanicolaou smear, cervicography will decrease colposcopy use and allow for detection of cases of high-grade dysplasia missed by the index Papanicolaou smear. If a provider typically uses watchful waiting with repeat Papanicolaou smears for all patients who have low-grade cytologic findings, cervicography will substantially increase the use of colposcopy. Many of these colposcopies will be done as a result of false-positive cervigrams.

Female↗