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Biomedical subjects

K Grumbach

Publications and source records attributed to K Grumbach.

At least 37 records · Page 2Linked to original sources
PubMed1999

Hormone replacement therapy for African American women: missed opportunities for effective intervention.

OBJECTIVES: Because of the potential benefits and risks of hormone replacement therapy (HRT), information about the efficacy of HRT in different groups of women is important to patients and providers. The objectives of this study were to review the evidence on the benefits and risks of HRT in African American women and to present a quantitative analysis of the potential reduction in mortality from osteoporotic fractures and coronary heart disease and the potential increase in risk of breast and endometrial cancer. METHODS: A MEDLINE search of English-language observational studies and clinical trials on the effects of HRT on osteoporotic fractures and coronary heart disease (CHD) was conducted for the time period from 1966 to September 1998. Using available CHD mortality data for African American women and white women, potential reductions in mortality with HRT were explored for African American and white women. RESULTS: In the 30 studies on CHD and HRT, African American women were known to comprise only 173 (0.1%) of 148,437 participants. In 11 studies of HRT and osteoporotic fractures, only 128 (0.4%) of 40,299 participants were known to be African American women. An analysis of CHD mortality by decade intervals indicated that African American women, aged 55 to 64, are more likely to die from CHD each year than white women. Despite a lower incidence of breast and endometrial cancer among African American women, the mortality rates of African American women with these cancers is higher compared with white women. CONCLUSIONS: With the higher underlying CHD mortality rate among African American women, HRT is an important potential preventive therapy. The absence of African American women and other non-white women from clinical studies of HRT makes it difficult to fully assess the risks and benefits of HRT in this group of women.

Black or African American↗
PubMed1998

Primary care physicians' experience of financial incentives in managed-care systems.

BACKGROUND: Managed-care organizations' use of financial incentives to influence the practice of primary care physicians is controversial. We studied the prevalence and effects of these incentives. METHODS: We surveyed a probability sample of primary care physicians practicing in the largest urban counties in California in 1996. The physicians were asked about the types of incentives they encountered, the amount of income that was keyed to incentives, their experience of pressure in their practices, and the ways in which such pressure affected patient care. RESULTS: Data were analyzed for 766 physicians involved in managed-care systems. Thirty-eight percent of these physicians reported that their arrangements with the managed-care system included some type of incentive in the form of a bonus. Fifty-seven percent of the physicians reported that they felt pressure from the managed-care organization to limit referrals (17 percent said they believed such pressure compromised patient care), and 75 percent felt pressure to see more patients per day (24 percent believed such pressure compromised patient care). The physicians who reported that their financial arrangements included an incentive based on referrals were more likely than others to have felt pressured to limit referrals in a manner that compromised care (adjusted odds ratio 2.5; 95 percent confidence interval, 1.2 to 5.0), and physicians with an incentive based on productivity were more likely to have felt pressure to see more patients that they believed compromised care (adjusted odds ratio, 2.1; 95 percent confidence interval, 1.2 to 3.8). The physicians whose health care systems used incentives keyed to productivity were less likely than others to be very satisfied with their practices (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.6), whereas those whose systems included incentives related to the quality of care or patients' satisfaction were more likely to be very satisfied (adjusted odds ratio, 1.8; 95 percent confidence interval, 1.1 to 3.0). CONCLUSIONS: Many managed-care organizations include financial incentives for primary care physicians that are indexed to various measures of performance. Incentives that depend on limiting referrals or on greater productivity apply selective pressure to physicians in ways that are believed to compromise care. Incentives that depend on the quality of care and patients' satisfaction are associated with greater job satisfaction among physicians.

Attitude of Health Personnel↗
PubMed1998

The fall and rise of carotid endarterectomy in the United States and Canada.

BACKGROUND: Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy in the prevention of stroke when the procedure is performed in regional centers of surgical excellence. However, the relative effects of these studies on the rates of carotid endarterectomy in the United States and Canada have been unclear. METHODS: We calculated the annual rate of carotid endarterectomy in the U.S. states of California and New York and in the Canadian province of Ontario from 1983 through 1995. We also studied whether patients in the early 1990s were selectively referred to hospitals with high volumes of procedures and historically low in-hospital mortality rates. RESULTS: Rates of carotid endarterectomy fell in all three regions from 1984 to 1989 (from 126 to 66 per 100,000 adults 40 years of age or older in California, from 65 to 40 per 100,000 in New York, and from 40 to 15 per 100,000 in Ontario), after the publication of studies demonstrating that the rates of complications of carotid endarterectomy were unacceptably high. However, the clinical trials of the 1990s, which showed benefit from carotid endarterectomy, were associated with a dramatic resurgence in the rates of the procedure from 1989 to 1995 (from 66 to 99 per 100,000 in California, from 40 to 96 per 100,000 in New York, and from 15 to 38 per 100,000 in Ontario). These increased rates were not associated with proportionally greater numbers of referrals of patients to hospitals with low mortality rates. CONCLUSIONS: There have been a dramatic fall and rise in the rates of carotid endarterectomy in both the United States and Canada, which correlate with the publication of first unfavorable and then favorable clinical studies. The absence of selective referral of patients to centers with the lowest mortality rates raises questions about whether the benefits of carotid endarterectomy in the general population are similar to those demonstrated in the clinical trials.

Adult↗
PubMed1998

Selection and exclusion of primary care physicians by managed care organizations.

CONTEXT: Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory. OBJECTIVE: To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care. DESIGN: Cross-sectional mail survey of a probability sample of primary care physicians. SETTING: A total of 13 large urban counties in California. PARTICIPANTS: Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice. MAIN OUTCOME MEASURES: Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts. RESULTS: Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice. CONCLUSIONS: Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.

California↗
PubMed1998

Antenatal diagnosis of lethal skeletal dysplasias.

Lethal skeletal dysplasias (LSD) are a heterogeneous group of rare but important genetic disorders characterized by abnormal growth and development of bone and cartilage. We describe the diagnosis and outcome of 29 cases of lethal skeletal dysplasias evaluated between January 1989 and December 1996 at the University of Maryland Medical Center and the Ultrasound Institute of Baltimore. Two cases presented at delivery with no prenatal care while the remaining 27 cases were identified by antenatal sonography. Final diagnoses included thanatophoric dysplasia (14), osteogenesis imperfecta, type II (6), achondrogenesis (2), short rib syndromes (3), campomelic syndrome (2), atelosteogenesis (1), and no evidence of a skeletal dysplasia (1). Twenty out of 27 pregnancies were terminated with an average at detection of 21.6 weeks. The other 7 pregnancies that went on to deliver had an average age at detection of 29.2 weeks. Fetal abnormalities in the terminated pregnancies were identified at a significantly earlier gestational age (P = 0.0016) than the pregnancies that continued. While the identification of LSD by sonography was excellent (26/27), only 13/27 (48%) were given an accurate specific antenatal diagnosis. In 8/14 (57%) cases with an inaccurate or nonspecific diagnosis there was a significant or crucial change in the genetic counseling. Thus, while antenatal sonography is an excellent method for discovering LSD, clinical examination, radiographs, and autopsy are mandatory for making a specific diagnosis.

Diagnosis, Differential↗
PubMed1998

Torsion of intraperitoneal renal transplants: imaging appearances.

OBJECTIVE: Torsion of a renal transplant is a rare complication with nonspecific clinical manifestations. Prompt detection is necessary to allow surgical treatment and to preserve renal function. We describe the radiologic appearances of torsion of intraperitoneal renal transplants in patients who have undergone simultaneous renal and pancreatic transplantation or dual renal transplantation. CONCLUSION: Renal transplant torsion should be suspected when a change in renal axis associated with abnormal perfusion occurs in an intraperitoneal kidney.

Adult↗
PubMed1998

Abdominal ultra sonographic findings detected in the course of a hepatitis survey in an Egyptian rural area.

The objective of this study was to determine the prevalence of abnormal findings detected by abdominal ultrasonography (US) in an Egyptian rural area. This study was a part of a community based cross sectional survey for virus hepatitis carried out at Kalama village in Nile Delta, 40 kilometers north of Cairo. People above 10 years of age living in a 10% systemic random sample of houses in the village were subjects of this study. A member of the team carried out US examination of the liver, biliary tree, spleen, kidneys, pancreas, para aortic areas and the pelvis. Examination included morphological assessment and organometry. All results are recorded on images by videoprinter. Abnormalities in abdominal US was detected in 34% of examined cases. Abnormal liver impressions were detected in 28.3% of cases. Ascites was detected in 13 cases (1.8%). Diseases of the gall bladder and kidneys were detected in 2.7% and 2.1%, respectively. US diagnosed pregnancy in 5 women, one of them had a blighted ovum. Some of these abnormalities were detected in subjects with no complaint. It is concluded that abdominal US may be a tool for early detection of asymptomatic disease.

Cholecystitis↗
PubMed1998

Physician supply and medical education in California. A comparison with national trends.

Concerns have been voiced about an impending oversupply of physicians in the United States. Do these concerns also apply to California, a state with many unique demographic characteristics? We examined trends in physician supply and medical education in California and the United States between 1980 and 1995 to better inform the formulation of workforce policies appropriate to the state's requirements for physicians. We found that similar to the United States, California has more than an ample supply of physicians in the aggregate, but too many specialists, too few underrepresented racial/ethnic minority physicians, and poor distribution of physicians across the state. However, recent growth in the supply of practicing physicians and resident physicians per capita in California has been much less dramatic than in the country overall. The state's unusually high rate of population growth has enabled California, unlike the United States as a whole, to absorb large increases in the number of practicing physicians and residents during 1980 to 1995 without substantially increasing the physician-to-population ratio. Due to a projected slowing of the state's rate of population growth, the supply of physicians per capita in the state will begin to rise steeply in coming years unless the state implements prompt reductions in the production of specialists. An immediate 25% reduction in specialist residency positions would be necessary to bring the state's supply of practicing specialists in line with projected physician requirements for the state by 2020. We conclude that major changes will be required if the state's residency programs and medical schools are to produce the number and mix of physicians the state requires. California's medical schools and residency programs will need to act in concert with federal and state government to develop effective policies to address the imbalance between physician supply and state requirements.

California↗
PubMed1998

Teaching community-oriented primary care through longitudinal group projects.

BACKGROUND: Though community-oriented primary care (COPC) has been advocated as an effective way of addressing health problems of communities, it is neither widely understood nor frequently practiced. Because COPC requires an extended period of time, as well as an approach and skills not generally learned in medical training, effectively incorporating COPC training into medical education is difficult and not frequently attempted. This paper describes a COPC curriculum for family practice residents based on required participation in a longitudinal group project. METHODS: Residents participated in successive groups that completed a COPC project over a 2-year period. Twenty-two of 26 PGY-2 residents completed an attitude and knowledge test before and after participation in the curriculum. A qualitative evaluation of the curriculum was also performed. RESULTS: Pretest and posttest responses showed significant improvement in residents' knowledge about COPC and a small but significant decline in attitudes toward COPC. Residents' reactions to the curriculum in the qualitative evaluation were both positive and negative. Residents enjoyed the group process and found it intellectually stimulating. Many reported, however, that they did not feel ownership of the project, that working through the four-step systematic COPC process was slow and cumbersome, and that they had learned only part of the COPC process. Residents consistently reported becoming more aware of the importance of discussing the focus of the project (i.e., childhood discipline or domestic violence) with their patients and feeling more comfortable initiating such discussions. CONCLUSIONS: A COPC curriculum based on required participation in a 2-year group project promoted completion of substantial projects. There were trade-offs in resident experience, including loss of continuity for individual residents. Effectively teaching COPC and engaging residents in community-oriented activities remains a challenge.

Community Health Services↗
PubMed1997

Choice of a personal physician and patient satisfaction in a health maintenance organization.

CONTEXT: Being able to choose one's health care plan has been shown to increase subsequent patient satisfaction with the plan, but it is not known whether choosing one's own primary care physician affects patient satisfaction with the physician. OBJECTIVE: To compare satisfaction with care between members of a group-model health maintenance organization (HMO) who chose their primary care physician and members who were assigned a physician. DESIGN: Cross-sectional mailed survey with response rate of 71.4%. SETTING: A large group-model HMO in northern California. MAIN OUTCOME MEASURE: Nine questions on satisfaction with the primary care physician. SUBJECTS: Random sample of HMO members 35 to 85 years of age who were impaneled with a primary care physician. RESULTS: Among the 10205 survey respondents, patients who chose their personal physician (n=4748) were 16 to 20 percentage points more likely to rate their satisfaction as "excellent" or "very good" than patients who were assigned a physician (n =5457) for 9 satisfaction measures (P<.001 for each comparison). The association of choice with satisfaction was not due to physicians with higher patient satisfaction being chosen more often, or to differences in patient demographic or socioeconomic characteristics, health values, or health beliefs, or to differences in physician demographics or specialty. In a logistic regression model that adjusted for all of these characteristics, having chosen one's physician was the single predictor most strongly related to having high overall satisfaction (odds ratio, 2.18, 95% confidence interval, 1.95-2.42). CONCLUSION: These results suggest that even in a setting of limited physician choice, the opportunity to select one's personal physician may influence subsequent satisfaction.

Adult↗
PubMed1997

Ultra sonographic measurements of the normal liver and spleen among Egyptians 10-50 years old.

OBJECTIVE: To determine reference values of ultra sonographic (US) measurements of the normal liver, spleen, portal vein, right and left periportal thickness, gall bladder wall thickness and common bile duct diameter of Egyptians. DESIGN: Community-based cross sectional study. SETTING: Kalama village in Nile Delta, 40 kilometers north of Cairo. SUBJECTS: 10% systematic sample of people above 10 years of age. Selection criteria included normal clinical examination, normal liver functions by ALT, absence of hepatitis B and C virus markers and liver or spleen pathology by US. MEASUREMENTS: Organometery of the liver, spleen, portal vein, right and left periportal thickness, gall bladder wall thickness and common bile duct diameter by US. RESULTS: 217 subjects were admitted to the study out of 700 examined. All measured parameters increased with age till 20 years. There was no significant difference in measurements between males and females. The means, standard deviation and 95th percentiles of all measurements were higher than those recorded in other studies. CONCLUSION: Egyptian norms for US organometery of the liver, spleen, portal vein and gall bladder are different from those of other countries. We suggest that Egyptian sonologists use these norms in routine practice.

Adolescent↗
PubMed1997

Charges for obstetric liability insurance and discontinuation of obstetric practice in New York.

BACKGROUND: The study objective was to determine whether New York physicians facing higher charges for obstetric liability insurance coverage are more likely to discontinue obstetric practice than physicians experiencing lower levels of increases in liability insurance charges. METHODS: We performed a physician-level analysis of factors predicting discontinuation of hospital-based obstetric practice by 1989 for physicians active in obstetrics in 1980. We examined both physicians who became completely clinically inactive in New York between 1980 and 1989, and physicians who remained clinically active but restricted their hospital practice to areas other than obstetrics. Multiple logistic regression models were used to analyze predictors of discontinuation of obstetrics, including regional malpractice insurance charges, physician characteristics, and practice characteristics. RESULTS: Although increases in malpractice insurance charges differed considerably among regions within New York State, there was no association between level of increase of charges for liability insurance and discontinuation of obstetric practice. A greater number of years since medical licensure was associated both with complete discontinuation of hospital practice in New York and selective discontinuation of obstetrical practice. Compared with obstetrician-gynecologists, family physicians were less likely to become completely clinically inactive. Among physicians who remained clinically active in hospital care, however, family physicians were less likely than obstetrician-gynecologists to continue to include obstetrics in their practice. CONCLUSIONS: There is no relationship between the level of increase in liability insurance premiums and the likelihood of discontinuing obstetric practice in New York. Discontinuation of obstetric practice appears to mainly reflect trends in the physician's life cycle of practice activity and in the scope of family and general practice.

Costs and Cost Analysis↗
PubMed1997

Primary care and patient perceptions of access to care.

BACKGROUND: Although much is known about how insurance affects access to care, it is unclear whether good primary care contributes to access. The purpose of this study was to determine how optimal primary care given by providers at a regular place of care, defined in terms of continuity, comprehensiveness, communication, and availability, contributed to perceptions of access to care in a large population-based probability sample of adults. METHODS: Data were from a cross-sectional survey of 6674 English- and Spanish-speaking adults 18 to 64 years of age, randomly sampled from 41 urban California communities with a range of levels of access to care. RESULTS: Following adjustment for sociodemographics and need for care, we found that having "optimal" primary care contributed independently to improved self-rated access, as did having health insurance, a regular place, and a regular provider. The largest difference n access was between having any health insurance and not having insurance. Once insurance was available, each additional element contributed in a cumulative manner to self-rated access. For those with insurance and a regular place, adding optimal primary care improved self-rated access to an extent similar to adding a regular provider. CONCLUSIONS: We conclude that although providing insurance to the uninsured is the most effective means of improving self-rated access, the other elements each improve access as well. Once insurance and a regular place are provided, good primary care at that place may be equivalent to having a regular provider in terms of perceived access. Results support promotion of primary care as a model of health care that encourages good access.

Adolescent↗
PubMed1997

Tamoxifen induced endometrial abnormalities: evaluation by saline infusion sonohysterography.

Patients receiving tamoxifen therapy for breast cancer are at an increased risk for endometrial hyperplasia, polyps, and adenocarcinoma. Therefore, any bleeding in the post-menopausal patient on tamoxifen warrants further investigation. Sonohysterography is a new technique for evaluating the uterine cavity and clarifying the location of endometrial and peri-endometrial processes. Differentiating subendometrial cyst formation from endometrial proliferation can save patients from further, invasive investigative diagnostic procedures.

Antineoplastic Agents, Hormonal↗