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Biomedical subjects

L Culpepper

Publications and source records attributed to L Culpepper.

67 records · Page 4Linked to original sources
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Trends in adult visits to primary care physicians in the United States.

BACKGROUND: Although numerous changes are apparent in the US health care system, little is known about how these changes have altered the work of primary care physicians. METHODS: We analyzed a nationally representative sample of 136,233 adult office visits to general internists, general practitioners, and family physicians contained in the 1978 through 1981, 1985, and 1989 through 1994 National Ambulatory Medical Care Surveys. Annual sample sizes varied between 5662 and 19,977 visits. Measures included the characteristics of patients presenting to primary care physicians, physician activities during these visits, and the disposition of the visits to primary care physicians. RESULTS: Visits to primary care physicians have diminished as a proportion of all adult visits from 52% in 1978 to 41% in 1994. Dramatic trends in adult primary care included the growing racial or ethnic diversity of patients, the doubling (since 1985) of health maintenance organization coverage, increased provision of prevention services, changes in the most common medications, and an 18% increase in the duration of adult visits to primary care physicians. CONCLUSIONS: Trends in primary care practice reflect changes in society and in the US health care system, including demographic changes, an emphasis on prevention, and the growth of managed care. The increasing role of managed care, with its emphasis on increased productivity, appears at odds with primary care physicians' increasing responsibility for prevention and the associated increase in the duration of primary care visits.

Age Distribution↗
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A cross-national study of acute otitis media: risk factors, severity, and treatment at initial visit. Report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN).

BACKGROUND: Treatment of acute otitis media (AOM) differs worldwide. The Dutch avoid antimicrobials unless fever and pain persist; the British use them for 5 to 7 days, and Americans use them for 10 days. If effects of therapies are to be compared, it is necessary to evaluate rates of risk factors, severity of attacks, and their influence on treatment decisions. We wanted to compare the prevalence of risk factors for AOM and evaluate their association with severity of attacks and of severity with antimicrobial treatment. METHODS: We undertook a prospective cohort study of 2,165 patients with AOM enrolled by primary care physicians; 895 were enrolled from North America, 571 were enrolled from the United Kingdom, and 699 were enrolled from The Netherlands. The literature was searched using the key words "acute otitis media," "severity," and "international comparisons." RESULTS: The prevalence of several AOM risk factors differs significantly among patients from the three country networks; these factors include race, parent smoking habits, previous episodes, previous episodes without a physician visit, tonsillectomy or adenoidectomy, frequency of upper respiratory tract infections, day care, and recumbent bottle-feeding. Dutch children have the most severe attacks as defined by fever, ear discharge, decreased hearing during the previous week, and moderate or severe ear pain. In country-adjusted univariate analyses, increasing age, exposure to tobacco smoke, day care, previous attacks of AOM, previous attacks without physician care, past prophylactic antimicrobials, ear tubes, adenoidectomy, and tonsillectomy all contribute to severity. Only country network, age, history of AOM, previous episode without physician care, and history of adenoidectomy and tympanostomy tubes are independently related to increased severity, while current breast-feeding is protective. Severity of attacks influences treatment decisions. Dutch children are least likely to receive antimicrobials, and even for severe attacks the British and Dutch physicians usually use amoxicillin or trimethoprim-sulfa; North American children with severe attacks are more likely to receive a broad-spectrum second-line antimicrobial. CONCLUSION: Dutch children have the highest ratings in all severity measures, possibly reflecting parental decisions about care seeking for earaches. When comparing groups of patients with AOM, it is necessary to adjust for baseline characteristics. Severity of episode affects physician treatment decisions. Adoption of Dutch guidelines restricting use of antimicrobials for AOM in the United States could result in annual savings of about $185 million.

Acute Disease↗
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Prenatal care.

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Female↗
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The International Primary Care Network: purpose, methods, and policies.

The International Primary Care Network (IPCN), a consortium of practice based primary care research networks, including the Ambulatory Sentinel Practice Network (ASPN), is described. The purpose, methods, and policies are presented as an example of international networking to address problems of global concern in primary care. IPCN's experience with organizing a framework for collaboration and conducting a study of otitis media in nine countries suggests that efforts of this type are possible and may lead to new insights available only through international investigation.

Ambulatory Care Information Systems↗
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Preventing hepatitis B: focus on women and their families.

BACKGROUND: Infections contracted during infancy or childhood are responsible for 42 percent of case of chronic hepatitis B disease, and in 25 percent or more these infections result in death from hepatoma or cirrhosis during adulthood. Hepatitis B vaccine and immune globulin provide the means of preventing the disease and its sequelae, but their proper use requires clinical strategies for deciding which patients are at risk and which responses are appropriate for family practice. METHODS: A MEDLINE search of the literature pertaining to hepatitis B and its prevention, a review from the Centers for Disease Control (CDC), and critique by both practitioners and members of the CDC Hepatitis Branch led to the development of the clinical guidelines reported in this review. RESULTS AND CONCLUSIONS: Women at high risk for hepatitis B should be screened, including during pregnancy, by testing for hepatitis B core antibody. Those at low risk should be screened by testing for hepatitis B surface antigen. Susceptible high-risk women should be vaccinated; pregnancy is not a contraindication. Administration of hepatitis B immune globulin and vaccine to newborns is 95 percent effective in preventing transmission from a hepatitis B-infected mother. Follow-up vaccination is critical. Prophylaxis of contacts can include hepatitis B immune globulin and vaccination with or without previous testing, depending on age group and risk. Testing for hepatitis B surface antibody to assess development of immunity after vaccination is indicated only for those with ongoing exposure.

Carrier State↗
PubMedDate not supplied

Acute otitis media in adults: a report from the International Primary Care Network.

BACKGROUND: Of 22 million visits annually to United States physicians for acute otitis media, almost 4 million are by patients 15 years old or older. Yet the clinical spectrum and variables related to recovery have not been reported for adults. METHOD: Data originated from 3224 primary care patients with acute otitis media, of whom 500 were 15 years old or older, who were enrolled in a prospective study in eight countries. At the initial visit, history, symptoms, physical findings, and treatment were recorded. At a 2-month follow-up visit, changes in treatment and recovery were recorded. RESULTS: Compared with children, adults sought care more quickly after symptom onset; were more likely to have had a tonsillectomy or adenoidectomy; and were more likely to complain of ear pain, decreased hearing, sore throat, and ear discharge. Children were more likely to have a history of recent upper respiratory tract infection, serous otitis media, and ear tubes; symptoms of fever, diarrhea, and vomiting; and tympanic membrane findings of redness, bulging, and ear tubes in place. History of reduced hearing, allergy, prophylactic antibiotics, and tympanic membrane findings characterized as opaque or dull, fluid, draining pus, perforation, and not visualized were equally frequent in both age groups. For adults, neither type nor duration of antibiotic affected outcome. Patients receiving antibiotics had lower rates of recovery than those who did not. The likelihood of a poor outcome increased with an increasing number of past episodes of acute otitis media and with increasing age. CONCLUSION: Although history and symptoms differ in adults and children, the similarity of tympanic membrane findings is consistent with previous reports of a similar bacterial spectrum in both groups. Recovery is related more to individual patient characteristics and history than to antibiotic therapy. Adults have an increased rate of poor outcome at 2 months compared with children.

Acute Disease↗