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Biomedical subjects

P Franks

Publications and source records attributed to P Franks.

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

Variations in primary care physician referral rates.

OBJECTIVE: To examine primary care physician referral rate variations, including their extent and their stability over time and across diagnostic categories. DATA SOURCES: 1995/1996 claims data for adult patients from a large Independent Practitioner Association (IPA) model managed care organization (MCO) in the Rochester, NY metropolitan area. The IPA includes over 95 percent of area primary care physicians (PCPs), and the MCO includes over 50 percent area residents. STUDY DESIGN: Referral rates (patients referred to and seen by specialists one or more times/patients seen by PCP/year) were developed for the PCPs (457 general practitioners, family physicians, and internists) in the MCO, including observed referral rates, expected referral rates based on case-mix adjustment across the whole sample, physician-specific case mix-adjusted referral rates (empirical Bayes estimates), and diagnostic category-specific case mix-adjusted referral rates. PRINCIPAL FINDINGS: Wide variations in observed referral rates (0.01-0.69 patients referred/patients seen/year) were attenuated relatively little by case-mix adjustment and persisted in case mix-adjusted empirical Bayes estimates (0.02-0.65). The year-to-year case mix-adjusted referral rate correlation was .90. Correlations of case mix adjusted-referral rates across diagnostic categories were moderate (r=.46-.67). CONCLUSIONS: PCP referral rates exhibit wide variations that are independent of case mix, remain stable over time, and are generalizable across diagnostic categories. Understanding this physician practice variation and its relationship to costs and outcomes is critical to evaluating the effect of current efforts to reduce PCP referral rates.

Adult↗
PubMed1999

The adequacy of Papanicolaou smears as performed by family physicians and obstetrician-gynecologists.

BACKGROUND: Little is known about the quality of Papanicolaou (Pap) smears performed by family physicians and obstetrician-gynecologists. METHODS: Using hospital archival records of Pap smears performed from 1995 to 1997, we compared the quality of Pap smear sampling and the rate of detection of significant cytologic abnormalities by family physicians and obstetrician-gynecologists. Using hierarchic logistic regression, we examined the relationship between physician specialty and Pap smear reports, controlling for patient age and socioeconomic position, multiple Pap smears performed by the same clinician, and physician attending status. RESULTS: A total of 34,916 Pap smears performed by 130 family physicians and 88 obstetrician-gynecologist residents and attending physicians were included in the analysis. There were no statistically significant differences by specialty in the rates of unsatisfactory reports (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI], 0.48 - 1.38), satisfactory but limited reports (AOR = 1.16; 95% CI, 0.93 - 1.48), or detection rates of significant cytologic abnormalities (AOR = 0.83; 95% CI, 0.66 - 1.04). However, family physicians submitted more Pap smears with an absent endocervical component (AOR = 1.50; 95% CI, 1.07 - 2.11). CONCLUSIONS: These findings show no significant differences by specialty in Pap smear quality as measured by rates of unsatisfactory and satisfactory but limited reports, or detection of cytologic abnormalities. The finding of higher rates of absent endocervical cells, if replicated by further study, may suggest the need for improved training of family physicians in sampling the endocervix.

Clinical Competence↗
PubMed1999

Is family care associated with reduced health care expenditures?

BACKGROUND: Specific components of family medicine associated with reduced health care costs are not well understood. We examined whether people who received "family care," the sharing of a personal physician across familial generations, had lower health care expenditures than those who received "individual care" that lacked generational continuity. METHODS: We studied 1728 children and 2543 adults using a data subset of the 1987 National Medical Expenditure Survey, a representative sample of the civilian noninstitutionalized US population, to examine the relationship between care category and total health care expenditures, adjusting for potential confounders and effect modifiers. Survey respondents from households with either a married or a single woman aged 18 to 55 years as head of household and at least 1 child younger than 18 years were included. Only individuals reporting a family physician (FP) or general practitioner (GP) as their personal doctor were examined, since intergenerational family care is provided almost exclusively by FPs and GPs. RESULTS: Family care provided by an FP or GP was associated with 14% lower expenditures for adults ($51), after adjustment for covariates (P = .04), compared with individual care provided by a family or general practitioner. Although not statistically significant, for children family care was associated with 9% lower expenditures ($19). CONCLUSIONS: These findings suggest that family care provided by FPs or GPs is associated with lower health care costs. Policies promoting family care may reduce health care costs.

Adolescent↗
PubMed1998

The risk of low birth weight associated with vaginal douching.

OBJECTIVE: To examine the association between vaginal douching and low birth weight (LBW) after accounting for known risk factors. METHODS: We used cross-sectional interview data from the 1988 National Survey of Family Growth, a nationally representative sample of 4665 women of child-bearing age and 11,553 singleton live births. We compared the risk of LBW among women who reported they douched regularly with the risk among women who did not douche, after controlling for potential confounders including maternal age, race, household income, marital status, total number of pregnancies, smoking, alcohol use, drug use during the pregnancy, year of birth of each infant, geographic region, and self-reported history of pelvic inflammatory disease. RESULTS: In multivariate analysis, regular douching was associated with an increased risk of LBW (adjusted odds ratio [OR], 1.29; 95% confidence interval [CI] 1.06, 1.57). Frequency of douching and LBW exhibited a dose-response. The adjusted OR for the association between daily douching and LBW was 2.49 (95% CI 1.23, 5.01) compared with an adjusted OR of 1.13 (95% CI 0.83, 1.55) for the association between monthly douching and LBW. There was no racial difference in the risk of LBW associated with douching. CONCLUSION: These preliminary data suggest an association between douching and LBW risk. If these findings are replicated in future studies, douching may represent a major preventable risk factor for LBW.

Black or African American↗
PubMed1998

Skepticism toward medical care and health care utilization.

OBJECTIVES: As health care moves toward systems that assume accountability for defined populations, there has been increasing emphasis on developing performance measures for those systems and their providers, with little attention given to patient demand or attitudinal factors. The impact of skepticism toward health care providers on health behavior and health care utilization was assessed using a cross-sectional analysis of data from the 1987 National Medical Expenditure Survey (NMES). METHODS: A nationally representative sample from the United States comprising 18,240 persons 25 years and older was surveyed. Skepticism, defined as doubts about the ability of conventional medical care to appreciably alter one's health status, was assessed through a 4-item scale. Outcome measures included health behavior, access (health care insurance, having a regular source of care, and physician type), utilization (annual number of physician or emergency department visits and hospitalizations), total annual health care expenditures, and preventive health care behavior (having had a Pap smear within 3 years or ever having had a mammogram). RESULTS: In multivariate analyses, skepticism was associated with younger age, white race, lower income, less education, and higher health perceptions. After adjusting for these variables, skepticism was associated with less healthy behavior, with not having health insurance, not having one's own physician, choice of a physician, fewer physician and emergency department visits, less frequent hospitalizations, lower annual health care expenditures, and less prevention compliance. CONCLUSIONS: Medical skepticism represents a relevant patient demand factor that demonstrates significant associations with a variety of health care access and utilization measures with important policy implications.

Adult↗
PubMed1998

Toward consistency in cost-utility analyses: using national measures to create condition-specific values.

OBJECTIVES: The authors developed an "off-the-shelf" source of health-related quality of life (HRQL) scores for cost-effectiveness analysts unable to collect primary data. METHODS: The authors derived and conducted preliminary validation on a set of health-related quality of life scores for chronic conditions using nationally representative data from the National Health Interview Survey (NHIS) and the Healthy People 2000 Years of Healthy Life measure developed to monitor the health (longevity and health-related quality of life) of Americans during this decade. The measure comprises two domains, role function and self-rated health, and is scaled from 0 (death) to 1 (best health state). Health-related quality of life scores for chronic conditions were calculated using the Years of Healthy Life scores associated with chronic conditions reported in the 1987-1992 National Health Interview Survey. Preliminary validation was examined by comparing the health-related quality of life scores with those obtained in two other studies. RESULTS: Tables provide health-related quality of life scores for persons with and without conditions. The scores had reasonable face validity, ranging from 0.87 for allergic rhinitis to 0.27 for hemiplegia. Correlations of the health-related quality of life condition weight scores with those from two other studies were 0.78 and 0.86. CONCLUSIONS: These condition weights may prove useful to investigators conducting cost-effectiveness analyses using secondary data, where community ratings of health-related quality of life for chronic conditions are required. Use of a standard set of health-related quality of life weights gathered from a national sample can enhance the comparability of cost-effectiveness analyses. Improvements in national data collection techniques, with empirical gathering of preferences, will further strengthen this measure.

Activities of Daily Living↗
PubMed1998

Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience.

BACKGROUND: The advent of managed care has resulted in considerable debate regarding the relative effects of specialist and primary care on patient outcomes and costs. Studies on these subjects have been limited to a disease-focused orientation rather than a patient-focused orientation inherent in primary care management. We examined whether persons using a primary care physician have lower expenditures and mortality than those using a specialist as their personal physician. METHODS: Using data on a nationally representative sample of 13,270 adult respondents tot he 1987 National Medical Expenditure Survey reporting as their personal physician either a primary care physician (general practitioner, family physician, internist, or obstetrician-gynecologist) or a specialist, we examined total annual health care expenditures and 5-year mortality experience. RESULTS: Respondents with a primary care physician, rather than a specialist, as a personal physician were more likely to be women, white, live in rural areas, report fewer medical diagnoses and higher health perceptions and have lower annual healthcare expenditures (mean: $2029 vs $3100) and lower mortality (hazard ratio = 0.76, 95% confidence interval [CI], 0.64-0.90). After adjustment for demographics, health insurance status, reported diagnoses, health perceptions, and smoking status, respondents reporting using a primary care physician compared with those using a specialist had 33% lower annual adjusted health care expenditures and lower adjusted mortality (hazard ratio = 0.81; 95% CI, 0.66-0.98). CONCLUSIONS: These findings provide evidence for the cost-effective role of primary care physicians in the health care system. More research is needed on how to optimally integrate primary and specialty care.

Economics, Medical↗
PubMed1997

Poverty or income inequality as predictor of mortality: longitudinal cohort study.

OBJECTIVE: To determine the effect of inequality in income between communities independent of household income on individual all cause mortality in the United States. DESIGN: Longitudinal cohort study. SUBJECTS: A nationally representative sample of 14,407 people aged 25-74 years in the United States from the first national health and nutrition examination survey. SETTING: Subjects were followed from initial interview in 1971-5 until 1987. Complete follow up information was available for 92.2% of the sample. MAIN OUTCOME MEASURES: Relation between both household income and income inequality in community of residence and individual all cause mortality at follow up was examined with Cox proportional hazards survival analysis. RESULTS: Community income inequality showed a significant association with subsequent community mortality, and with individual mortality after adjustment for age, sex, and mean income in the community of residence. After adjustment for individual household income, however, the association with mortality was lost. CONCLUSIONS: In this nationally representative American sample, family income, but not community income inequality, independently predicts mortality. Previously reported ecological associations between income inequality and mortality may reflect confounding between individual family income and mortality.

Adult↗
PubMed1997

Does psychological distress contribute to racial and socioeconomic disparities in mortality?

Being black or poor are powerful predictors of mortality. Although psychological distress has been proposed as mediating the effects of race and socioeconomic status on mortality, this hypothesis has not been previously directly tested. We used data from the National Health and Nutrition Examination I (NHANES I), a nationally representative sample from the U.S, and the NHANES I Epidemiological Follow-up Survey (NHEFS) of subsequent mortality to test this hypothesis. Both black race and lower family income were associated with significantly higher psychological distress as measured at the time of the initial survey by reports of hopelessness, depression, and life dissatisfaction. Black race and low income in addition to each of the measures of psychological distress were associated with higher mortality at follow-up. In a series of Cox proportional hazards models that controlled for the effects of age and gender, additional adjustment for hopelessness, depression, or life dissatisfaction had little effect on the relationship between either African American race or family income and subsequent all-cause mortality. We conclude that the effects of both race and income on mortality are largely independent of psychological distress. These findings do not support the hypothesis that psychological distress is a significant mediator of the effects of race or class on health.

Adult↗
PubMed1997

Family care in the United States. A national profile.

OBJECTIVES: The authors describe the epidemiology of family care in the United States. METHODS: A cross-sectional analysis of data from the household component of the 1987 National Medical Expenditure Survey was performed. A representative sample of the civilian, noninstitutionalized US population was analyzed. Participants in the study were all households with at least a mother between the ages of 18 and 55 years and at least one child younger than age 18 (n = 2,975). For this analysis, family care was defined as all families in which there was provider congruence between at least one parent and one child, compared with individual care, defined as families with separate providers. RESULTS: Family care occurred in 35% of families studied. As opposed to individual care, family care was more prevalent in families that resided in non-standard metropolitan statistical area regions and outside of the Northeast, as well as in families whose female heads of household were less educated, older, and had higher unhealthy behavior scores. Except for unhealthy behavior scores, these results remained significant after multivariate adjustment for race, marital status, family income, insurance status, and health care attitudes. Family or general practitioners were more likely than other physicians to provide family care. CONCLUSIONS: Family care occurs in a significant proportion of US families, and location and education are significant determinants of this kind of care. This descriptive epidemiologic analysis of a nationally representative sample provides a foundation for studies examining the cost and quality implications of family care.

Adolescent↗
PubMed1997

Defining primary care. Empirical analysis of the National Ambulatory Medical Care Survey.

OBJECTIVES: Efforts to contain health care costs have increased interest in defining which specialties provide primary care and in developing tools to assess the delivery of primary care services. METHODS: Using data from the 1985-1991 National Ambulatory Medical Care Surveys, the authors examined the activities of 29 physician specialty groups to determine whether the recent Institute of Medicine definition of primary care could be operationalized. Ten elements were identified that addressed comprehensiveness (first-contact care, a Herfindahl Index, previous contact for other problems, prevention, and care through the life cycle), coordination (referrals), continuity (any previous contact), and accessibility (care provided to black patients, those on Medicaid, and patients in rural areas). RESULTS: Principal component and factor analyses suggested that each element, except care through the life cycle, contributed to the construct of primary care. Principal component analysis enabled ordering of specialties according to their "primary careness," suggesting that specialties other than family/general practice, pediatrics, and internal medicine make significant contributions to primary care. Factor analysis suggested that two factors related to process and content underlie the definition of primary care and emphasize the importance of integration of services provided. This analysis provides a basis for further empirical work to develop measures of primary care performance. CONCLUSIONS: National surveys need to be modified to provide a more comprehensive assessment of primary care in the United States.

Ambulatory Care↗
PubMed1997

Perceived family criticism and primary care utilization: psychosocial and biomedical pathways.

We explored the relationship of perceived family criticism to subsequent healthcare utilization in patients attending a family medicine center. We examined: a) the relationship of perceived criticism to subsequent utilization for biomedical and psychosocial/somatic problems; b) the mediating effects of self-rated mental health and physical function; and c) the mediating effects of social support. The analyses were adjusted for age, sex, race, education, health insurance, and martial status. Higher perceived criticism predicted more psychosocial/somatic and biomedical visits. The relationship of perceived criticism with psychosocial/somatic visits was entirely mediated through self-rated mental health. The relationship of perceived criticism with biomedical visits was partly mediated through self-rated physical function and, in part, independent. Social support played no role in explaining these relationships. Further research is needed to determine whether lowering perceived family criticism lowers primary care utilization.

Family↗
PubMed1997

Methotrexate. A single agent for early abortion.

OBJECTIVE: To determine whether methotrexate as a single agent for induced abortion in pregnancies up to 5 weeks is as effective, has fewer side effects and is as acceptable to subjects as the combination of methotrexate and misoprostol. STUDY DESIGN: Women with no greater than a 5-week gestation were compared with a historical control group of consecutive women presenting for a medical abortion matched for gestational age. Subjects received intramuscular methotrexate on day 1. The study group received no misoprostol until day 21, when it was offered if the abortion had not yet occurred. The control group self-administered one or more doses of misoprostol within the first week after methotrexate. A complete abortion was defined by either negative transvaginal ultrasound or negative urine pregnancy test. All subjects completed a daily symptom log and satisfaction questionnaire. The analysis consisted of a comparison of the study group and control group for completion and timing of the abortion, symptoms and subject satisfaction. RESULTS: There were 40 study subjects and 53 controls. All subjects had a medical abortion without surgery. Ten (25%) of the 40 study subjects reached study day 21 without bleeding: 4 used misoprostol and 6 chose to wait for the abortion to occur spontaneously. One of the 10 subjects had persistent embryonic cardiac activity at 21 days and aborted after misoprostol. The mean number of days to bleeding was 15.5 days (SD 7.8 days) for the study group as compared with 8.1 days (SD 11.3) (P = .0003) for the control group. There was no significant difference in the number of days of bleeding, gastrointestinal side effects or reported subject satisfaction. CONCLUSION: While methotrexate as a single agent was effective in inducing abortion in early pregnancy, 15% of the study subjects finally used misoprostol, the abortion took significantly longer, and side effects were not less common as compared with those in subjects who received the combination of methotrexate and misoprostol.

Abortifacient Agents, Nonsteroidal↗
PubMed1997

Vaginal misoprostol administered at home after mifepristone (RU486) for abortion.

BACKGROUND: There have been no US studies published on the effectiveness, safety, time to bleeding, and acceptability of misoprostol administered by vagina at home and repeated, if needed, after mifepristone was administered for abortion in women up to 8 weeks pregnant. METHODS: A prospective trial was conducted with women up to 8 weeks pregnant wanting an abortion. After receiving mifepristone 600 mg orally, subjects self-administered vaginal misoprostol 800 micrograms at home 2 days later. Subjects returned within 7 days, and if the gestational sac was still present on ultrasound, a repeat dose of misoprostol was administered in the office. Subjects completed a daily symptom log and a questionnaire on the acceptability of the procedures. RESULTS: Of the 166 subjects, 163 (98%) had a complete medical abortion. Three subjects presented with persistent bleeding and an incomplete abortion from 27 to 35 days after taking mifepristone and required surgical intervention. Vaginal spotting or bleeding occurred in 104 (62%) subjects before taking misoprostol, and 18 (11%) did not use misoprostol. Bleeding occurred on average 3.5 hours (SD, 3.2) after taking misoprostol. Six (4%) subjects required a second dose of misoprostol. Gastrointestinal side effects were common, mild, and brief. One hundred fifty-nine (96%) subjects agreed that the procedure went well, and 146 (90%) agreed that home administration of misoprostol was acceptable. CONCLUSIONS: Two days after taking mifepristone, misoprostol administered by vagina was found to be safe, highly effective, and acceptable to women. Since only 6 subjects needed a second dose of misoprostol, conclusions about repeat doses are not possible. This procedure is a promising alternative to surgical abortion.

Abortifacient Agents, Nonsteroidal↗
PubMed1997

Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance.

BACKGROUND: Increasing enrollment in managed care organizations and dissatisfaction with policies to restrict direct access to specialists have intensified interest in referrals from primary care physicians to specialists. We examined the associations of demographic factors and insurance with referrals of adult patients by primary care physicians. METHODS: Office visits of adult patients to primary care physicians (general practitioners, family physicians, and internists) reported in the National Ambulatory Care Survey for the years 1985 through 1992 were used to examine referrals by primary care physicians. Regression analyses were adjusted for patient factors (age, sex, race, insurance, case mix, diagnostic category, new problem or not, new patient or not, and visit length), physician factors (age, sex, specialty, and degree of specialization), and practice factors (proportion of HMO patients, rural location, region, and study year). RESULTS: Overall, 4.5% of patients were referred compared with 7.5% of patients with HMO insurance. After adjustment, an increased likelihood of referral was associated with being a male patient, having fewer medications prescribed, not being seen before for the presenting problem, a longer visit, less physician specialization, seeing a female physician, seeing an internist, and seeing a physician with a greater proportion of patients with HMO insurance. Among patients with HMO insurance, no gender disparity in referral rate was observed, and patients who also had Medicaid or Medicare insurance were more likely to be referred. CONCLUSIONS: Male patients are more likely to be referred. HMO insurance may reduce this gender disparity and increase the access of patients with Medicaid and Medicare to specialty care.

Adult↗
PubMed1997

Utilization of specialty and primary care: the impact of HMO insurance and patient-related factors.

BACKGROUND: Appropriate utilization of primary and specialty care has stimulated substantial debate, but the portion of the discussion focused on policies that restrict or discourage direct access to specialists has been largely uninformed by empirical analysis. Using data from the National Ambulatory Care Survey (1985 to 1992 surveys), we examined the associations of patient and physician demographics and health maintenance organization (HMO) insurance status with the utilization of primary compared with specialty care. METHODS: Office visits for adult patients seen by primary care physicians and specialists were analyzed for: (1) patient-initiated utilization of specialists (patient self-referral) compared with that of primary care physicians; and (2) utilization of specialists compared with that of primary care physicians, stratified by HMO insurance status. RESULTS: After multivariate adjustment, patient self-referral was less likely among black patients (adjusted odds ratio [AOR] = 0.67; 95% confidence interval [CI] = 0.59 to 0.76), self-pay (AOR = 0.81; 95% CI = 0.74 to 0.88), or patients with Medicaid (AOR = 0.51; 95% CI = 0.43 to 0.61). The proportion of non-HMO patients seeing specialists remained stable (44.9%). For HMO patients, the proportion of total visits made to specialists increased from 27.6% in 1985 to 41.3% in 1991, then dropped to 33.2% in 1992. Disparities in utilization of specialists by women, blacks, and patients with Medicaid observed among non-HMO patients were not found in the HMO population. Specialists were more likely to see HMO patients for follow-up of a known problem, whereas non-HMO patients were more likely to have specialist follow-up visits for new problems. CONCLUSIONS: The results suggest greater utilization of specialists by male, white, and privately insured patients. The findings may partially account for disparities in specialty procedure use, and suggest that HMO insurance may reduce some of these disparities. The less frequent and more selective use of specialists among HMO patients suggests an evolving role for specialists in managed care.

Adult↗
PubMed1996

Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counseling.

OBJECTIVE: To determine the incremental cost-effectiveness of the transdermal nicotine patch. DESIGN: Decision analytic model that evaluated the incremental cost-effectiveness of the addition of the nicotine patch to smoking cessation counseling. Costs were based on physician time and the retail cost of the nicotine patch, and benefits were based on quality-adjusted life years (QALYs) saved. PATIENTS: Male and female smokers aged 25 to 69 years receiving primary care. INTERVENTION: Addition of the nicotine patch to physician-based smoking cessation counseling. MAIN OUTCOME MEASURE: Costs (1995 dollars) per QALYs save discounted by 3% annually. RESULTS: The use of the patch produced 1 additional lifetime quitter at a cost of $7332. The incremental cost-effectiveness of the nicotine patch by age group ranged from $4390 to $10 943 per QALY for men and $4955 to $6983 per QALY for women. A clinical strategy involving limiting prescription renewals to patients successfully abstaining for the first 2 weeks improved the cost-effectiveness of the patch by 25%. CONCLUSIONS: The findings provide support both for the routine use of the nicotine patch as an adjunct to physicians' smoking cessation counseling and for health insurance coverage of nicotine patch therapy.

Administration, Cutaneous↗