Search PubMed⌕ Search

Biomedical subjects

S A Flocke

Publications and source records attributed to S A Flocke.

At least 37 records · Page 2Linked to original sources
PubMed1998

Patient and visit characteristics associated with opportunistic preventive services delivery.

BACKGROUND: This study's purpose was to identify patient and visit characteristics associated with the use of illness visits as opportunities for the delivery of preventive services and to determine if time is allocated differently during illness visits that make use of these opportunities. METHODS: Research nurses directly observed the delivery of preventive services during consecutive patient visits on 2 separate days in the offices of 138 family physicians. Data on patient eligibility for preventive services were collected by medical record review. Time use during patient visits was categorized using the Davis Observation Code (DOC). Patient characteristics, visit characteristics, and time use were compared during illness visits in which at least one service recommended by the US Preventive Services Task Force was delivered to eligible patients, compared with illness visits during which no recommended preventive services were delivered. RESULTS: Preventive services were delivered during 32% of 3547 illness visits. Adults, overweight patients, those who smoke or drink alcohol, new patients, and patients with fewer visits in the past year were more likely to receive preventive services. Patient request was also associated with increased delivery of preventive services. The presence of another family member, visits for an acute illness, and the prescription of a drug were associated with a decreased likelihood of a patient's receiving preventive services. When preventive services were delivered during illness visits, less time was spent on chatting, procedures, and physical examination, and more time was spent on history-taking. CONCLUSIONS: Family physicians take greater advantage of opportunities for the delivery of preventive services during the illness visits of high-risk patients. The results of our study suggest strategies that could be used to expand the opportunistic delivery of preventive services to other patients and types of visits.

Adolescent↗
PubMed1997

Intermittent claudication in 8343 men and 21-year specific mortality follow-up.

PURPOSE: As Western populations live longer, peripheral vascular disease will become a greater individual and public health problem. Therefore, the long-term natural history of intermittent claudication (IC) needs further delineation. The study objective was to describe the 21-year mortality and relative risk for cause-specific mortality for subjects with incident IC. METHODS: The subjects were 8343 Israeli male governmental employees aged 40-65 years who were free of coronary heart disease and symptomatic peripheral vascular disease in 1963. These men were followed for 21 years to measure differences in mortality between those who did and did not develop incident IC. Incident IC was diagnosed in 1965 and 1968 by the London School of Hygiene IC Questionnaire. All other cardiovascular disease risk factors were measured by standardized and validated procedures. Cause-specific mortality through 1986 was determined through death certificates from the Israeli Mortality Register. RESULTS: A total of 360 men with IC and 7983 symptom-free men were followed for survival from 1965 to 1986; 159 men with IC (44%) and 2330 symptom-free men (29%) died. For total mortality, the Kaplan-Meier 21-year survival probabilities were 56% for IC and 71% for symptom-free men (P < 0.0001 for the entire 21-year survival difference between the two groups). For coronary heart disease (CHD), stroke, and other causes of death, the survival probabilities for men with IC and symptom-free men were, respectively: 85% vs. 90%, 89% vs. 97%, and 79% vs. 83% (P = 0.0004; P < 0.0001; and P = 0.007, respectively, for the entire 21-year survival difference between the two groups). Cox's proportional hazards model was used to control confounding from incident myocardial infarction and angina through 1968, as well as for demographic, physiologic, psychosocial, and other cardiovascular disease risk factors. The 21-year adjusted all-cause mortality relative risk for IC was 1.50 (95% confidence interval (CI), 1.28-1.77). For stroke deaths the relative risk was 2.76 (95% CI, 1.89-4.02). For stroke mortality, IC was the third strongest predictor of death after elevated systolic blood pressure and increasing age. Incident IC had a relative risk of CHD deaths of 1.31, but it was not statistically significant (P = 0.08; 95% CI, 0.97-1.77). IC was not statistically significantly related to other causes of death (P = 0.10) after adjustment for covariates. CONCLUSIONS: IC is strongly predictive of long-term cerebrovascular disease mortality among men. Incident IC is a stronger indicator of cerebrovascular than of CHD death.

Adult↗
PubMed1997

Measuring attributes of primary care: development of a new instrument.

BACKGROUND: The purpose of this study was to evaluate the measurement properties of an instrument developed to measure seven key aspects of the delivery of primary care from the perspective of patients visiting their family physician, and to report the association of these aspects with patient satisfaction. METHODS: A cross-sectional study design was used to examine the responses of 2899 patients visiting 138 family physicians' offices in Northeast Ohio. A 20-item research tool, the Components of Primary Care Index (CPCI), was created to measure the domains of primary care based on the new Institute of Medicine definition and on additional domains based on the literature. Patient satisfaction was measured with the Medical Outcomes Study 9-item visit rating form. The usual provider continuity (UPC) index was calculated as the proportion of visits to the index physician with relation to all physician visits for the past year by patient report. The CPCI was subjected to item and factor analysis. Scale scores were computed, and the association with patient satisfaction with the visit was tested by correlation. RESULTS: The factor analysis resulted in four stable and internally consistent factors. The factors were named: interpersonal communication, physician's accumulated knowledge of the patient, coordination of care, and patients' preference to see their regular physician. Each of the CPCI scale scores was significantly associated with patient satisfaction with the visit. The UPC index, length of time as a patient, and intensity of visits were not as strongly associated with the patient satisfaction measure. CONCLUSIONS: The CPCI provides a brief and reliable measure of four important aspects of the delivery of primary care. The components of primary care are associated with patient satisfaction with visits to family physicians. The CPCI could be used with other outcomes and to assess the effect of interventions and systems changes on the delivery of critical aspects of primary care.

Adult↗
PubMed1997

The impact of insurance type and forced discontinuity on the delivery of primary care.

BACKGROUND: The effect of managed care on important attributes of primary care is poorly understood. Of particular concern is the potential for annual bidding on managed care contracts, which may cause forced discontinuity of care. We examined the effect of insurance type and insurance-mandated disruption in continuity of care on the quality of primary care. METHODS: A cross-sectional study design was used to examine 1839 patient visits to 138 community-based primary care physicians. The quality of primary care delivery was measured with the Components of Primary Care Instrument, a patient-reported indicator of physician knowledge of the patient, interpersonal communication, coordination of care, continuity of care, and patients' preference to see their regular physician. RESULTS: No significant differences in any of the five indicators of primary care quality were found between patients with independent provider association/preferred provider organization (IPA/PPO) and fee-for-service insurance. Patients with IPA/PPO health insurance were four times as likely as patients with fee-for-service insurance to report a forced change in their primary care physician (P < or = .01). Individuals forced to change their physician because of changes in their health care insurance scored significantly lower on all five indicators of primary care quality (P < or = .01). CONCLUSIONS: The quality of primary care appears to be less dependent on the payment system than on the maintenance of the patient-physician relationship. Forced disruption of continuity of care is detrimental to patient receipt of quality primary care, and is a potential negative consequence of annual bidding for managed care contracts.

Adult↗
PubMed1997

Improved discriminative and evaluative capability of a refined version of Skindex, a quality-of-life instrument for patients with skin diseases.

OBJECTIVE: To improve Skindex, a dermatologic quality-of-life instrument. DESIGN: Cross-sectional and longitudinal questionnaire study. SETTING: Dermatology clinic of a Veterans Affairs hospital and private dermatology practices. PATIENTS: Patients waiting for dermatology appointments; 201 patients responded to the original version of Skindex and 692 additional patients to the revised version. MAIN OUTCOME MEASURES: Reproducibility, internal consistency reliability, and validity of the revised version of Skindex. The revised version was compared with the original in 3 ways: the amount of time patients need to complete it; discriminative capability, determined as the number of items to which patients chose the same response; and evaluative capability, determined as the number of scales that were responsive to patients' reports of clinical change. RESULTS: With the revised 29-item version of Skindex, scale scores were reproducible after 72 hours (r = 0.88-0.92) and were internally reliable (Cronbach alpha = 0.87-0.96). The instrument demonstrated both construct and content validity; patients with psoriasis and eczema responded with higher scores than those with isolated lesions; in an exploratory principal axes factor analysis with an oblique rotation, 97% of the common variance was explained by 3 factors that correlated with the a priori scales; and most patients' responses to an open-ended question about their skin disease were addressed by items in the instrument. The average time to complete the revised instrument was 5 minutes (compared with 15 minutes for the original version). For only 3 items (10%) did 70% or more of patients choose the same response (vs 17 [28%] of items in the original version). All scales changed significantly in the expected direction in patients who reported that their skin had changed after 3 months (vs only 3 of 8 scales originally). CONCLUSION: The 29-item version of Skindex remains reliable and valid, but has decreased respondent burden and improved discriminative and evaluative capability.

Humans↗
PubMed1996

Selection of key community descriptors for community-orientated primary care.

BACKGROUND: Community-oriented primary care (COPC) requires the development of practical tools if it is to be carried out. A previous study demonstrated a practical approach to carrying out one portion of a community assessment for COPC using a few representative health indicators. OBJECTIVE: To determine the validity of this process elsewhere, we tested whether these findings were generalizable to other settings and to the same setting a decade later. METHOD: In a cross-sectional study design, data on 18 health indicators were collected for census tracts in two target areas and for the entire state of Ohio, USA, for 1990. A factor analysis was performed to identify factors underlying the health indicators in the three areas examined. RESULTS: Two underlying factors, termed age and poverty, were present in all locations and over time. Each factor was defined by core indicators and a cluster of associated indicators. CONCLUSIONS: These results suggest that one part of a COPC community assessment can be done by selecting very few indicators. The distribution of indicators of age and income explains the variability of most of the health related indicators studied. These factors are stable over time and location. A community assessment should include indicators which, at a minimum, provide information on these two factors.

Adolescent↗
PubMed1996

A comparison of US and Canadian family physician attitudes toward their respective health-care systems.

OBJECTIVES: To examine how family physicians in the United States and Canada evaluate their respective health-care systems. METHODS: The study design was a cross-sectional survey of 300 randomly selected US family physicians and 300 Canadian family physicians. Outcome measures included: attitudes about professional satisfaction and views on health-care delivery and government involvement in health care. RESULTS: Sixty-one percent of the US sample and 67% of the Canadian sample responded. After performing factor and discriminant analyses, we were able to identify nine characteristics differentiating the two groups of physicians. United States physicians were more likely to be older, male, working in rural areas, conservative in their political thinking, and satisfied with their ability to obtain diagnostic tests. United States physicians viewed the health-care system as being in need of fundamental changes, less likely to advocate a central role for government, and more likely to report that litigation concerns influence their clinical decisions. CONCLUSIONS: This study documents differences between Canadian and US family physicians, and suggests that US family physicians might not easily accept a Canadian-style health-care system. Policy makers implementing health-care system changes should be cognizant of the attitudes of physicians that might determine their acceptance or rejection of such changes.

Adult↗
PubMed1996

Academic achievement of successful candidates for tenure and promotion to associate professor.

BACKGROUND AND OBJECTIVES: For faculty to achieve promotion and tenure, a clear understanding is needed of the measures by which performance will be judged. This study describes the specific academic achievements of successful candidates for tenure and promotion to associate professor in family medicine. METHODS: A survey questionnaire was mailed to all members listed in the Society of Teachers of Family Medicine database as holding the rank of associate professor. The questionnaire sought information about items as they were at the time the individual was being considered for promotion to associate professor with tenure. The items included scholarly accomplishments, time for research, areas of scholarly expertise, and departmental policy regarding promotion and tenure. RESULTS: Of the 296 eligible faculty, 197 (67%) returned a completed survey. The mean number of publications of these successfully promoted individuals was 10. The respondents averaged 78% of their publications in peer-reviewed journals and were first author on 64% of their peer-reviewed articles. The mean number of peer-reviewed publications per year was 1.5. Research grant support as principal or coinvestigator was reported by 44%, and respondents averaged 9 hours a week on scholarly activities. Scholarly activity was found to vary significantly by type of school, degree, and tenure track status. CONCLUSIONS: Information reported here can be of value for prospective promotion and tenure candidates, their advisors, and members of review committees.

Achievement↗
PubMed1995

Self-reported physical activity predicts long-term coronary heart disease and all-cause mortalities. Twenty-one-year follow-up of the Israeli Ischemic Heart Disease Study.

OBJECTIVE: To determine whether self-reported physical activity predicts a decreased rate of coronary heart disease (CHD) and all-cause mortalities in middle-aged men when rates are adjusted for known confounders. DESIGN: Cohort Analytic Study of Israeli government employees in 1963. SUBJECTS: Eight thousand four hundred sixty-three Israeli male government employees, aged 40 years or older, representing six areas of birth, excluding those with known cardiovascular disease in either 1963 or 1965, from an original cohort of 10,059. MAIN OUTCOME MEASURE: Comparison of rates of death due to CHD and all causes, determined from death certificates in 21 years of follow-up, for subjects with different baseline levels of self-reported leisure-time and work-related physical activities measured in 1965. RESULTS: Self-reported leisure-time but not work-related physical activity was inversely related to both CHD (adjusted relative risk, 0.79; 95% confidence interval, 0.66 to 0.95) and all-cause mortalities (adjusted relative risk, 0.91; 95% confidence interval, 0.83 to 0.99). Most of the apparent benefit accrued was from light physical activity on less than a daily basis. These inverse relationships persisted after adjustment for age, systolic blood pressure, cigarette smoking, total and high-density lipoprotein cholesterol levels, body mass index, psychosocial factors, and other potential confounders. CONCLUSION: Baseline levels of self-reported leisure-time physical activity predicted a decreased rate of CHD and all-cause mortalities in employed middle-aged Israeli men followed up prospectively for 21 years.

Adult↗
PubMed1995

Factors associated with medication noncompliance in rural elderly hypertensive patients.

This study sought indicators of patient noncompliance with medications prescribed for hypertension. A sample of 62 elderly, rural hypertensive patients were interviewed regarding demographics, history and knowledge of hypertension, quality of life, the physician-patient relationship, drug use, and side effects encountered. A five-variable composite was able to detect the patients who were defined as noncompliant. The composite included: 1) number of chronic illnesses, 2) perceived amount of time the physician spends with the patient, 3) the patient's household composition, 4) family history of hypertension, 5) and whether hypertension affects work or home activities. More accurate identification of noncompliant patients sets the stage for interventions to improve compliance.

Aged↗
PubMed1995

Taped therapeutic suggestions and taped music as adjuncts in the care of coronary-artery-bypass patients.

A randomized, single-blinded, placebo-controlled trial examined the benefits of taped therapeutic suggestions and taped music in coronary-artery-bypass patients. Sixty-six patients listened to either suggestion tapes or music tapes, intraoperatively and postoperatively; 29 patients listened to blank tapes intraoperatively and listened to no tapes postoperatively. Half the patients who listened to a tape found it helpful. There were no significant differences between groups in length of SICU or postoperative hospital stay, narcotic usage, nurse ratings of anxiety and progress, depression, activities of daily living, or cardiac symptoms. There were no significant differences in these same outcomes between the patients who were helped by the tapes and the patients not helped. These results suggest that if taped therapeutic suggestions have a measurable effect upon cardiac surgery patients, demonstrating this effect will require more detailed patient evaluations to identify subgroups of patients responsive to this type of intervention.

Aged↗
PubMed1995

A practical tool for community-oriented primary care community diagnosis using a personal computer.

BACKGROUND AND OBJECTIVES: Community-oriented primary care (COPC) is considered an attractive concept by many but has had limited implementation due to a lack of practical methodology. An important step in COPC is assessment of a community's health status, using health indicators as one means of assessment. Currently, there is no easy way to combine these indicators and examine their distribution over a community. This study analyzed a process for doing that by using a personal computer. METHODS: For the community studied, all available community-based health indicators were identified. A process for combining these indicators, using commonly available database and spreadsheet software, was developed and analyzed for cost, clinical utility, and problems encountered. RESULTS: Problems were encountered with collecting and combining some data, but a clinically useful tool was produced. Costs, including purchase of all software (with mapping software), were $1,500-$2,000. CONCLUSIONS: With efforts to reduce the initial costs, this is a practical and clinically useful tool for viewing the geographic distribution of community health indicators. Such practical methodology is essential for COPC development.

Community Health Planning↗
PubMed1994

Epidemiology of intermittent claudication in middle-aged men.

Intermittent claudication, myocardial infarction, and angina pectoris share many epidemiologic and biologic features. Yet few large cohort studies describing the prevalence, incidence, and risk factors for intermittent claudication have been done. The authors evaluated intermittent claudication in 10,059 Israeli men aged 40-65 years, of whom 8,343 were free of coronary heart disease and symptoms of peripheral vascular disease; this latter group was followed for 5 years from 1963 to 1968. Prevalent and incident cases of intermittent claudication were defined by the London School of Hygiene Cardiovascular Disease Questionnaire, and all cardiovascular disease risk factor evaluations were standardized. Baseline prevalence was 27.0/1,000 (211/10,029). A total of 360 previously healthy men developed intermittent claudication for a crude 5-year incidence rate of 43.1/1,000 (360/8,343) or a crude annual incidence of 8.6/1,000. Following univariate analysis with demographic, physiologic, psychosocial, and other cardiovascular disease variables, logistic regression was used to identify risk factors for intermittent claudication. These were the following: > 20 cigarettes per day, odds ratio (OR) = 2.02, 95% confidence interval (CI) 1.54-2.66; serum cholesterol (50-mg/dl difference), OR = 1.35, 95% CI 1.18-1.54; 11-20 cigarettes per day, OR = 1.69, 95% CI 1.24-2.30; anxiety (high vs. low), OR = 1.85, 95% CI 1.29-2.65; socioeconomic status, OR = 1.82, 95% CI 1.26-2.64; and diabetes, OR = 1.85, 95% CI 1.25-2.75. Other significant predictors of smaller magnitude included in the regression were age, psychosocial coping factors, Quetelet's index, and exsmoking. The risk factors for intermittent claudication were a blend of those related to myocardial infarction (smoking, cholesterol, diabetes, but not hypertension) and others related to angina pectoris but not to myocardial infarction (stress and coping variables). There is reason to believe that preventing or modifying these factors will prove effective in altering the natural history and clinical outcomes of peripheral vascular disease as shown in other forms of atherosclerosis.

Adult↗
PubMed1994

Dissemination of information about the US Preventive Service Task Force guidelines.

We assessed the familiarity of family physicians with the US Preventive Service Task Force guidelines and targeted groups for interventions to increase the practice of recommended preventive services. A national random sample of 480 family physicians were mailed a survey consisting of demographic items and a question regarding their level of exposure to the guidelines. The association of demographic factors with the level of exposure was assessed. Of the 263 responding physicians, 37% reported that they had not read any of the recommendations. Physicians who had read at least some of the recommendations were younger, more recently graduated from medical school, less likely to be in solo practice, more likely to be residency trained, and more likely to be white. Only year of graduation and race remained significantly associated with exposure to the guidelines in a logistic regression model. Additional dissemination efforts should focus on solo practitioners, less recent graduates, and nonwhite physicians.

Adult↗
PubMed1994

Markers of successful recruitment of students to family practice residency programs.

BACKGROUND AND OBJECTIVES: With limited numbers of medical students choosing a primary care specialty, family practice residency programs have had to complete to fill available residency positions. The purpose of this study was to determine the characteristics of the recruiting process used by US family practice residencies and to compare recruiting strategies used by successful and unsuccessful programs. METHODS: We surveyed program directors of all 361 nonmilitary, accredited, US family practice residency programs in existence for more than 2 years. The questionnaire elicited information on program descriptors, recruitment process, and fill rate in the National Resident Matching Program. RESULTS: Seventy-eight percent (282) of the program directors returned usable questionnaires. Success in filling available positions through the Match was significantly associated with high quality of current housestaff and faculty and current residents' positive feelings about the program (P < .01). Program directors perceived successful programs as having an outstanding reputation and being regarded positively by other departments within the institution (P < .01). Programs in the Pacific and Mountain regions of the United States are more successful in recruitment. Programs not filling available positions through the Match spent more effort in recruiting strategies such as mailing and marketing materials (P < .01). CONCLUSION: Having high-quality faculty, housestaff, and residents with good attitudes are markers of success in the Match. Less successful programs appear to try harder to attract residents.

Academic Medical Centers↗
PubMed1993

Long-term mortality of Nazi concentration camp survivors.

Nazi concentration camp survivors have been shown to have excess mortality in the first 20 years following their release. To determine if this excess persists, Israeli civil servants were studied. Mortality of camp survivors and of other post-war European immigrants was compared 20-41 years following World War II. Using survival analysis and proportional hazards models, no difference in mortality rates was found.

Adult↗
PubMed1991

Effect of the white blood count on the clinical management of the febrile infant.

BACKGROUND: The white blood count is commonly used in the evaluation of the febrile infant without a focal source of infection. This study describes the physician's use of diagnostic tests in this clinical situation and also evaluates the effect of an elevated white blood count (WBC) on diagnostic test ordering and patient management. METHODS: A case scenario describing a febrile infant was mailed to all 294 pediatric, family, general, and emergency physician members of the Academy of Medicine of Cleveland. Questions about test ordering and case management were asked, both before and after the patient's WBC was known. Physicians were randomly assigned to receive a case scenario with either a normal or an elevated WBC. RESULTS: Of the 294 physicians contracted, 196 (67%) returned usable questionnaires. Physicians ordered an average of 1.4 tests in the initial management of the case, for an average cost of $82. Emergency physicians ordered more tests than other physicians (2.4 vs 1.2 tests, P = .001). Once the WBC was known, physicians in the high WBC group ordered more additional tests than the normal WBC group (0.89 vs 0.33 tests, P less than .001), and were more likely to change to a more aggressive therapeutic management strategy (P less than .001). CONCLUSIONS: The cost of physician-ordered laboratory testing is significant for the clinical scenario of a febrile infant without a localizing source. An elevated WBC affects physician management by causing more tests to be ordered and by influencing some physicians to choose more aggressive management strategies.

Clinical Laboratory Techniques↗