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PubMed1995

Decision processes in the management of dental disease. Part 2: Rationalizing dental treatment decisions in clinical practice.

Continuing from a previous paper, the authors outline methods that dental practitioners should use in making decisions in clinical practice. Using the analysis techniques described in both articles the dentist will be able to focus on key issues in the decision-making process and, perhaps as importantly, ignore issues that are peripheral. This article demonstrates a method (decision analysis) in which the practitioner can incorporate this information into the process of deciding which dental treatment to offer.

Decision Support Techniques↗
PubMed2005

The UTAH VBAC Study.

BACKGROUND: In July 1999, The American College of Obstetricians and Gynecologists (ACOG) issued Practice Guideline number 5 on vaginal birth after cesarean section (VBAC) and trial of labor (TOL). This updated guideline recommends that a physician be immediately available during a TOL in the rare case of complications. We examined the effect this new guideline would have on physician's VBAC/TOL practices in Utah. OBJECTIVE: 1) Explore physician knowledge of ACOG Practice Guideline number 5; 2) Evaluate change in physician's VBAC practices in the previous 12 months; 3) Evaluate physician's ability to comply with ACOG Practice Guideline number 5 recommendations by rural, suburban, and urban location. METHODS: In spring 2001, we surveyed by mail all physicians practicing obstetrics in Utah. Questions included demographics, hospital data, VBAC/TOL practice patterns and awareness of ACOG Practice Guideline number 5. Physicians were classified as urban, suburban, or rural by their primary delivery hospital. RESULTS: We found 97% of obstetricians and 79% of family physicians were aware of ACOG Practice Guideline number 5. Forty-five percent of all physicians reported a decline in VBAC practices in the preceding 12 months. Urban physicians' use of VBAC/TOL decreased the least, followed by rural and suburban. Eighty-seven percent of physicians had C/S "immediately" available during TOL: urban physicians 100%, suburban 88%, and rural physicians 76%. Emergency C/S delivery was performed fastest at urban hospitals, slower at suburban, and slowest at rural hospitals. CONCLUSION: Physicians use of VBAC/TOL has changed. TOL is offered less by obstetrical providers in Utah and more repeat C/S are performed since 1999 when ACOG updated this policy guideline. This decline has been more noticeable in suburban and rural hospitals and is consistent with recent national trends. Many rural physicians are unable to comply with ACOG Practice Guideline number 5 recommendations.

Adult↗
PubMed2001

Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology.

OBJECTIVE: To update the 1994 practice parameter for the diagnosis of dementia in the elderly. BACKGROUND: The AAN previously published a practice parameter on dementia in 1994. New research and clinical developments warrant an update of some aspects of diagnosis. METHODS: Studies published in English from 1985 through 1999 were identified that addressed four questions: 1) Are the current criteria for the diagnosis of dementia reliable? 2) Are the current diagnostic criteria able to establish a diagnosis for the prevalent dementias in the elderly? 3) Do laboratory tests improve the accuracy of the clinical diagnosis of dementing illness? 4) What comorbidities should be evaluated in elderly patients undergoing an initial assessment for dementia? RECOMMENDATIONS: Based on evidence in the literature, the following recommendations are made. 1) The DSM-III-R definition of dementia is reliable and should be used (Guideline). 2) The National Institute of Neurologic, Communicative Disorders and Stroke--AD and Related Disorders Association (NINCDS-ADRDA) or the Diagnostic and Statistical Manual, 3rd edition, revised (DSM-IIIR) diagnostic criteria for AD and clinical criteria for Creutzfeldt--Jakob disease (CJD) have sufficient reliability and validity and should be used (Guideline). Diagnostic criteria for vascular dementia, dementia with Lewy bodies, and frontotemporal dementia may be of use in clinical practice (Option) but have imperfect reliability and validity. 3) Structural neuroimaging with either a noncontrast CT or MR scan in the initial evaluation of patients with dementia is appropriate. Because of insufficient data on validity, no other imaging procedure is recommended (Guideline). There are currently no genetic markers recommended for routine diagnostic purposes (Guideline). The CSF 14-3-3 protein is useful for confirming or rejecting the diagnosis of CJD (Guideline). 4) Screening for depression, B(12) deficiency, and hypothyroidism should be performed (Guideline). Screening for syphilis in patients with dementia is not justified unless clinical suspicion for neurosyphilis is present (Guideline). CONCLUSIONS: Diagnostic criteria for dementia have improved since the 1994 practice parameter. Further research is needed to improve clinical definitions of dementia and its subtypes, as well as to determine the utility of various instruments of neuroimaging, biomarkers, and genetic testing in increasing diagnostic accuracy.

Dementia↗
PubMedDate not supplied

Changes in acute myocardial infarction risk and patterns of practice for patients older and younger than 70 years, 1987-90.

OBJECTIVE: To evaluate temporal changes in risk and patterns of hospital practice for acute myocardial infarction (AMI). DESIGN/PATIENTS: Retrospective analysis of age-related medical therapy and outcome of 342 consecutive patients (132 at least 70 years old and 210 younger than 70) with AMI between July 1, 1989, and June 30, 1990, and comparison with data from two previous analyses of AMI practice in 1987 (n = 207) and 1988-89 (n = 402). SETTING: Tertiary care medical centre. INTERVENTIONS: No direct interventions; results of the two previous AMI practice pattern analyses, however, were propagated during the practice time of the most recent analysis. RESULTS: In 1989-90, hospital mortality was higher (19%) among patients at least 70 years old compared with patients younger than 70 (8%) (P less than 0.01). Therapies proven by repeated clinical trials to be effective in reducing AMI risk were all used less frequently in patients aged at least 70 years: thrombolysis (20 versus 43%); beta-blockers (41 versus 62%); acetylsalicylic acid (71 versus 87%); and nitrates (86 versus 97%). Qualitatively, these age-specific patterns of AMI mortality and therapy were similar to previous studies. Quantitatively, however, comparing 1987 with 1989-90 demonstrated parallel and marked increases in the use of all proven medications in both age groups, ranging from 42 to 230% (P less than 0.01). There was also a significant overall decrease in mortality from the 1987 patient cohort (20%) to the 1989-90 cohort (13%) (P less than 0.05). The decrease in mortality was entirely due to decreased mortality within the group 70 years or older; 35% in 1987 versus 19% in 1989-90 (P less than 0.05). Mortality in the AMI patients younger than 70 years old remained unchanged from 1987 to 1989-90. CONCLUSIONS: Pattern of practice analyses were associated with, and may have contributed to, improved patient care and outcomes in AMI. Increased use of effective AMI medical therapy had a greater benefit in elderly higher risk AMI patients than lower risk younger patients. Persisting age-specific differences in AMI therapy may respond to more direct quality improvement measures, such as critical path management.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Personality types of family practice residents as measured by the Myers-Briggs type indicator.

This study was initiated to test the hypothesis that individuals currently choosing family practice as a career are likely to have different personality types than those who previously pursued general practice. Incoming residents to the University of Utah Family Practice Residency Program were compared to a group of private primary care physicians serving rural areas. Personality types were determined by administering the Myers-Briggs Type Indicator to both groups. Results showed that the current resident group differed significantly from the primary care physician group and that the residents' personality types were similar to personality types of faculty in other studies. This raises the concern that many family practice residents may not choose to practice in underserved areas. Further studies need to follow personality types through medical school and residency training and into practice to help determine which prospective physicians are likely to choose a primary care career and a rural practice. This information may be useful in health manpower planning and in examining admissions policies of medical schools and residencies.

Family Practice↗
PubMed1987

Predictors of physician prescribing change in an educational experiment to improve medication use.

In analyzing a university-based program to educate physicians about proper medication use, we sought to measure whether physician background characteristics and the quality or number of educational exposures influenced the rate of relinquishment of inappropriate prescribing. A sample of 435 doctors was randomized to control and experimental groups; interventions consisted of printed educational materials and face-to-face visits by clinical pharmacists. The program sought to reduce inappropriate use of three drug categories: propoxyphene, peripheral/cerebral vasodilators, and cephalexin. Outcome data included the total volume (tablets/capsules) of these drugs prescribed through Medicaid by each study physician 9 months before and after the program. We estimated average changes in prescribing levels by experimental and control physicians within each physician subgroup (e.g., board-certified versus uncertified), adjusting for prescribing level in the same 9 months of the previous year. The results indicated that the rate of prescribing change was independent of most physician background characteristics studied, including age, board certification, specialty, rural versus urban practice, intensity of previous target drug use, and size of Medicaid practice. Experimental effects were highly significant (-9% to -20%, P less than 0.025) in 11 of 14 physician subgroups. The presence of a follow-up reinforcement visit was a strong independent predictor of prescribing change (P less than 0.05). An increase from one visit to two visits was associated with an approximate doubling of the size of the program effect. However, total exposure time was not related to changes in prescribing behavior. These findings document that face to face education can be effective in improving the prescribing practices of a wide variety of physicians, and that brevity, repetition, and reinforcement of recommended practices are important components in the design of such programs.

Drug Prescriptions↗
PubMed1989

Pilot study report: obstetrical care by Texas family physicians.

Fewer family physicians are including obstetrics in their practices. This has caused concern about access to obstetrical care and has fueled the debate about the need for obstetrics curriculum in family practice residencies. Reasons frequently cited by previous research for this change in practice pattern include the rapidly escalating cost of liability insurance and the threat of lawsuit for obstetrical malpractice. The decrease in the availability of obstetrical care from family physicians has hampered access to obstetrical care, especially for rural Texans. Texas family physicians have not been surveyed previously about their obstetrical practices. For this pilot study I surveyed 205 of Texas' 4,700 family physicians and general practitioners (4%) about their past and present obstetric practices. The sample was randomly selected, and included both MDs and DOs. Of the 64.9% who responded, 28% were practicing obstetrics, 11% had never included obstetrics in their practices, and 61% had practiced obstetrics in the past. Forty percent of those who had discontinued obstetric practice did so after 1983. High malpractice premiums and fear of lawsuits were the most frequently chosen reasons for discontinuing the obstetric component of practice. Documenting this trend of decreasing availability of obstetrical care from family physicians, and sharing the data with policymakers, may help to prevent the disappearance of the family physician who delivers babies.

Female↗
PubMed1989

Breast self-examination: knowledge, attitudes, and performance among black women.

This survey assessed the reported frequency of breast self-examination (BSE): the knowledge of the technique and attitudes regarding the self-exam of 180 black women. Most respondents indicated having practiced the exam during the previous year, and 50% reported practicing it monthly or more often. Less than half of the sample indicated performing the exam according to American Cancer Society guidelines, although 92% reported being either very confident or somewhat confident of their performance ability. Attitudinal and demographic variables were tested for significant relationships with BSE practice. Compared with nonperformers, BSE performers were older, had higher annual incomes, and were more likely to believe in the benefits of BSE, to perceive social approval for BSE practice, to have been taught to perform BSE, to have had a Pap smear, a clinical breast exam, and a general physical exam within one year, and to visit a physician in a private office or clinic (as opposed to a hospital emergency room). Frequency of self-examination was significantly associated with the performer's competency level, age, belief in the benefits of performing BSE, perceived social approval for practice, having been taught to perform the exam, and level of confidence in ability to perform it.

Adolescent↗
PubMedDate not supplied

Improvements in prehospital medication storage practices in response to research.

UNLABELLED: Previously the authors showed that prehospital medications were stored outside their recommended temperature range. In response, the state office of emergency medical services (EMS) issued regulations regarding temperature control and monitoring of prehospital medications. OBJECTIVE: To determine the impact of previous research (on medication storage conditions) on current practices among the mobile intensive care units (MICUs) within the state. METHODS: A statewide, structured telephone survey of MICU directors was conducted between April and December 2000. Questions focused on changes in storage and monitoring practices (including modifications to vehicles, medication boxes, and the use of temperature monitoring devices) since the authors' previous research. RESULTS: Thirty-three of 35 (94%) programs (100 vehicles) participated in the survey. Eighty-five percent changed their practices since the research five years ago. Of the five that did not change, three already had temperature control measures in place, while two have not made any changes. Twenty-one (63%) of the programs reported changing specifically because of state regulations. Eighty-one percent of the programs have taken some measure to control temperature. Currently, 63% of the 100 vehicles in use have both heating and cooling devices specifically for the medications, whereas 14% have only a heater and 23% have neither. Thirty-one (94%) MICUs monitor the temperature in some manner: 42% in the vehicle, 58% in the medication box. Of these, 68% are using 30-day electronic temperature data recorders, whereas 32% are using non-recording digital thermometers. CONCLUSIONS: This survey demonstrates a positive impact from previous research. Most of the MICUs in the state have changed their practices in controlling and monitoring prehospital medication storage temperature.

Critical Care↗
PubMed1993

Factors associated with HIV seropositivity in European injecting drug users. The European Community Study Group on HIV in Injecting Drug Users.

OBJECTIVE: To study factors associated with HIV seropositivity among European injecting drug users (IDU). METHODS: Data on behavioural and other factors potentially associated with HIV status were collected retrospectively by personal interview with IDU (n = 2330) in a multicentre cross-sectional survey conducted in 12 European countries from 1989 to 1990. HIV status tested at the time of the survey was examined in relation to demographic data, history of imprisonment, travel to foreign countries, high-risk drug-using practices in the previous 6 months (re-using other IDU's injecting equipment without effective disinfection) and high-risk sexual behaviour in the last 6 months (multiple partners, unless none was IDU and condoms were always used). Analysis excluded IDU who claimed to be seropositive from previous testing. RESULTS: Imprisonment was significantly associated with current HIV status [odds ratio (OR), 1.70; 95% confidence interval (CI), 1.2-2.87]. High-risk drug-use practices were significantly associated with current HIV status in respondents not previously tested (OR, 2.86; 95% CI, 1.09-7.35) but not in respondents claiming to be seronegative. No significant association was found for high-risk sexual behaviour. CONCLUSIONS: Our experience supports the validity of retrospective investigation of behaviour in a population that is notoriously difficult to study. However, any interpretation of the apparently different associations of HIV status with high-risk sexual behaviour and high-risk drug-use practices must consider that factors tending to attenuate the correlations may operate differently in these two areas.

Adolescent↗
PubMed2000

The effect of capitation on GPs' referral decisions.

In the Norwegian capitation trial, the payment system for general practitioners (GPs) has been changed; a practice allowance component has been replaced by a capitation component and the fee-per-item component constitutes a smaller part of a GPs practice income than previously. From the theoretical modelling of GPs' referral decisions, we predict that the replacement of the practice allowance by a capitation component will increase the rate of referrals to specialists. This hypothesis is supported by an exploratory empirical study with data from a sample of GPs participating in the experiment.

Aged↗
PubMedDate not supplied

The silence and the silencing of the nurse's voice: a reading of patient progress notes.

Content analysis of text offers a method for exploring experiences which usually remain unquestioned and unexamined. In this paper the authors analyse a set of patient progress notes by re-framing them as a narrative account of a significant event in the experience of a patient, her family and attending health care workers. Examination of these notes provides insights into aspects of clinical practice which are usually dealt with at a taken-for-granted level. An interpretation of previously unexamined therapeutic practices within the social and political context of institutional health care is offered.

Communication↗
PubMed1991

Parental fertility and infant hypospadias: an international case-control study.

The authors have performed an international case-control study on the significance of exogenous hormones for the origin of hypospadias (Källén et al., 1991 a,b). Using data from this study on 846 infants with isolated hypospadias and equally many controls (next male infant born in the same hospital as the case), variables that might indicate an increased rate of fertility problems in couples who had a boy with hypospadias were studied. Cases had slightly fewer previous pregnancies, there was practically no difference in the rate of previous induced abortions, and no demonstrable difference in menstrual history. Infertility periods of at least 6 months were more likely among cases than controls but the difference did not reach statistical significance in a two-tailed test. There was no demonstrable difference in the time to conceive between cases and controls. The difficulties of directly studying subfertility problems are stressed.

Case-Control Studies↗
PubMed1987

A linked muscular activation model for movement generation and control.

A new model for movement control is presented which incorporates characteristics of impulse-variability and mass-spring models. Movements in the model were controlled with phasic torque impulses in agonist and antagonist muscles and a tonic agonist torque. Characteristics of the phasic agonist and antagonist torque profiles were based on observed properties of movement-related EMGs and muscle isometric torques. Variability of the phasic impulses depended on impulse magnitude as in impulse-variability models. The model therefore predicted a speed-accuracy tradeoff for limb movement. The time of onset and magnitude of the antagonist torque depended on the magnitude of the preceding agonist torque as indicated in studies of movement-related EMGs. This led to the new concept of linkage between the agonist and antagonist muscle forces which was shown to be important for reducing variability of fast movements. Progressive development of linkage during practice could explain the previous findings of decreased movement variability with practice coupled with increased variability of movement-related EMGs. It was concluded that an inherently variable motor system deals with the variability associated with generation of large muscle forces by linking the forces produced by opposing muscles. In this way, variability in net joint torques and in movements can be decreased without the need for the nervous system to closely regulate the individual torques.

Journal Article↗
PubMed2003

Safety practices, neurological symptoms, and pesticide poisoning.

Depression, anxiety, inability to concentrate, and spatial disorientation associated with pesticide poisoning may influence farmers' ability to comply with established safety procedures. The purpose of this article is to describe the relationship between safety practices, neurological symptoms, and pesticide poisoning. A survey of farm residents was conducted in an eight-county area in Colorado. Multivariate logistic regression models were used to determine associations between safety practices, neurological symptoms, and previous pesticide poisoning. A number of safety practices were associated with the following neurological symptoms: difficulty concentrating; feeling irritable; relatives noticing memory difficulties; and difficulty understanding reading materials. The associations between safety practices and neurological symptoms were increased in the presence of pesticide poisoning. Factors associated with failure to engage in established safety practices in this study were neurological symptoms.

Adult↗
PubMed1994

The quality of clinical trials published in The Journal of Family Practice, 1974-1991.

BACKGROUND: Previous analyses of published clinical trials have identified major deficiencies in reporting, design, analysis, and overall quality. The purpose of this study was to determine the strengths and weaknesses of published clinical trials in family practice, and to identify predictors of quality in these trials. METHODS: Randomized controlled clinical trials published in The Journal of Family Practice from 1974 to 1991 were eligible for the study. Two raters independently evaluated the adequacy and appropriateness of reporting, design, and analysis for each clinical trial, using the Chalmers index for assessing clinical trial quality. Multiple linear regression was used to determine the predictors of quality. RESULTS: The 53 trials included in the study showed deficiencies in reporting, design, and analysis, although fundamental design issues, such as blinding, were a relative strength. On average, the trials scored 35% of the possible points on the scale. Three factors were positively associated with overall quality: year of publication, number of pages of the published report, and the type of intervention. Trials with pharmacologic and non-medication therapy interventions, such as diet, had higher quality scores than did trials with psychosocial or educational interventions. CONCLUSIONS: The overall quality of these clinical trials was less than optimal but comparable to previously analyzed groups of trials. The improvement in quality over time may be related to improvement in the quality of the trials themselves, or more exacting editorial standards, or a combination of the two.

Bias↗
PubMed2003

Overcoming the undersupply--supporting midwives' return to practice.

UNLABELLED: The current critical shortage of midwives is a worldwide phenomenon that has created the need for educational programs that prepare midwives, who have previously left midwifery practice, for return to the contemporary clinical workforce. This paper focuses on the support requirements of midwives involved in a refresher program as determined by a research project conducted at The Northern Hospital in Melbourne during 2001. The project was a small-scale case study involving eight program participants. Questionnaires and semi-structured interviews were used to generate data. Analysis of the data revealed that the concept of support must be considered from personal and professional perspectives, if successful outcomes are to be achieved. INTRODUCTION: The response of the Federal Government to the dire shortage of midwives currently working in public healthcare facilities has been to allocate funding to the states and territories for education and re-skilling programs, with the aim of enticing midwives back to clinical practice (Walsh 2001). In Victoria, refresher programs have been developed to meet the needs of midwives whose level of expertise has diminished due to lack of clinical experience, but who have fulfilled the necessary requirements.

Adult↗