Suicide within 12 months of contact with mental health services. Rural and suburban populations can have more contact with mental health services.
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England↗
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Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices.
Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of outpatient visits by trained research nurses involving 4,454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.
Adult↗
Pediatric dentists' participation in the California Medicaid program.
PURPOSE: The purpose of this study was to determine pediatric dentists' participation in the California Medicaid program and investigate barriers to participation. METHODS: A 24-question mail-in survey with a follow-up was sent to all pediatric dentists in California with questions including demographics, Medicaid participation, and barriers to participation. Data were analyzed using descriptive statistics, chi-square tests, bivariate analysis, and multivariate logistic regression. RESULTS: Pediatric dentists returned 364 useable mail-in surveys for a response rate of 70%. Forty-five percent participated in the Medicaid program, one third of which would accept all patients and two thirds of which placed some restriction on their participation. Twenty-five percent of respondents had at least 10% Medicaid patients in their practice, and 25% accepted 6 or more new Medicaid patients per month. Dentists in rural areas were significantly more likely than those in urban or suburban areas to accept a new Medicaid patient (P < .05). Eighty-nine percent of all respondents reported low fees and 82% reported broken appointments as important reasons for not participating or limiting participation. CONCLUSIONS: Participation of California pediatric dentists in Medicaid is low compared to other states that have participation studies. Pediatric dentists in rural areas are most likely to participate. Among the reasons that contribute to California dentists not participating in the Medicaid program, the major ones appear to be low fees, broken appointments, and denial of payment.
Adult↗
What affects influenza vaccination rates among older patients? An analysis from inner-city, suburban, rural, and Veterans Affairs practices.
BACKGROUND: Despite strong evidence of the effectiveness of influenza vaccination, immunization rates have reached a plateau that is below the 2010 national goals. Our objective was to identify facilitators of, and barriers to, vaccination in diverse groups of older patients. METHODS: A survey was conducted in 2000 by computer-assisted telephone interviewing of patients from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural practices, and suburban practices. The inclusion criteria were age > or =66 years and an office visit after September 30, 1998. RESULTS: Overall, 1007 (73%) interviews were completed among 1383 patients. Influenza vaccination rates were 91% at VA clinics, 79% at rural practices, 79% at suburban practices, and 67% at inner-city health centers. There was substantial variability in vaccination rates among practices, except at the VA. Nearly all persons who were vaccinated reported that their physicians recommended influenza vaccinations, compared with 63% of unvaccinated patients (P <0.001). Thirty-eight percent of unvaccinated patients were concerned that they would get influenza from the vaccine, compared with only 6% of vaccinated persons (P <0.001). Sixty-three percent of those vaccinated, in contrast with 22% of unvaccinated persons, thought that an unvaccinated person would probably contract influenza (P <0.001). CONCLUSION: Older patients need intentional messages from physicians that recommend vaccination. Furthermore, more patient education is needed to counter myths about adverse reactions.
Aged↗
Asthma care and management before an emergency department visit in children in western Michigan: how well does care adhere to guidelines?
OBJECTIVES: Asthma is one of the more common reasons for children's visits to the emergency departments (EDs). Many studies show that the level of asthma care and self-management in children before an ED visit for asthma is often inadequate; however, most of these studies have been conducted in the inner cities of large urban areas. Our objectives were to describe asthma care and management in children treated for asthma in 3 EDs located in an urban, suburban, or rural setting. METHODS: We studied a prospective patient cohort consisting of children aged 2 to 17 years who presented with an acute asthma exacerbation at 3 EDs in western Michigan. An in-person questionnaire was administered to the parent or guardian during the ED visit. Information was collected on demographics; asthma history; usual asthma care; frequency of symptoms during the last 4 weeks; current asthma treatment, management, and control; and past emergency asthma care. A telephone interview conducted 2 weeks after the ED visit obtained follow-up information. The 8 quality indicators of asthma care and management were defined based on recommendations from national guidelines. RESULTS: Of 197 children, 70% were enrolled at the urban site, 18% at the suburban site, and 12% at the rural site. The average age was 7.9 years; 60% were male, and 33% were black. At presentation, nearly half (46%) of the children had mild intermittent asthma, 20% had mild persistent asthma, 15% had moderate persistent asthma, and 19% had severe persistent asthma. One quarter of the children had been hospitalized for asthma, and two thirds had at least 1 previous ED visit in the past year. At least 94% had health insurance coverage and 95% reported having a primary care provider. Less than half of the children had attended at least 2 scheduled asthma appointments with their regular asthma care provider in the past year. Although only 5% of the subjects reported that the ED was their only source of asthma care, at least 30% reported that they always went directly to the ED when they needed urgent asthma care. Only 3 in 5 children possessed either a spacer or a peak-flow meter, whereas approximately 2 in 5 reported having a written asthma action plan. Among those with persistent asthma, there was considerable evidence of undertreatment, with 36% not on either an inhaled corticosteroid or a suitable long-term control medication. Only 20% completed a visit with their regular asthma care provider within 1 week of their ED visit. CONCLUSIONS: Despite very high levels of health care coverage and access to primary care, the overall quality of asthma care and management fell well short of that recommended by national guidelines.
Adolescent↗
Using the American Medical Association physician masterfile to measure physician supply in small towns.
The goal of this study was to describe the magnitude, direction and sources of error of the American Medical Association's (AMA) masterfile (MF) in estimating physician supply in small towns. A random sample of nonmetropolitan towns in the United States was selected, and physicians with AMA MF (MFMDs) addresses in these towns were listed. Local pharmacists were asked to confirm or disconfirm the identities and locations of practice for the listed physicians and to add any unlisted physicians who were there. We took pharmacist confirmed or identified local source physicians (LSMDs) to be the "gold standard." The sample of 57 towns yielded 1,341 potential physician names. In these towns, there were 377 physician listings only from the MF, 188 only from local pharmacists, and 776 from both sources. About 80 percent of physicians identified by local informants were also listed on the MF; only 67 percent of physicians listed on the MF were identified by local informants as currently practicing in the town where they were listed. The error in these measures declined with increasing town size. The aggregate ratio of MFMDs to LSMDs was 1.20, ranging from 1.10 to 1.28 across size classes of towns. Given the persistence of local shortages of physicians, despite a national oversupply, accurate measurement of physician supply should be a priority of rural health care planners and advocates. Although the MF is the most comprehensive available national physician database, reliance on it alone to make local estimates of physician supply might lead one to believe that there are 20 percent more physicians in small rural communities than are actually there. Local pharmacists can be valuable informants about rural physician availability and their in- and out-migration.
American Medical Association↗
Alternative models for academic family practices.
BACKGROUND: The Future of Family Medicine Report calls for a fundamental redesign of the American family physician workplace. At the same time, academic family practices are under economic pressure. Most family medicine departments do not have self-supporting practices, but seek support from specialty colleagues or hospital practice plans. Alternative models for academic family practices that are economically viable and consistent with the principles of family medicine are needed. This article presents several "experiments" to address these challenges. METHODS: The basis of comparison is a traditional academic family medicine center. Apart of the faculty practice plan, our center consistently operated at a deficit despite high productivity. A number of different practice types and alternative models of service delivery were therefore developed and tested. They ranged from a multi-specialty office arrangement, to a community clinic operated as part of a federally-qualified health center, to a team of providers based in and providing care for residents of an elderly public housing project. Financial comparisons using consistent accounting across models are provided. RESULTS: Academic family practices can, at least in some settings, operate without subsidy while providing continuity of care to a broad segment of the community. The prerequisites are that the clinicians must see patients efficiently, and be able to bill appropriately for their payer mix. CONCLUSION: Experimenting within academic practice structure and organization is worthwhile, and can result in economically viable alternatives to traditional models.
Academic Medical Centers↗
[How long does it take for an ambulance to arrive?].
BACKGROUND: There are few Norwegian recommendations for quality and efficacy of ambulance performance. A report commissioned by the Ministry of Health and Social Affairs concluded that the ambulance service was the weakest link in the chain of survival. The report proposed standards for response intervals in emergencies: 90% of the population in cities and urban areas should be reached by an ambulance within eight minutes. In rural areas, 90% should be reached within 25 minutes. MATERIAL AND METHODS: This study describes the ambulance response interval for the 2,589 red code emergencies in the 15 municipalities in Vestfold County in 1998, a county with a population of 208,687, or 97.5 inhabitants per square kilometre, with seven ambulance stations. A retrospective analysis was made of data for the year 1998. RESULTS: The proposed standard was not reached in any municipality in the county. The city of Tønsberg had the best performance, but even here only 48.9% of the population were reached by ambulance within eight minutes. The worst performance was found in the rural municipality of Tjøme; here, only 63.3% were reached within 25 minutes. INTERPRETATION: Achieving the standards proposed will require a major restructuring of existing ambulance services.
Ambulances↗
National survey of diabetes care in general practice.
This survey was mounted to assess the extent and organisation of diabetes care in general practice in Ireland. It was a postal questionnaire surveying 25% of general practitioners, The response being 396 (70%). 355 (92%) report providing most care to a mean 65% of their type 2 patients, and 243 (64%) provide most care to 38% of their type 1 patients. The extent of structured care is less frequent with 43% maintaining a diabetes register, and 51% using a recall system. Access to multidisciplinary diabetes expertise in the community is low, particularly for dietetics (50%) and diabetes specialist nursing (7%). Rural doctors are significantly more likely to report providing care to patients with type 1 and 2 diabetes. Irish general practitioners report providing a substantial amount of care, particularly for patients with type 2 diabetes, but this is largely unstructured. Significant investment is needed to ensure uniformly structured care in this setting.
Diabetes Mellitus, Type 1↗
Factors governing the use of child health services in suburban area in Egypt.
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Child Health Services↗
[Suburban child health services for immigrant families].
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Child Health Services↗
Meeting the health care needs of suburban youth: review of a clinical service.
The demographic and medical data from the first 1,000 patients registered at a suburban adolescent health service were reviewed and the findings compared with the results of an initial survey performed in the same community and other health services located in urban communities. Most of the patients were white (92%), girls (82%), and 16 to 18 years of age (63%) and had parents who graduated from high school (59%) or college (28%). They reported higher rates of participation in health-risk behaviors, including smoking (50%), drinking (60%), drug use (67%), and sexual intercourse (83%), than their peers. Seventy-two percent of the patients sought medical attention for sexuality-related or gynecologic concerns, including contraception (39%), pregnancy determination (20%), and evaluation of possible sexually transmitted disease (9%), and 28% sought attention for general medical or emotional needs, including checkups or immunizations (11%), nutritional or weight problems (4%), and emotional issues or substance abuse (4%). Management of sexuality-related issues differed from that reported in urban settings, whereas laboratory screening tests indicated that problems were similar to those in other settings. Many problems described in an initial survey of youth in the community were not seen at the adolescent health service. We conclude that a suburban-based health service may meet certain health care needs of the higher risk youth of the community but that ultimate care for adolescents remains with the private physicians in this setting.
Adolescent↗
Comprehensive community-based mental health outreach services for suburban seniors.
An outreach program to deliver mental health services to mentally ill older adults has been developed in Baltimore County, Maryland. Incorporating prevention and early intervention strategies, this program targets persons aged 60 and over with late-onset or previously undiagnosed psychiatric histories. Services are provided through a novel one-third/one-third/one-third delivery schedule in senior centers, in community mental health centers, and in seniors' homes.
Aged↗
St. Mary cooks up awareness with heart-healthy booklet, television.
St. Mary Medical Center, Langhorne, Pa., distributed a half-million copies of its copyrighted booklet, "Heart Healthy Living" as the first of a larger, long-term marketing initiative to raise awareness of the suburban medical center. In addition to the medical center and physicians' offices, St. Mary had the booklet distributed by regional food markets and Fleet Bank. These partnerships and those with food products manufacturers helped reduce expenses. St. Mary physicians appeared on a cable television cooking show as well as in selected grocery markets.
Health Education↗
Evaluation of American College of Surgeons trauma triage criteria in a suburban and rural setting.
In suburban and rural counties, patient transport to specialized facilities such as trauma centers may result in prolonged transport times with the resultant loss of ambulance coverage in the primary service area. We evaluated the American College of Surgeons trauma triage criteria as modified by New York State to determine the ability of these criteria to predict the need for trauma center care in victims of blunt traumatic injury. Blunt trauma patients were retrospectively identified through review of patient care reports for the presence either of mechanism or of physiological criteria for transport to a trauma center. Controls were randomly selected from patients with blunt trauma not meeting any of the criteria. Main outcome parameters were the emergency department (ED) disposition, length of hospital stay, need for intensive care unit (ICU) care, and major nonorthopedic operative interventions. There were 857 patients enrolled. The presence either of mechanism or of physiological criteria increased the likelihood of hospital admission (control, 11%; mechanism, 35%; and physiological, 33%). Relative to patients without any criteria, the presence of mechanism criteria alone did not identify patients who required a prolonged length of stay (67% vs 71%), intensive care unit services (13% vs 19%) or major nonorthopedic operative interventions (0.2% vs 1.6%). The presence of physiological criteria increased the likelihood of requiring all of these services. These comparisons held true for victims of motor vehicle accidents, pedestrians struck by motor vehicles, and people who fell from heights above ground level. Patients with physiologic criteria may benefit from transport directly to a trauma center. Because of the low need for operative intervention and ICU services, patients with no criteria or mechanism criteria at long distances from a trauma center may be initially evaluated at the closest hospital and transferred to a trauma center if hospitalization or ICU care is necessary. Further study to determine the predictive value of certain individual mechanism criteria is warranted.
Adolescent↗
Practice profile differences among Swedish dentists. A questionnaire study with special reference to prosthodontics.
A questionnaire measuring differences in prosthodontic practice profiles was sent to 2100 Swedish dentists working as general practitioners. The response rate was 76%. Among the responders, 58% were men and 42% women. Fifty per cent were private practitioners, the other 50% being publicly employed. The practice profile variables showed a great variation, and several of the distributions differed with regard to sex and dental care system. The working hours per week the time spent on prosthodontics were on average higher for men than for women. Private practitioners more frequently worked in large communities and cities than did dentists working in the Public Dental Health Service. Practically all (98%) of the private practitioners used more than 75% of their clinical time on treating adults, compared with less than half of the dentists in the Public Dental Health Service. Male dentists reported higher percentage figures with regard to clinical time used for dental care of adults and for prosthodontic services than did female dentists. The figures for fixed prosthodontic service rates varied in the same manner. Fixed prosthodontic services were much more common in private practice than in the Public Dental Health Service, in which more removable dentures were made. Even though private practitioners used more time for prosthodontic services, they referred fewer patients to specialists in prosthodontics and consulted a specialist less often than did the dentists in the Public Dental Health Service.
Adult↗
Accessibility of genitourinary medicine clinics.
OBJECTIVES: to examine and compare the accessibility and acceptability of a range of genitourinary medicine (GUM) clinics. DESIGN: five GUM clinics representing different types of locations in the West Midlands Region were selected. All patients attending over the sampling period were included, with data collected by anonymous self completed questionnaire. RESULTS: 297 completed questionnaires were obtained from 360 attendees; 87.4% of attendees had taken 30 minutes or less to get to the clinic, and 66% had used public transport, with variations found between locations. The majority (72.5%) of attendees visited the clinics during their preferred part of the day. Examination of narrower time preferences showed that those wanting to visit in the evening were less likely to be seen during their preferred time than those wanting daytime visits (32% compared with 90%). Of the attendees 98.6% found clinic staff to be friendly and 97.5% did not feel they were being judged because of their sexual activities. The most common reasons for choosing a clinic were recommendation (38.2%) and proximity (36.4%). CONCLUSIONS: the clinics were generally found to be physically accessible, although clinic opening hours need to be reconsidered. Further work is needed on the acceptability of the service in relation to expectations.
Ambulatory Care Facilities↗
What works. Tip of the iceberg. Chicago health system uses database and analytics software to save its call center and increase its business via targeted campaigns.
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Chicago↗