Telephone triage by primary care physicians.

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P less than .05) or injured (P less than .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P less than .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.

The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center.

Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year. In most busy practice settings, it is difficult for primary care physicians to identify every patient in need of preventive health interventions. The purpose of this study was to assess the effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. The practice uses an interactive encounter form system from which updated clinical information is routinely entered into a cumulative database. During a 2-month period, 686 patients were identified in the database as eligible to receive influenza vaccine according to accepted criteria. Practice physicians (n = 32) were stratified by level of training and randomized to one of three groups, thereby receiving printed reminders on the encounter forms of all, none, or half of their eligible patients. Patients of physicians who always received reminders were more likely to receive influenza vaccine during the study period than patients of the never-reminded physicians (51 percent versus 30 percent, P less than 0.001). Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed (38 percent) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed (20 percent, P less than 0.001). This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter.

Obstetric care among family physicians in Pennsylvania. Trends, association with residency training, and policy implications.

A study was designed to investigate the status of obstetric practice by Pennsylvania family physicians and its relationship to family practice residency training. A 50% probability sample of all family and general physicians and of all graduates of Pennsylvania family practice residency programs was surveyed by mail. Ten percent of Pennsylvania family physicians and general practitioners reported currently practicing obstetrics, 44% of whom said they planned to stop within 3 years. Telephone survey information from nonresponders suggests that even fewer (5%) of the state's family physicians may actually be practicing obstetrics. Family practice residency training, postresidency obstetric training, and small community size were the best predictors of current obstetric practice. Family physicians in the smallest communities, however, were also those most likely to be planning to stop, and graduates of residency programs were increasingly choosing not to practice obstetrics. Cost of liability insurance and fear of lawsuits were primary reasons cited for stopping obstetrics. Family physicians have been major providers of obstetric care in the nation's rural areas. Now, increasingly firm evidence that fewer family physicians are practicing obstetrics signals increasing shortages in obstetric care for women in rural communities. Changes in the practice climate and obstetric training programs for family physicians seem essential to help reverse these trends.

Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines.

Recent studies have documented that physician compliance with recommended periodic health screening improves with reminders to physicians. These reminders, however, are often costly to maintain and modify. This study investigates the influence of a microcomputer tickler system on the ordering of mammograms. All women (N = 1262) aged 40 years and older who made visits to an outpatient office during a 6-month period were randomly assigned to one of two groups. For the experimental group, the date of the last mammogram ordered and recorded in the clinical database was printed on the encounter form generated for each patient visit. No information regarding previous mammograms was printed for patients in the control group. Women in the experimental group were more likely to have a mammogram ordered during the study period (19% compared with 12%, P = .001) and, as a result, were more likely to be in compliance with mammography guidelines at the study's completion (27% compared with 21%, P = .011). Microcomputerized data storage and retrieval systems may help increase physicians' attention to preventive health screening recommendations.

Patterns of change in disability and well-being.

Longitudinal data that track the course of disability and well-being are being collected for older populations, with remeasurements taken at annual or longer intervals. These can miss much of the genuine dynamics that older people experience. This analysis uses a data set with fine-grained data on health and function. It involves 165 persons ages 55 and over who were followed for minimum of 1 year (up to 2 years) after hospitalization for a chronic condition (six of which were specified). Within that period, each person had nine separate contacts for assessment of cognitive, physical, social, and emotional function. Respondents also kept health diaries continuously for a year. This article reports patterns of change for the diaries only, focusing on two items recorded daily: self-rated health and activity level. We analyze the data visually, by plots of these items over time for each person, and statistically, by numerical indicators of changes and levels for the items. Differentials in changes and levels by patient characteristics (e.g., age, sex, marital status, diagnosis) were explored. Most people experience a posthospital improvement, with the majority attaining their usual levels of well-being and activity, despite their serious illness. But this recovery is usually interrupted by episodes of low well-being and activity and even further hospital stays. Statistical analyses show that, overall, physical health suffers a small decline over the year whereas activity levels tend to improve. Health is worst and activity levels lowest, gains are smallest and declines largest, for elderly (ages 75 and older) men and for nonmarried people, especially men. Together, the visual and statistical analyses confirm the profound dynamics in health and function that middle-aged and older people with chronic conditions experience.

The antihypertensive response to lisinopril: the effect of age in a predominantly black population.

After a 2-4 week no-treatment period, 24 patients (12 young, age 29-45 yr.; 12 elderly, age 65-81 yr.; 20 black, 4 white) with an untreated sitting diastolic blood pressure between 91-120 mm Hg received the nonsulfhydryl angiotensin converting enzyme inhibitor, lisinopril for three weeks in a singleblind, parallel group comparison. Patients who did not achieve goal blood pressure with the initial low-dose (10 mg/day) were treated with a high-dose regimen (40 mg/day) for three weeks. In those who remained incompletely responsive, hydrochlorothiazide 25 mg/day was added for four weeks in an attempt to normalize blood pressure (less than or equal to 90 mm Hg). Low-dose lisinopril monotherapy produced comparable reductions in the mean systolic and diastolic blood pressures (approximately -15/-8 mm Hg in both younger and older patients). Increasing the dose produced a slightly greater fall in mean blood pressures which normalized the blood pressure in five of six elderly patients unresponsive to the lower dose; addition of hydrochlorothiazide normalized three of the five remaining subjects from both groups who were unresponsive to high dose lisinopril. Lisinopril administration resulted in a rise in plasma renin activity and a fall in plasma aldosterone concentrations which were similar in both groups and which returned over time toward the baseline. The drug was well tolerated, producing one episode of symptomatic hypotension following the addition of hydrochlorothiazide to lisinopril monotherapy. Lisinopril alone or in combination with hydrochlorothiazide produces favorable antihypertensive effects in both younger and older predominantly black, low-renin patients with essential hypertension.

Follow-up study of an urban family medicine home visit program.

A home visit program was established by a large urban family practice in an academic setting. At the program's inception, 198 patients were randomly assigned to either an experimental group, to be eligible for home visits, or a control group, to continue receiving only office-based care. Two years after this randomization, follow-up data were obtained on 194 of the 198 subjects to assess the program's effectiveness. Fifty-one of the subjects had died. There were an increased number of deaths in the experimental group (30 percent) compared with the control group (21 percent), although this difference was not statistically significant. No statistically significant differences were found between the remaining 143 experimental and control group patients in function or well-being. Patients in the experimental group had a significantly higher number of hospitalizations, although there was no difference in the number of days spent in the hospital. Although methodologic considerations limit the ability to draw policy conclusions from this follow-up study, this home visit program did not have a measurable sustained impact on health outcomes or utilization of health services.

Assessment of depression in a family practice center.

This study examined the presence of depressive symptoms in an adult outpatient population. Through review of 100 randomly selected patient charts, it was found that a diagnosis of depression was recorded in 31 percent, with an additional 31 percent having symptoms and diagnoses suggestive of depression noted. Data collection on a sample of 123 patients in a second study phase designed to assess agreement among alternative methods for identifying depression included patient interviews (using the Beck Depression Inventory, the Zung Self-Rating Depression Scale, and a visual analog), physician interviews, and chart abstracts. The proportion of patients considered depressed using each of the measures ranged from 21 percent to 38 percent. The patient-reported measures were more closely correlated with each other than with the physician-reported measures. The finding that depressive symptoms are highly prevalent in this population supports the need for training physicians in recognition, treatment, and documentation of depression. Future research imperatives should include differentiating between depressive symptoms and diagnoses, investigating the use of interviewer-administered measures of depression as screening tools, and investigating the relationships between depression, physiologic disease, and use of health services.

Weights for scoring the quality of well-being instrument among rheumatoid arthritics. A comparison to general population weights.

The importance of measuring health outcomes such as functional status and quality of life has increased with the greater emphasis on efficiency and on judgements of clinical effectiveness of therapies for patients with chronic disease. One measure of health status, the quality of well-being (QWB), has received significant attention as a health policy model because it quantifies health on a scale ranging from "zero" (death) to "one" (optimal health). The scale is based on weights (values) that were derived by having several thousand individuals in the general population rate scenarios in which a patient is described in terms of mobility, physical activity, social activity, and major symptom or problem. The present study was undertaken to determine if a disease-specific population composed of patients with moderate and moderately severe rheumatoid arthritis who were participating in a national multicenter trial of a new oral therapeutic agent, would rank scenarios similarly to the general population sample. In this study, close agreement was found between the weights obtained from the general population sample and the weights obtained from the sample of rheumatoid arthritic patients (R = 0.937). The investigators believe that the study supports the use of the original general population weights and suggest that the index may be used for populations with a specific condition as well as for general populations.

Hepatitis B antigen and antibody in the U.S. Army: prevalence in health care personnel.

The prevalence of Hepatitis B surface antigen (HB(S)Ag) and antibody (anti-HB(S)) seropositivity and the association of seropositivity with demographic, personal health, and professional experiences were studied in a cohort of Army Medical Department officer personnel. Serologic evidence of Hepatitis B infection was found in 5.0 per cent of personnel and was associated with age, sex, place of birth, history of hepatitis, history of blood transfusion, and previous overseas assignments. Seropositivity rates were higher for patient care oriented officer personnel, especially for those in surgical specialties, and rose with increasing professional experience. These data present a composite of risk factors operative in the acquisition of Hepatitis B seropositivity and identify a cohort for prospective study.