The impact of clinical audit on antibiotic prescribing in general dental practice.

OBJECTIVE: To reduce the number of antibiotics inappropriately prescribed by general dental practitioners, and to increase overall prescription accuracy. DESIGN: A prospective clinical audit carried out between September and March of 2002-3 and 2003-4. SETTING: General dental practices in Eastern England. SUBJECTS AND METHODS: The pre-audit antibiotic prescribing practices of 212 general dental practitioners were recorded over an initial six week period. On each occasion this included which antibiotic had been chosen, together with its dose, frequency and duration, as well as the clinical condition and reason for which the prescription had been raised. When related to prophylaxis, the patient's medical history was also noted. Following education on contemporary prescribing guidelines, presentations which illustrated the practitioners' previous errors, and the agreement of standards to be achieved, the process was repeated for another six weeks, and the results compared. RESULTS: In the pre-audit period, 2,951 antibiotic prescriptions were issued, and during the audit this was reduced by 43.6% to 1,665. The majority were for therapeutic reasons, with only 10.5% and 13.6% for medical prophylaxis during the pre-audit and audit periods respectively. Over both periods, amoxicillin and metronidazole were the two most commonly prescribed antimicrobials (63.4% and 21.2% respectively). In the pre-audit period, only 43% of all prescriptions were error free in dose, frequency, and/or duration of use, but this rose significantly to 78% during the audit. Equally, using contemporary published guidelines, out of all the prescriptions made in the pre-audit period, only 29.2% were deemed to be justified, as compared to 48.5% during the audit. CONCLUSIONS: Clinical audit, in conjunction with education, and prescribing guidelines can favourably change antibiotic prescribing patterns among general dental practitioners.

Training, re-training and getting back to practice.

Career breaks occur for many reasons and may well be the pattern for the future. In a recent survey, reasons given for career breaks included personal and family sickness, childrearing, travelling and study. Childrearing was the most common reason for women to have a break and personal sickness for men. Although these breaks may be short, they may be multiple and therefore have enormous implications for workforce planning.

Beyond the Folstein: dementia in primary care.

As the population of elderly patients continues to increase world-wide, the importance of identifying patients with dementia in primary care practices will increase. Our ability to see patients for an extended period of time may enable primary care physicians to identify patients with dementia early in their disease process. This enables patients, families, and caregivers to initiate treatment early, with the hope that future research will identify successful treatment modalities. This article discusses the identification of dementing syndromes, the importance of identifying familial needs and coping strategies, and the importance of caregiver stress.

Care of persons with AIDS in the nursing home.

BACKGROUND: AIDS is becoming a chronic illness for some patients whose significant accumulated functional impairments may limit community-based care. Nursing homes can provide an appropriate level of care, although reported experience caring for persons with AIDS in this setting is limited. METHODS: A retrospective case-series review was conducted in a 242-bed community teaching nursing home to describe the initial 26-month experience in providing care for patients with AIDS requiring nursing home admission. RESULTS: A total of 42 admissions by 32 patients with AIDS (mean age = 33.5 years, 81% male) involved a shorter length of stay (mean 63.1 days) and higher numbers of medications (mean = 11.2), facility charges (mean $11,971/admission, $189/day), and greater clinical management complexity than usual nursing home patients. Thirteen patients were discharged, seven for rehospitalization and six into community settings, although ultimately 29 of the 32 patients died in the facility. CONCLUSIONS: AIDS care in the nursing home presents significant, distinct challenges in complex management and terminal care prioritization.

Chronic bronchitis: primary care management.

Chronic bronchitis is a clinical diagnosis characterized by a cough productive of sputum for over three months' duration during two consecutive years and the presence of airflow obstruction. Pulmonary function testing aids in the diagnosis of chronic bronchitis by documenting the extent of reversibility of airflow obstruction. A better understanding of the role of inflammatory mediators in chronic bronchitis has led to greater emphasis on management of airway inflammation and relief of bronchospasm. Inhaled ipratropium bromide and sympathomimetic agents are the current mainstays of management. While theophylline has long been an important therapy, its use is limited by a narrow therapeutic range and interaction with other agents. Oral steroid therapy should be reserved for use in patients with demonstrated improvement in airflow not achievable with inhaled agents. Antibiotics play a role in acute exacerbations but have been shown to lead to only modest airflow improvement. Strengthening of the respiratory muscles, smoking cessation, supplemental oxygen, hydration and nutritional support also play key roles in long-term management of chronic bronchitis.

Does teaching medical students in the office affect the way physicians complete patient-encounter forms?

PURPOSE: To determine whether teaching medical students has concurrent economic effects on physicians and their practices. METHOD: The authors reviewed 869 patient-encounter forms completed in April 1994 and July 1995 by four family medicine physicians who were clinical faculty at the State University of New York Health Science Center at Syracuse. The authors compared those forms that were completed when a third-year medical student was present for the patient encounter with those completed when a student was not present. The authors looked for differences in the distributions of billing codes and in the frequencies of in-office procedures performed and diagnostic tests ordered. RESULTS: The presence or absence of a third-year medical student had no significant effect on the variables studied. CONCLUSION: In the clinical settings studied, concurrent medical student teaching did not appear to affect the distribution of billing codes or the frequency of in-office procedures performed or diagnostic tests ordered.

Chlamydia trachomatis infection update.

Chlamydia trachomatis has become the most common sexually transmitted infection in the United States. Aggressive screening of sexually active young adults is needed, as well as prompt and reliable treatment of infected partners, to mitigate the effects of this disease. Tests using enzyme immunoassay and DNA probe have increased the efficiency of diagnosis through rapid detection, although culture remains the most reliable test. Treatment with single-dose azithromycin is a successful alternative to the definitive treatment, seven days of doxycycline therapy.

Outpatient management of chronic bronchitis in the elderly.

Chronic bronchitis, one of the principal manifestations of obstructive lung disease, causes significant morbidity, especially among older patients. The "blue bloater" type of clinical presentation arises from hypoxemia and is characterized by breathlessness and functional impairments of communication and mobility. Acute infectious episodes often respond to antibiotic therapy, but the underlying problems of impaired airway immune responsiveness and hypersecretions cause chronic symptoms in many patients. Long-term management strategies are directed at optimizing immune defenses, improving airway patency through the use of anticholinergic and bronchodilating medications, correcting hypoxemia, providing supportive nutritional care and instituting measures to maximize the function of respiratory musculature.

The health beliefs of health fair participants.

The motivations and health beliefs of adults who participate in community-based health promotion were studied through a survey of 303 adults attending five community health fairs. Subjects were predominately female (69.9%), over age 60 (66.8%), and had at least yearly contact with a family physician (85.3%). Obtaining laboratory testing services was the sole reason for attendance for 47% of participants, was thought to be of much greater importance than health educational materials also offered at the health fair, and identified as providing a sense of control over personal health care. Receiving their own normal test results was perceived as assuring a "healthy" future for 86% of participants and few used these results to support erroneous health beliefs. A theme of "positive health feedback", identified through factor analysis of survey responses, may prove useful for family physicians to incorporate into more directed and useful health promotion efforts for enhanced patient participation and satisfaction.

Outpatient geriatric assessment: associations between referral sources and assessment findings.

A review of 431 outpatient geriatric assessments conducted over 2 years examined the associations of referral problems, assessment diagnoses, and therapeutic recommendations with the source of patient referral, as well as that referral source's diagnostic accuracy in identifying the referral problems. Families referred 52% of patients, primarily for problems of memory and behavior, whereas social service agencies made 32.9% of all referrals, primarily for bladder control problems or safety-related concerns. Physicians made only 6% of referrals in this setting. Referral source was found not to be associated with any of the seven categories of medical diagnoses resulting from the assessment process and was associated with only two of the functional diagnostic categories. Therapeutic recommendations were also broadly distributed among referral sources, though social service agencies did refer more patients who required urgent nursing home placement, financial representation, or adult protective service involvement. The performance of family referral sources in accurately referring patients with dementia and psychiatric impairment was comparable to that of physicians, though all referral sources frequently missed patients with incontinence. Non-physician referral sources appear to serve as important and quite valid case-finders for outpatient geriatric assessment.

The clinical presentation of lumbar spinal stenosis.

A retrospective review of 49 patients hospitalized with newly diagnosed lumbar spinal stenosis describes the presentation of this unusual cause of back pain. The pain distribution was bilateral in half of the cases and neurogenic claudication, thought to be diagnostic, was reported in only 20% of cases. Multiple levels of stenosis were identified in the majority of patients, with L 4/5 being the most common site, and stenosis co-existed with lumbar disc disease in one-third of patients. The diverse presentation and lack of a screening clinical marker make spinal stenosis difficult to recognize clinically in patients presenting with low-back pain.

Comprehensive functional assessment of the elderly.

The addition of function assessment in a formalized way into the primary care delivery for elderly patients can be viewed as an extension of the traditional concerns of primary care physicians when asking patients how they are doing. Functional assessment strategies simply provide a format for doing this in a reproducible, recordable, and reliable fashion. Although the complexity of functional assessment instruments can be intimidating to clinicians, the principles behind instruments of functional assessment are quite familiar. Physicians already are doing a significant amount of this performance assessment, though frequently it is not labeled as such. Table 8 provides a summary of these performance functional assessments that are easily accomplished in an ambulatory setting and applicable to the hospital or long-term care setting. The direct observation of these elements, combined with the selection of an appropriate assessment instrument for functional assessment, should allow for enhanced patient assessment and better application of the biopsychosocial model of medical care into practice to benefit the future care of our geriatric patients.

Pyoderma gangrenosum in an elderly woman. Course marked by extensive morbidity.

A case of extensive medical and functional morbidity in an elderly patient during treatment of pyoderma gangrenosum is described. Pyoderma gangrenosum is an uncommon cause of ulcerative skin lesions often involving areas of skin trauma about the lower extremity. Because of the possibility of underlying disease and the special treatment requirements, the condition must be differentiated from other, more common causes of skin ulceration. Treatment includes local care, systemic corticosteroid therapy, and control of any underlying disease. Pyoderma gangrenosum serves as a model for the interactions of various types of morbidity in the healthcare of the elderly.