Reducing the cost of frequent hospital admissions for congestive heart failure: a randomized trial of a home telecare intervention.

BACKGROUND: The high cost of caring for patients with congestive heart failure (CHF) results primarily from frequent hospital readmissions for exacerbations. Home nurse visits after discharge can reduce readmissions, but the intervention costs are high. OBJECTIVES: To compare the effectiveness of three hospital discharge care models for reducing CHF-related readmission charges: 1) home telecare delivered via a 2-way video-conference device with an integrated electronic stethoscope; 2) nurse telephone calls; and 3) usual outpatient care. RESEARCH DESIGN: One-year randomized trial. SUBJECTS: English-speaking patients 40 years of age and older with a primary hospital admission diagnosis of CHF. MEASURES: Our primary outcome was CHF-related readmission charges during a 6-month period after randomization. Secondary outcomes included all-cause readmissions, emergency department (ED) visits, and associated charges. RESULTS: Thirty-seven subjects were randomized: 13 to home telecare, 12 each telephone care and 12 to usual care. Mean CHF-related readmission charges were 86% lower in the telecare group ($5850, SD $21,094) and 84% lower in the telephone group ($7320, SD $24,440) than in the usual care group ($44,479, SD $121,214). However, the between-group difference was not statistically significant. Both intervention groups had significantly fewer CHF-related ED visits (P = 0.0342) and charges (P = 0.0487) than the usual care group. Trends favoring both interventions were noted for all other utilization outcomes. CONCLUSIONS: Substantial reductions in hospital readmissions, emergency visits, and cost of care for patients with CHF might be achieved by widespread deployment of distance technologies to provide posthospitalization monitoring. Home telecare may not offer incremental benefit beyond telephone follow-up and is more expensive.

Early detection and treatment of skin cancer.

The incidence of skin cancer is increasing by epidemic proportions. Basal cell cancer remains the most common skin neoplasm, and simple excision is generally curative. Squamous cell cancers may be preceded by actinic keratoses-premalignant lesions that are treated with cryotherapy, excision, curettage or topical 5-fluorouracil. While squamous cell carcinoma is usually easily cured with local excision, it may invade deeper structures and metastasize. Aggressive local growth and metastasis are common features of malignant melanoma, which accounts for 75 percent of all deaths associated with skin cancer. Early detection greatly improves the prognosis of patients with malignant melanoma. The differential diagnosis of pigmented lesions is challenging, although the ABCD and seven-point checklists are helpful in determining which pigmented lesions require excision. Sun exposure remains the most important risk factor for all skin neoplasms. Thus, patients should be taught basic "safe sun" measures: sun avoidance during peak ultraviolet-B hours; proper use of sunscreen and protective clothing; and avoidance of suntanning.

Identification and management of tuberculosis.

Although the resurgence of tuberculosis in the early 1990s has largely been controlled, the risk of contracting this disease remains high in homeless persons, recent immigrants and persons infected with the human immunodeficiency virus (HIV). Purified protein derivative testing should be targeted at these groups and at persons with known or suspected exposure to active tuberculosis. Most patients with latent tuberculosis are treated with isoniazid administered daily for nine months. In patients with active tuberculosis, the initial regimen should include four drugs for at least two months, with subsequent therapy determined by mycobacterial sensitivities and clinical response. To avoid harmful drug interactions, regimens that do not contain rifampin may be employed in HIV-infected patients who are taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. To maximize compliance and minimize the emergence of mycobacterial drug resistance, family physicians should consider using directly observed therapy in all patients with tuberculosis.

Applied medical informatics and computing skills of students, residents, and faculty.

BACKGROUND AND OBJECTIVES: Little is known regarding the applied medical informatics and computing skills of family practice residents and faculty, yet such information is critical when planning a medical informatics curriculum. We conducted a survey at our institution to collect this information. METHODS: An applied medical informatics and computing skills survey was administered to 93 first-year medical students, 42 family practice residents, and 14 family medicine faculty. Responses were compared between groups before and after stratification by age and gender. RESULTS: A total of 92% of students, 100% of residents, and 79% of faculty responded. Faculty had the highest rate of computer ownership (91%), followed by students (86%) and family practice residents (79%). Students and interns had the highest overall confidence using computers, followed by faculty and then senior residents. Faculty, students, and junior residents were significantly more confident than senior residents in their ability to perform several specific tasks, such as conducting a MEDLINE search. Residents perceived lack of money and time as barriers to improving their skills. CONCLUSIONS: Current senior residents may require remedial training to graduate with the computer skills specified in curricular guidelines. While upcoming medical students and interns will demand more advanced training, faculty may not have the skills to provide it.

Does the use of electronic medical records improve surrogate patient outcomes in outpatient settings?

BACKGROUND: We reviewed the evidence regarding the effectiveness of electronic medical records (EMRs) as tools for improving surrogate patient outcomes in the outpatient primary care setting. METHODS: We searched the MEDLINE database (1966-1999) to find relevant articles for inclusion in the systematic review. Reference lists of retrieved publications were also searched for relevant citations. We included original published reports of all prospective studies evaluating the use of hybrid or complete EMR systems as a method of improving surrogate patient outcomes in the outpatient primary care setting. Criteria for evaluation included the use of a random study group assignment, appropriateness of control group, blinded assessment of outcomes, number and reasons for withdrawal of subjects, and attempts to minimize confounding interventions. RESULTS: Seven prospective trials of complete EMRs and 9 prospective trials of hybrid EMRs were located. Most evaluated the impact of EMR-generated reminders on provider and patient compliance with health maintenance interventions. Findings were equally positive for both complete and hybrid EMRs, and all but 1 trial reported positive results. However, the methodologic quality of the trials was modest. Design problems included lack of concurrent control groups, non-blinded outcome assessment, and the presence of potentially confounding concurrent interventions. CONCLUSIONS: Evidence from published trials suggests that utilization of either complete or hybrid EMRs can improve some surrogate outpatient care outcomes. However, rigorous trials that evaluate their impact on morbidity and mortality, and employ current technologies are required before widespread adoption of EMRs can be confidently recommended.

Patients' perceptions regarding home telecare.

While home telecare's potential to reduce health care costs appears clear, patients' perceptions regarding this new technology have not been studied. We conducted structured interviews to elicit patients' perceptions regarding home telecare. We developed a 34-item survey instrument, which was administered during structured home interviews to a convenience sample of patients who were currently or had previously been enrolled in the Sonora Health System or University of California Davis home telecare pilot projects. Fifteen (56%) of the 27 past or present enrollees agreed to be interviewed. Most had either a neutral (9 of 15, 60%) or positive (5 of 15, 33%) outlook regarding home telecare before their enrollment. Following enrollment, all were either very satisfied (10 of 15, 67%) or somewhat satisfied (5 of 15, 33%) with services they had received. Fourteen of 15 (93%) were willing to receive home telecare services in the future, and all 15 would recommend home telecare to friends or family members. Despite education to the contrary, patients perceived that the presence of telecare equipment in the home implied 24-hour-a-day access to a nurse. Some interviewees felt uncomfortable disclosing intimate information during televisits, and others lamented the reduced amount of time nurses spent "socializing" as compared to in-person visits. Despite concerns regarding its confidentiality and its ability to approximate the social stimulation of in-person nursing visits, patients in these pilot trials seemed satisfied with home telecare and appeared ready to accept its widespread use.

The home visit.

With the advent of effective home health programs, an increasing proportion of medical care is being delivered in patients' homes. Since the time before World War II, direct physician involvement in home health care has been minimal. However, patient preferences and key changes in the health care system are now creating an increased need for physician-conducted home visits. To conduct home visits effectively, physicians must acquire fundamental and well-defined attitudes, knowledge and skills in addition to an inexpensive set of portable equipment. "INHOMESSS" (standing for: immobility, nutrition, housing, others, medication, examination, safety, spirituality, services) is an easily remembered mnemonic that provides a framework for the evaluation of a patient's functional status and home environment. Expanded use of the telephone and telemedicine technology may allow busy physicians to conduct time-efficient "virtual" house calls that complement and sometimes replace in-person visits.

Training residents in medical informatics.

BACKGROUND AND OBJECTIVES: A number of medical educators have called for an increased emphasis on medical informatics training, but few family practice residency programs have provided more than cursory teaching efforts in this area. This paper provides an overview of approaches to medical informatics education that have been implemented with some success by "pioneer" programs. A comprehensive review of the literature reveals many promising teaching applications of informatics tools, such as palmtop computing devices, e-mail, decision support software, and videoconferencing. However, barriers to the advancement of informatics training in residency remain, including low rates of computer ownership and use among residents, a lack of information regarding faculty computer skills, and lack of collaboration among programs teaching informatics. Based on the literature review and tempered by expert recommendations, an eight-step process for developing or refining a family medicine informatics curriculum is proposed: 1) conduct a needs assessment 2) review expert recommendations, 3) enlist faculty and local institutional support, 4) espouse a human-centered approach, 5) integrate informatics training into the larger curriculum, 6) provide easy access to computers, 7) provide practical training, and 8) measure and report educational outcomes.

Varicella susceptibility and vaccination strategies in young adults.

BACKGROUND: Varicella infection causes substantial morbidity in young adults. Most military basic trainees are 18 to 21 years old, yet the Army has no varicella vaccination policy. We therefore determined varicella susceptibility in a population of Army basic trainees, examined variables that might predict antibody status, and developed a vaccination strategies model. METHODS: Fifteen-hundred ninety-five trainees completed a demographic and historical questionnaire. Varicella antibody status was determined on 1201 volunteers. These data plus information from the literature were used to construct a decision tree of vaccination strategies that was applied to the total population of Army basic trainees in 1995 (n = 65,298). RESULTS: Fifty (4.2 percent) of 1201 soldiers were antibody negative. Trainees who lived with no or 1 sibling while growing up were most likely to be seronegative (P < 0.01). The positive predictive value of a history of varicella was 98.5 percent, whereas the negative predictive value of a negative history of varicella was 23 percent. In the vaccination strategies model, serologically testing soldiers with a negative history of varicella and vaccinating those without protective antibodies was the most cost-effective approach. CONCLUSIONS: In young adults a positive varicella history accurately predicts immunity, but verification of a negative history with antibody testing is recommended before vaccination.

Medical support for Operation Cooperative Nugget '95: joint readiness training in the post-cold war era.

The purpose of this paper is to report the demographic characteristics, injury and illness profiles, and dispositions of patients seen at the 249th General Hospital during its month-long deployment in support of Operation Cooperative Nugget '95 at the Joint Readiness Training Center (JRTC), Fort Polk, Louisiana. A descriptive analysis of patient demographic, diagnostic, and disposition data was performed. A total of 769 patient contacts were made, with orthopedic injuries (31%), dermatologic disorders (17%), upper respiratory infections (6%), and heat injuries (5%) accounting for the majority of visits. Because of aggressive preventive medicine interventions, there were no cases of heat stroke despite daily heat indices of 110 to 120 degrees F. In addition to emphasizing the importance of anticipating environmental medical threats, the authors relate some lessons learned, which should be valuable to medical providers tasked for future multinational operations other than war at the JRTC and elsewhere.

Adenocarcinoma of the uterine cervix.

BACKGROUND: Adenocarcinoma of the uterine cervix is an increasingly common cervical neoplasm that has received little attention in the primary care literature. The purpose of this paper is to describe an illustrative case that provides an excellent opportunity to review the symptoms, diagnostic pitfalls, treatment options, and prognosis of this important disease. METHODS: Case report is described, along with results of a literature review using MEDLINE and pertinent references from retrieved articles. RESULTS: The relative incidence of cervical adenocarcinoma has risen from 5 to 10 percent of all cervical neoplasms in the 1950s to 10 to 20 percent in recent series. Some studies have also reported an increasing absolute incidence linked to widespread oral contraceptive use. The diethylstilbestrol-associated clear-cell variant accounts for only 2 to 3 percent of cases. About 10 percent of patients have only a nonbloody vaginal discharge. Cervical adenocarcinoma might be more easily missed on a Papanicolaou smear than squamous cell dysplasia and cancer, and it has no characteristic colposcopic appearance. The prognosis is excellent with early detection. CONCLUSIONS: Family physicians should maintain a high index of suspicion for cervical adenocarcinoma when symptoms suggest this disease regardless of Papanicolaou smear results.