[ Depression during late period of life: perception of morbidity in elderly residents of St. Petersburg].

This cross-sectional cohort study describes older patients' perceptions about depression and characteristics associated with acceptance of treatments. The majority of the 109 respondents consider depression as disease, which should be treated. Many patients cited affordability as an obstacle and considered self-treatment options including alcohol intake for depression control.

Physician use of and attitudes regarding the minimum data set.

OBJECTIVE: To determine physician use of the Minimum Data Set (MDS), part of the Resident Assessment Instrument (RAI). DESIGN: A population-based survey. SETTING: The United States. PARTICIPANTS: A total of 2223 physicians listing geriatrics as their primary specialty, 1921 of whom are internists and 302 family physicians. MEASUREMENTS: A 34-item questionnaire asking nine physician-specific demographic questions; nursing home caseload; percent time spent reviewing MDS and care plan; how the information on the MDS was used. Physicians were also asked to describe their attitudes about the MDS. RESULTS: Among the 472 physicians who completed the survey and cared for nursing home patients, 357 were internists and 107 were family physicians. Ninety-one percent of the physicians were board certified, 76% had certificate of added qualifications in geriatrics,65% oversaw 20 nursing home patients. Only 11% of physicians reported reviewing the entire MDS, and 21% part of the MDS for all of their patients. Nineteen percent of physicians did not review the care plan for any of their patients. Fifty-six percent of 461 comments made by physicians regarding the MDS were negative or derogatory. CONCLUSIONS: Many practicing geriatricians are not using MDS to facilitate medical decisions. If this physician population is not using the MDS, there is a need to improve the information transfer from the MDS form to the busy clinician.

Community characteristics associated with elder abuse.

OBJECTIVES: To help define the relationship between elder abuse rates and counties' demographics, healthcare resources, and social service characteristics. DESIGN: County-level data from Iowa were analyzed to test the association between county characteristics and rates of elder abuse between 1984 and 1993 using univariate correlation analysis and stagewise linear regression. SETTING: Ninety-nine counties in Iowa. PARTICIPANTS: Iowa residents aged 65 years and older. MEASUREMENTS: County-level population-adjusted numbers of abused elderly, abused children, children in poverty, high school dropouts, physicians and other healthcare providers, hospital beds, social workers and caseworkers in the Department of Human Services (DHS). RESULTS: Community characteristics that had a positive association with rates of reported or substantiated elder abuse at the P < .001 level were population density, children in poverty, and reported child abuse. Lower substantiated elder abuse rates were associated at P < .05 with higher community rates of high school dropouts, number of chiropractors, and number of nurse practitioners. After adjusting for number of DHS caseworkers and reported child abuse rates (a surrogate for workload) a district effect persists for substantiated elder abuse cases (P = .002). CONCLUSION: County demographics are risk factors for reported and substantiated elder abuse. The strongest risk factor for reported elder abuse was reported child abuse. The difference in districts may reflect differences in resources and/or differing characteristics of caseworkers who substantiate elder abuse. The risk factors may reflect conditions that influence the amount of elder abuse or the detection of existing elder abuse.

Russian family practice training program: a single step on a long journey.

BACKGROUND AND OBJECTIVES: Since 1992, when the Russian government recognized family practice as a medical specialty, efforts have begun to progress from the idea stage to the delivery of patient care via family practice methods. We describe an educational effort to help teach Russian physicians family practice skills. METHODS: Five young Russian physicians were selected from an initial pool of 15 candidates on the basis of standardized testing, English language skills, and their potential to teach future Russian family physicians. Clinical, teaching, and business curricula were developed and used during the 6-month training period for the five selected physicians. Trainees were evaluated by mentors' and preceptors' written evaluations and by the American Board of Family Practice In-training Examination before, during, and at completion of the training. Subsequently, a fully equipped family practice office was opened in St Petersburg to serve as an on-site training facility. RESULTS: The trainees' self-perceived knowledge in community medicine, geriatrics, medical decision making, patient education, behavioral science, preventive medicine, and general family practice topics improved over the course of training. The composite scores on the in-training examinations improved from baseline (30 versus 308). Preceptors noted the greatest improvements in the use of clinical instruments, proficiency in physical exams, accessing medical information, and formulating differential diagnoses. The St Petersburg family practice office opened on October 1, 1996. The trainees now participate in the care of patients in this office and teach a new class of family medicine interns. CONCLUSION: The training program we describe has allowed Russian physicians to acquire new skills and knowledge that they can use and adapt to training future Russian family physicians.

Skills that Iowa family physicians desire in a new physician partner.

BACKGROUND AND OBJECTIVES: The importance of specific skills in primary care continues to be debated. As a result, there is not consensus on which skills need to be stressed during residency training. Our project asked community-based family physicians to rate the importance of specific skills in a new family physician partner. METHODS: Data were collected through a cross-sectional survey of all active members of the Iowa Academy of Family Physicians. Participants were surveyed by mail, using a list of 83 skills pertinent to primary care. Physicians were asked to rate the importance of a new member of their practice having the individual skills on this list. RESULTS: A total of 546 family physicians (67%) completed questionnaires. Fourteen skills (seven cognitive and seven psychomotor) were reported to be "essential" or "very important" by at least 80% of the physicians. A total of 43 skills were rated as "essential" or "very important" by at least 50% of responding family physicians. Many of the hospital-based procedural skills, particularly those used in an intensive care setting, were rated as less important. The importance ratings of many skills were associated with the physicians' ages, size of their primary hospitals, and availability of other medical specialties. CONCLUSIONS: Family physicians tended to rate office-based procedural skills, counseling skills, and management skills as "essential or very important" to their practices. These rating might be used to guide residency training in family practice.

Home visit program for teaching elder abuse evaluations.

BACKGROUND AND OBJECTIVES: A home visit program was designed to teach family practice residents how to evaluate patients for elder abuse and capacity (the ability to make one's own decisions). METHODS: Residents assessed potential abuse victims reported to Arizona's Adult Protective Service (APS) in their homes. Written evaluations prepared immediately following each home visit were abstracted for diagnoses (including abuse), recommendations, and patient demographics. Follow-up surveys by APS case workers determined whether the home visit recommendations were accomplished. Graduates of the residency were surveyed about their perceptions of the educational value of the program and their practice characteristics. RESULTS: The residents evaluated 201 patients. The mean age was 77, and 73% of patients were female. Seventy-five percent were incapacitated, 65% of these because of dementia. Ninety-one percent were abused, and the types of abuse included neglect (69%), exploitation (20%), physical abuse (8%), and unknown (3%). Recommendations were accomplished in the majority of cases: medical advice (68%), services (65%), medical evaluations (58%), guardian (53%), and conservator (52%). Graduates who participated in this program (1985-1992) rated their ability to diagnose elder abuse and to assess the patient's home environment significantly higher than earlier graduates who did not participate in the program (1977-1984). Earlier graduates made more home visits and provided more statements for guardianship than later graduates. CONCLUSIONS: The home visit program gave residents exposure to a population of elderly who were abused, demented, and living at home. This program provided clinical substance to build an effective teaching experience and furnished APS with a needed service.

Factors affecting primary care physician participation in Medicare.

OBJECTIVES: This study investigates the levels of participation and the relative association of economic and noneconomic factors on primary care physician participation in the Medicare program. METHODS: Demographic information, participation in Medicare, and attitudes toward both the Medicare program and Medicare patients were collected in a written survey mailed to half the primary care physicians in Iowa. Ordinary least squares and logistic regression analyses were conducted to determine factors associated with the percentage of Medicare patients in a practice and the acceptance of all new Medicare patients, respectively. RESULTS: Two thirds of physicians were accepting all new Medicare patients, whereas 16% were accepting no new Medicare patients. Factors associated with having a higher percentage of Medicare patients in a practice were as follows: (1) a larger proportion of Medicare recipients in the county, (2) practice as a general internal medicine physician, (3) more years in practice at the current location, (4) greater enjoyment treating elderly patients, (5) less concern about having too many Medicare patients, and (6) a stronger belief that the Medicare program respects their professional judgment. Physicians less concerned about having too many Medicare patients in their practice and physicians in counties with a higher percentage of Medicare patients were significantly more likely to accept all new Medicare patients. CONCLUSIONS: These results suggest that as Medicare reforms are discussed, careful consideration of the impact of these reforms on noneconomic issues is important to ensure adequate physician participation and access for elderly patients through the Medicare program.

Ticlopidine-induced elevated liver enzymes.

Ticlopidine is a reasonable alternative to prevent stroke and myocardial infarction when aspirin is intolerable or ineffective. It can be limited, however, by its severe adverse effect profile. The most worrisome of these is neutropenia, although clinicians must be mindful of other adverse events that may be caused by this drug. A patient experienced elevated liver function tests probably due to ticlopidine.

Identification of Turner's syndrome in an elderly woman. Case report and review.

Turner's syndrome is one of the most frequently occurring chromosomal defects and is associated with a well-characterized set of anatomic malformations. We studied clinical findings in an elderly woman who was diagnosed as having cytogenetically proved Turner's syndrome late in life. Because most patients with Turner's syndrome have normal intelligence and mild phenotypic abnormalities, the condition was never properly diagnosed in many affected women born earlier in this century. Given the range of clinical abnormalities and physiologic deficits to which these women are predisposed, it remains important to diagnose and treat them accurately irrespective of age.

Cost containment: the effect of educating family practice residents and their patients.

A study was carried out to see if medical costs could be lowered by educating twenty six family practice residents and their patients. Four study conditions were were created: both resident and patient educated, resident only educated, patient only educated, and neither educated. Encounter data were collected before and after the resident education phase and a follow-up phone call was made to patients to obtain information on their current health. Cost measures included 1) physician's fee, 2) laboratory fees and 3) total ambulatory costs. Costs were lowered only in the both-educated group for laboratory costs. It was not sufficient to educate only residents, the group generally targeted for education about cost. This finding suggests that the most effective educational programs may involve patients as well as physicians.

Antibiotic use among medical specialties in a community hospital.

Antibiotic use in a community hospital was evaluated to demonstrate specialty variations. A chart review was performed using the Veterans Administration's "Guidelines for Peer Review" to determine appropriate antibiotic use. Of the 1,054 patients discharged in August 1977, three hundred ten (29.4%) received 479 courses of antibiotics of which two hundred eighty-seven (60%) were considered appropriate. Seventy-two percent of the therapeutic courses and 36% of the prophylactic courses were appropriate. Prophylactic antibiotics were used in 12% of the hospitalized patients and accounted for 33% of the total antibiotics. No notable difference in appropriate antibiotic use was found among general surgeons (73%), internists (72%), orthopedists (71%), and family practitioners (67%). Substantially lower levels were found among urologists (54%), otolaryngologists (44%), and obstetricians (36%). Continued education in proper antibiotic use is needed especially for prophylaxis. Educational programs directed at specific specialties may be the most fruitful way to effect improved overall antibiotic use.