Response of confluent and reticulate papillomatosis of Gougerot and Carteaud to topical tretinoin.

Confluent and reticulate papillomatosis (CRP) of Gougerot and Carteaud is a rare cutaneous disorder characterized by persistent, usually asymptomatic, dark papules and plaques centrally located on the back, intermammary, and epigastric areas. The eruption spreads out peripherally into a fading reticulated pattern. The pathogenesis is poorly understood, but there are several theories. Many different treatments, with varying success rates, have been attempted. We present 3 patients with CRP who had excellent results in the areas treated with topical tretinoin. The only difficulty with therapy is applying the tretinoin to the back, which sometimes necessitates a second person. However, if this situation can be overcome, topical tretinoin provides an effective, safe alternative to systemic therapies. Response to tretinoin provides support that CRP is a disorder of keratinization. Finally, the fact that 2 of the patients were brothers may support the idea that CRP has a hereditary influence.

Sustained improvement of the quality of life of patients with psoriasis after hospitalization.

Psoriasis is a chronic, recurrent, and often disfiguring skin disease that may significantly affect patients' quality of life. Treatment of psoriasis, including hospitalization, has been shown to improve quality of life. A pilot study of 15 consecutive inpatients and 7 consecutive outpatients with psoriasis were asked to complete the Dermatology Life Quality Index (DLQI) before treatment and 3 months later. Hospitalized patients also completed the DLQI 1 week after discharge. Statistical analysis using t tests compared pretreatment and posttreatment DLQI scores as well as improvement of inpatients versus outpatients. Baseline DLQI scores for hospitalized patients were significantly higher (greater impairment of life quality) compared with oupatients' quality of life. After discharge, hospitalized patients' quality of life had significantly improved at 1 week and remained improved at 3 months.

Stasis in venous ulcers: a misnomer that should be abandoned.

Leg ulcerations secondary to chronic venous insufficiency have been termed 'stasis ulcers.' This is based on an original idea proposed by Homans in 1917. However, since then data has been generated suggesting in fact 'stasis' does not occur. In this paper, we review the information that has accumulated, refuting the concept of stasis. We suggest that the term 'stasis ulcer' is a misnomer, and should be abandoned.

Medication review and documentation in physician office practice.

CONTEXT: Adverse drug reactions and drug-drug interactions are common. Medication-induced morbidity might be prevented through the documentation of medicines in the medical record and review of the medical record before new medications are prescribed. PRACTICE PATTERN EXAMINED: Documentation and review by primary care physicians of patient use of prescription drugs, over-the-counter drugs (OTCs), nutritional supplements, and herbal and other alternative treatments. DATA SOURCE: A stratified random sample of 1802 internists and family practitioners from the American Medical Association Physician Masterfile was surveyed; 655 physicians responded (response rate, 36%). RESULTS: 99.8% of physicians reported documenting prescription drugs in the medical record. Fewer reported documenting OTCs (68%) or nutritional supplements (63%); only 47% documented herbal and other alternative treatments. Almost all respondents reported reviewing prescription medications before prescribing a new therapy (99.8%), but only 86% reported reviewing OTCs at the same time. Fewer than half of physicians reported reviewing nutritional supplements or herbal and other alternative treatments before prescribing a new therapy. CONCLUSIONS: This study draws on self-reported data, and the response rate was low. Thus, the results probably overestimate actual rates of documentation and review. Review and documentation of nonprescription substances are uncommon in primary care practice.

Effect of training on physician attitudes and practices in home and community care of the elderly.

OBJECTIVES: To evaluate the effectiveness of continuing medical education seminars in changing physician attitudes and practice approaches to the provision of home health care and use of community resources, to increase physician awareness of the needs of homebound older adults, and to teach physicians appropriate medical management in the home. DESIGN: A quasi-experimental pretest and multiple posttest design. SETTING: Twenty-six seminars were conducted at medical and specialty society annual meetings in 10 states selected for their high proportion of elderly and minority populations. PARTICIPANTS: Experimental subjects were a convenience sample of 355 primary care physicians who attended the seminars for which continuing medical education credits were granted. The control subjects were a proportional sample of 249 primary care physicians randomly selected from the American Medical Association Physician Masterfile matched for age, sex, locus of training (United States or abroad), and specialty. INTERVENTION: A half-day interactive seminar. Participants were given a packet of printed materials that reinforced subject matter presented during the seminar. Core faculty for each state consisted of 2 physicians, a home health nurse, and a case manager who was familiar with community resources; physician faculty were identified by peers as local opinion leaders. All participated in a "train-the-trainer" workshop held at the American Medical Association, Chicago, Ill. Questionnaires were administered to the experimental group before the start of the seminar, immediately following the seminar, and 3 months later. The control group completed baseline and follow-up questionnaires but did not attend the seminars. MAIN OUTCOME MEASURES: Change in physician attitudes toward providing geriatric home care, the degree to which physicians made accommodations in office practices to better manage care of patients at home, and physician willingness to use community resources. RESULTS: Compared with preseminar attitudes, participants reported a change in feelings of adequacy to provide home care, as well as changes in office practice, number of home visits, and referrals to community agencies (P=.001). Before and after the seminars, US-educated male physicians were more likely to make home visits than female physicians or international medical graduates. At the 3-month follow-up, male international medical graduates were similar to US-trained male physicians. Regardless of sex or locus of training, having a high proportion (>50%) of Medicaid or minority patients or both is inversely associated with willingness to make home visits. CONCLUSIONS: The seminars achieved the intended outcomes of bridging the gap in the awareness and provision of geriatric home health care and of producing physician attitude and behavior change.

Reported home health agency referrals by internists and family physicians.

OBJECTIVE: To evaluate the frequency of home health agency referrals (HHRs) by internists and family physicians. DESIGN: Telephone survey of a randomly selected, nationally representative, stratified physician sample. PARTICIPANTS AND SETTING: One thousand one hundred sixty-one interviews with 576 family physicians and 585 internists selected from the American Medical Association Physician Masterfile. MAIN RESULTS: Most respondents (88%) reported making HHRs (mean for those making HHRs = 43/year). Physicians with > or = 48 annual HHRs (n = 315) reported a mean of 2.6 hours/week in home care telephone management and 2.1 hours/week on related paperwork. Rural internists and family physicians (n = 230) reported less availability of several types of non-physician home health services than non-rural respondents (n = 931), yet rural physicians were more likely to refer patients to home health agencies. Using multivariate linear regression, the reported frequency of HHRs was significantly related to rural practice location, number of home-bound patients, proportion of geriatric patients, number of house calls, graduation from a U.S. or Canadian medical school, physician knowledge of community resources, and physician experience either as a medical director, a member of the board of directors, or a consultant for a home health agency. CONCLUSIONS: Internists and family physicians who work at least 10 hours per week in ambulatory care report making approximately three home health agency referrals per month and spending substantial amounts of time coordinating home health agency care. Despite reporting less availability of many home health agency services, rural physicians report greater involvement than non-rural physicians in the delivery of home care.

A national survey of the home visiting practice and attitudes of family physicians and internists.

BACKGROUND: Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians. METHODS: Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care. RESULTS: Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement. CONCLUSIONS: Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.

Home care education for physicians.

Home care is on the rise, but physicians' involvement in home care has decreased. A vital part of the remedy is educating physicians in the principles and practice of home care.

Home health care: surmounting the obstacles to Medicare coverage.

The very words that physicians use when ordering home health services for their patients may determine whether those services will be reimbursed under the Medicare benefit. Thus, it is crucial for all physicians to become aware of: 1) methods of assessing patient home care needs based on the underlying medical conditions; 2) Medicare eligibility criteria and expanded coverage now available since the Health Care Financing Administration (HCFA) coverage manual was rewritten in 1989; and 3) how to advocate to ensure that the patient receives the care to which he or she is entitled.

Home health care and rapid rehospitalization.

Early release from the hospital of the elderly ill patient may lead to failure of the home care plan and rapid rehospitalization. Review of 330 consecutive admissions to a large urban home health agency in 1980 revealed that 43 patients (13%) were rehospitalized within 2 weeks of admission. This high risk patient population is contrasted with the average home care population in terms of living arrangements, ambulatory status, primary diagnosis, age, sex, medications, etc. Home care was probably the appropriate long-term placement if better coordination between discharge planners, PSROs, physicians and home care staff could have been established with the extension of the hospital stay by 1-2 days and/or the provision of more intensive supportive care in the home at the time of admission to the home care agency. Simple guidelines for medical/social discharge planning to provide safer transfer of ill elderly patients from hospital to home are listed.