A framework for understanding visits by frequent attenders in family practice.

OBJECTIVE: Our purpose was to develop a typology of outpatient visits between family physicians and adult "frequent attender" patients. STUDY DESIGN: This was a cross-sectional observational study using qualitative analysis of family physician visits. Three family physician researchers reviewed detailed field notes for each patient based on direct observation of a single office visit to determine major themes and characteristics of physician-patient encounters. POPULATION: Non-pregnant adults in the top 5% for visit frequency, and age-and sex-mated non-frequent attenders were identified from among 1194 adult patients in 18 Midwestern family practice offices as part of The Prevention and Competing Demands in Primary Care Study. RESULTS: Visits by 62 patients who had made at least 25 visits in the previous 2 years were selected (frequent attender visits). Three major dimensions emerged to distinguish different encounter types: (1) biomedical complexity, (2) psychosocial complexity, and (3) the degree of dissonance between the patient and the physician. These 3 dimensions were used in a descriptive framework to characterize visit types as: simple medical, ritual visit, complicated medical, the tango, simple frustration, psychosocial disconnect, medical disharmony, and the heartsink visit. CONCLUSIONS: The discovery of a wide variation of encounter types among adult frequent attenders and the resulting descriptive framework laid a foundation for defining the appropriateness of outpatient health care utilization, for designing interventions to reduce inappropriate utilization, and for educating physicians regarding effective management of frequent attender patients.

Management of heart failure.

Heart failure imposes a major burden on society. Primary care physicians, who care for 70% of all heart-failure patients, have opportunities to reduce the economic and mortality impact of this disease by improved outpatient management. Management tasks for these patients are discussed. Successful completion of these tasks will lead to an improvement in functional capacity, fewer hospitalizations, and longer lives for heart-failure patients.

The female athlete triad.

The female athlete triad is defined as the combination of disordered eating, amenorrhea and osteoporosis. This disorder often goes unrecognized. The consequences of lost bone mineral density can be devastating for the female athlete. Premature osteoporotic fractures can occur, and lost bone mineral density may never be regained. Early recognition of the female athlete triad can be accomplished by the family physician through risk factor assessment and screening questions. Instituting an appropriate diet and moderating the frequency of exercise may result in the natural return of menses. Hormone replacement therapy should be considered early to prevent the loss of bone density. A collaborative effort among coaches, athletic trainers, parents, athletes and physicians is optimal for the recognition and prevention of the triad. Increased education of parents, coaches and athletes in the health risks of the female athlete triad can prevent a potentially life-threatening illness.

Congestive heart failure due to diastolic or systolic dysfunction. Frequency and patient characteristics in an ambulatory setting.

OBJECTIVE: To determine the age- and sex-specific frequencies and characteristics of patients with diastolic and systolic dysfunction heart failure. DESIGN: Retrospective medical record survey encompassing 1 year. SETTING: Community-based family practice office. PATIENTS: One hundred thirty-six patients who met the modified Framingham criteria for the diagnosis of congestive heart failure (CHF) and had a known left ventricular ejection fraction. Diastolic dysfunction was defined as an ejection fraction of 45% or greater and systolic dysfunction heart failure as an ejection fraction of less than 45%. MAIN OUTCOME MEASURES: Age- and sex-specific frequency; patient comorbid conditions; medications taken; and number of emergency department visits, hospitalizations, and deaths. RESULTS: The frequency of CHF increased with age for men and women (1.3% for patients 45-54 years old to 8.8% for patients > 75 years old). The distribution according to left ventricular ejection fraction and age varied according to sex. Women had later onset of CHF that was predominantly diastolic dysfunction heart failure. Men had proportionately more systolic dysfunction heart failure at all ages. Forty percent of all patients with CHF had diastolic heart failure, and these patients had fewer functional limitations (76% with New York Heart Association classes I and II), fewer hospitalizations for CHF, and a trend toward fewer deaths during the study year compared with patients with systolic dysfunction. CONCLUSIONS: Congestive heart failure is a heterogeneous condition in this family practice setting, and diastolic dysfunction heart failure occurs frequently. Further study of the natural history and treatment of diastolic dysfunction heart failure should be performed in the primary care setting.

Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics.

BACKGROUND: Many patients with congestive heart failure (CHF) receive care solely from a primary care physician, while some receive care from both a primary care physician and a cardiologist. Patients in the latter type of care relationships have not been described. The principal objectives of our study were to determine what percentage of patients with CHF are comanaged, the characteristics of comanaged CHF patients, and when in the natural history of CHF this relationship is initiated. METHODS: A retrospective record review was conducted of all patients who met the modified Framingham criteria for the diagnosis of CHF in a large community-based family practice office. Comanagement was defined as an ongoing relationship with a cardiologist characterized by a minimum of one visit to the cardiologist's office in the year of evaluation. We divided the natural history of CHF into 4 stages to describe the timing of the initial referral to the cardiologist: I Prediagnosis; II Diagnosis; III Progression; and IV Terminal. RESULTS: Of 151 patients identified with CHF, 36% of the patients were comanaged by a primary care physician and a cardiologist. The comanagement relationship often began early in the development of CHF, 20% at stage I and 54% at stage II. The patients who were comanaged were younger, predominately men, had a greater frequency of myocardial infarction, were more likely to have decreased systolic function, were on more cardiac medications, and had fewer hospitalizations for CHF exacerbations compared with CHF patients managed solely by family physicians. CONCLUSIONS: Comanagement of patients with CHF is a common occurrence, and comanaged CHF patients have distinct characteristics from those managed solely by family physicians. These results have implications for the quality and cost of caring for patients with CHF and suggest that more detailed study is required.

Practitioner self-confidence and patient outcomes in acute low back pain.

OBJECTIVE: To compare outcomes for patients with acute low back pain who received care from practitioners with different self-confidence scores on a 4-item scale. DESIGN: Cross-sectional survey of practitioners. Prospective cohort study of patient outcomes. SETTING: Private practices and a group model health maintenance organization. PARTICIPANTS: One hundred eighty-nine practitioners, including private practice traditionally trained medical physicians, chiropractors, and physicians in a group model health maintenance organization, who were randomly chosen from practices across the state of North Carolina. These practitioners enrolled 1633 patients with acute low back pain into a prospective cohort study. METHODS: The practitioner survey contained 10 questionnaire items that measured aspects of practitioner confidence and attitudes in assessing and treating patients with low back pain. Patients were interviewed by telephone after the initial office visit and at 2, 4, 8, 12, and 24 weeks, or until complete recovery, whichever came first. RESULTS: Of 189 study practitioners, 95% responded to the survey. A 4-item scale, shown by factor analysis to describe practitioners' self-confidence, demonstrated good internal consistency among physicians and chiropractors. Chiropractors had significantly stronger self-confidence scores than physicians. Among patients of primary care physicians and chiropractors, those who received care from practitioners with stronger self-confidence scores did not differ in the time to functional improvement, overall patient satisfaction, or their perception of the completeness of care. CONCLUSION: The level of practitioner self-confidence, as measured by a 4-item scale, did not predict patient outcomes in the treatment of acute low back pain.

Developments on the Internet: a practical guide for primary care physicians.

Recent developments have made the Internet a helpful professional resource for primary care practitioners. The introduction of the World Wide Web has overcome many of the barriers that previously made it difficult to access useful information on the Internet. For teachers of primary care, the capability of combining graphic, sound, and video files is particularly exciting. User-friendly search strategies help users find needed information quickly. This article provides practical steps for accessing the Internet, introduces the concept of the World Wide Web, and provides a list of specific resources useful to primary care teachers, clinicians, and researchers.

The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project.

BACKGROUND: Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. METHODS: Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. RESULTS: The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors. CONCLUSIONS: Among patients with acute low back pain, the outcomes are similar whether they receive care from primary care practitioners, chiropractors, or orthopedic surgeons. Primary care practitioners provide the least expensive care for acute low back pain.

Evidence of thorough reporting of sexually transmitted diseases in a southern rural county.

BACKGROUND AND OBJECTIVES: Private physicians outside the South have been found to report half or fewer of the sexually transmitted diseases that they diagnose. The authors studied whether this is also true in a Southern rural county. STUDY DESIGN: Reports of gonorrhea and chlamydia infection from private physician practices in a rural North Carolina county were compared with laboratory records of positive test results. The proportions reported through 8 months of passive surveillance were compared with the proportion reported during 2 months of active weekly telephone surveillance. RESULTS: A total of 72% of all positive gonorrhea test results and 55% of all chlamydia test results were reported through passive surveillance. The proportions increased to 88% and 79%, respectively, with active surveillance. A separate system of multiple checks ensured complete reporting of syphilis that was not affected by surveillance type. CONCLUSIONS: A relatively high proportion of sexually transmitted diseases diagnosed by private physicians was reported in this rural county. Potential reasons included physician awareness of reporting requirements, delegation of reporting to clinical staff, and personal acquaintance with the health department staff.

Outpatients' attitudes regarding advance directives.

BACKGROUND: Although many bedside ethical dilemmas can be avoided if patients discuss their wishes regarding the use of life-prolonging treatment and aggressiveness of care, many physicians are reluctant to raise this issue with their patients. Physicians may wait for such discussions until a patient is ill or elderly or until the patient raises the issue first. METHODS: Three hundred adult patients visiting their family physician's office were asked to complete a 19-item questionnaire. In addition to providing demographic information, they were asked whether they had discussed their wishes regarding life-prolonging treatments with their physician; what their attitude was toward having these discussions in various situations; whom they wanted to initiate the discussion, and with whom else they had discussed their wishes. RESULTS: Of the respondents who had not previously discussed their wishes with their physician, 68% wanted the physician to initiate the discussion. Only 11% did not want their physician to bring up the subject. A majority of respondents in all age groups thought it was somewhat or very important to discuss this matter both when healthy and when very ill. CONCLUSIONS: Very few patients would be upset if their physician raised the issue of life-prolonging treatment even if he or she did so during an initial patient visit. To avoid problems later, physicians should take an active role by raising these questions early in the patient-physician relationship rather than waiting for the patient to do so.

Postvasectomy semen analysis: why patients don't follow-up.

Semen analysis following elective vasectomy is necessary to confirm that the procedure was successful. However, many patients fail to follow postoperative instructions to obtain semen analysis. One hundred forty-one patients who had undergone vasectomy at the Family Practice Center of the Medical College of Ohio were surveyed to assess reasons for a poor rate of follow-up after vasectomy. Only 26 percent of respondents had returned two or more semen samples following surgery. Forty-five percent had not returned any samples. The inconvenience and embarrassment of having to bring semen specimens to the laboratory were identified as factors that can affect patient adherence to instructions. Respondents who had not returned any semen specimens were more likely to answer that their spouse would not be very upset if the vasectomy failed and pregnancy resulted. Our survey results identify issues for improving patient care following vasectomy. These include patient education and postoperative protocols.

PIP: This survey of the 141 post-operative vasectomy patients at the Family Practice Center of the Medical College of Ohio resulted in suggestions for modifying postoperative patient care protocol and patient education. The concern centered on the poor response rate for post operative semen analysis, where 29% returned 1 specimen, 26% returned 2 or more samples following surgery, and 45% had not returned any samples. Patient education was repetitions with the 1st verbal instructions preoperative, the 2nd verbal instructions postoperative, and a typewritten instruction sheet postoperative; additional reinforcement was given at the 1 week followup visit. Masturbation, condom, or withdrawal were recommended method of collection. 2 sterile containers were provided and the request made for a 1st collection after 12 ejaculations and a 2nd 2 or more weeks after the first. The requirement was for 2 specimens completely sperm free. The results of the questionnaire analyzed with Pearson chi-square for nominal or ordinal data and the 2 tailed remembered all 3 methods of collection; remembering was not related to whether the specimen was returned. Of those returning specimens, 70% masturbated, 20% used condoms, and 17% withdrew. 99% knew the reason for collection. Convenience was an important factor. 68% found daytime drop off inconvenient and 77% agreed that refrigeration and a next day dropoff was better. 50% were embarrassed to bring the specimen in. 59% felt that a failure in vasectomy with pregnancy was upsetting. Those not returning specimens had wives less concerned about the failure of vasectomy. 69% had mutual agreement about the vasectomy decision. 58% did not return due to inconvenience, 38% embarrassment, 29% confidence in sterility, 17% forgot, 4% afraid of repeat surgery. Recommended protocol is for a 1st aspermic specimen or a fresh specimen that shows only few, nonmotile sperm turned in in a brown bag provided along with a separate handout on semen collection and joint signatures. Motility checks should be made monthly if sperm persist. Ambivalence about future pregnancy means reevaluation of suitability of couple for vasectomy.

Dysfunctions of micturition in the male.

A basic knowledge of the anatomy and neurophysiology of the lower urinary tract is necessary to understand voiding dysfunction in the male. Enuresis is the most common voiding problem in children. Evaluation and treatment of incontinence and neurogenic voiding dysfunction in the adult male is easily understood by using a failure to store/failure to empty classification system. Treatment focuses on behavioral, pharmacologic, and surgical means of influencing the storage and emptying functions of the bladder and sphincter. The goals of any treatment plan for dysfunctions of micturition in the male are to preserve renal function, maintain continence, and promote normal voiding patterns.

Urinary tract infections in the elderly.

Urinary tract infections in the elderly present many diagnostic and therapeutic challenges. Signs and symptoms may be confusing, and complications are more likely to occur. Prompt recognition, appropriate treatment and thorough follow-up are essential to minimize morbidity and mortality.

Obstetrics in family practice in the state of Ohio.

Two hundred eighty-two active members of the Ohio Academy of Family Physicians responded to a survey questionnaire regarding the content of obstetrics in their practices. Factors that may influence physicians to discontinue obstetrics were also evaluated. Sixty respondents (21 percent) were performing vaginal deliveries in 1987. Only 45 (16 percent) planned to continue delivering babies beyond 1989. Family physicians who started practice within the past seven years were less likely to include obstetrics in their first year of practice than those who began practice prior to 1980. To those physicians who have eliminated obstetrics from their practice in the past five years, fear of litigation and increasing malpractice insurance costs were significantly more important issues than to their colleagues who had stopped doing obstetrics prior to 1976. Every year fewer family physicians choose to provide care to their obstetric patients. The results of this study suggest that only with changes in the medicolegal and liability environments will obstetrics continue to be a part of family practice in Ohio.