A community-based study of abscess self-treatment and barriers to medical care among people who inject drugs in the United States.

Skin and soft tissue infections (SSTIs) are the most common medical complication of injection drug use in the United States, though little work has been done assessing SSTI treatment among people who inject drugs (PWID). We examined past-3-month abscess characteristics, treatment utilization, and barriers to medical treatment among N = 494 community-recruited PWID. We used descriptive statistics to determine the frequencies of self-treatment and medical treatment for their most recent past-3-month abscess as well as barriers to seeking medical treatment. We then used bivariate and multivariate logistic regression to identify factors associated with having an abscess in the past 3 months. Overall, 67% of participating PWID ever had an abscess and 23% had one in the past 3 months. Only 29% got medical treatment for their most recent abscess whereas 79% self-treated. Methods for self-treatment included pressing the pus out (81%), applying a hot compress (79%), and applying hydrogen peroxide (67%). Most (91%) self-treated abscesses healed without further intervention. Barriers to medical treatment included long wait times (56%), being afraid to go (49%), and not wanting to be identified as a PWID (46%). Factors associated independently with having an abscess in the past 3 months were injecting purposely into muscle tissue (adjusted odds ratio [AOR] = 2.64), having difficulty finding a vein (AOR = 2.08), and sharing injection preparation equipment (AOR = 1.74). Our findings emphasize the importance of expanding community-based access to SSTI education and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking resources.

The Significance of Harm Reduction as a Social and Health Care Intervention for Injecting Drug Users: An Exploratory Study of a Needle Exchange Program in Fresno, California.

Infectious disease remains a significant social and health concern in the United States. Preventing more people from contracting HIV/AIDS or Hepatitis C (HCV), requires a complex understanding of the interconnection between the biomedical and social dimensions of infectious disease. Opiate addiction in the US has skyrocketed in recent years. Preventing more cases of HIV/AIDS and HCV will require dealing with the social determinants of health. Needle exchange programs (NEPs) are based on a harm reduction approach that seeks to minimize the risk of infection and damage to the user and community. This article presents an exploratory small-scale quantitative study of the injection drug using habits of a group of injection drug users (IDUs) at a needle exchange program in Fresno, California. Respondents reported significant decreases in high risk IDU behaviors, including sharing of needles and to a lesser extent re-using of needles. They also reported frequent use of clean paraphernalia. Greater collaboration between social and health outreach professionals at NEPs could provide important frontline assistance to people excluded from mainstream office-based services and enhance efforts to reduce HIV/AIDS or HCV infection.

Objective evidence of severe disease: opioid use in chronic pain.

Treating chronic pain presents numerous challenges. First, assessing patients with chronic pain is complicated by the lack of objective measures of pain itself. Chronic pain guidelines already developed by national organizations rely on careful history taking rather than objective measures. Second, opioids are an accepted element of chronic pain management, but their use is tempered by risks of overdose, dependency, and the potential for diversion. This essay proposes a new standard for the use of long-term opioids for chronic pain: the presence or absence of objective evidence of severe disease. This standard, which supports responsible prescribing of opioids, is one that clinicians can understand and apply when considering prescribing long-term opioids for chronic pain. Until we have measures of pain itself, we should insist upon objective evidence of severe disease before prescribing opioids for chronic pain.

Creating an effective and efficient publicly sponsored health care delivery system.

An effective and efficient publicly sponsored health care delivery system can increase access to care, improve health care outcomes, and reduce spending. A publicly sponsored health care delivery system can be created by integrating services that are already federally subsidized: community health centers (CHCs), public and safety-net hospitals, and residency training programs. The Patient Protection and Affordable Care Act includes measures that support primary care generally and CHCs in particular. A publicly sponsored health care delivery system combining primary care based in CHCs with safety-net hospitals and the specialists that serve them could also benefit from incentives in the Patient Protection and Affordable Care Act for the creation of accountable care organizations, and reimbursement based on quality and cost control.

Controlling for race/ethnicity: a comparison of California commercial health plans CAHPS scores to NCBD benchmarks.

BACKGROUND: Because California has higher managed care penetration and the race/ethnicity of Californians differs from the rest of the United States, we tested the hypothesis that California's lower health plan Consumer Assessment of Healthcare Providers and Systems (CAHPS(R)) survey results are attributable to the state's racial/ethnic composition. METHODS: California CAHPS survey responses for commercial health plans were compared to national responses for five selected measures: three global ratings of doctor, health plan and health care, and two composite scores regarding doctor communication and staff courtesy, respect, and helpfulness. We used the 2005 National CAHPS 3.0 Benchmarking Database to assess patient experiences of care. Multiple stepwise logistic regression was used to see if patient experience ratings based on CAHPS responses in California commercial health plans differed from all other states combined. RESULTS: CAHPS patient experience responses in California were not significantly different than the rest of the nation after adjusting for age, general health rating, individual health plan, education, time in health plan, race/ethnicity, and gender. Both California and national patient experience scores varied by race/ethnicity. In both California and the rest of the nation Blacks tended to be more satisfied, while Asians were less satisfied. CONCLUSIONS: California commercial health plan enrollees rate their experiences of care similarly to enrollees in the rest of the nation when seven different variables including race/ethnicity are considered. These findings support accounting for more than just age, gender and general health rating before comparing health plans from one state to another. Reporting on race/ethnicity disparities in member experiences of care could raise awareness and increase accountability for reducing these racial and ethnic disparities.

The relationship between a statewide preceptorship program and family medicine residency selection.

OBJECTIVE: The purpose of this study was to investigate the extent to which participation in the California Academy of Family Physicians Foundation Family Medicine (FM) Preceptorship Program, as well as medical school, degree earned, gender, and match year predicted FM residency match. METHODS: Allopathic and osteopathic students who applied to the preceptorship program from 1996 to 2002 were followed until residency match. Chi-square (chi(2)) analysis was used to compare preceptorship participants, nonparticipants (students who applied but did not complete the preceptorship), and nonapplicants (students who did not apply to the preceptorship) for FM match rates and to compare participants to nonparticipants for primary care match rates. FM match data for California schools from 1999 to 2005 were used to perform a logistic regression predicting FM match. RESULTS: Twenty-four percent of participants matched into FM residency programs whereas only 13% of nonparticipants and 13% of nonapplicants selected FM (chi(2) = 24.97; P < .001). There was not a statistically significant difference between the proportion of participants and nonparticipants who matched into primary care (chi(2) = 0.12; P = .73). Odds ratio results of logistic regression for participants compared with nonapplicants matching into FM was 2.7 (95% CI, 2.0-3.6; P < .001). CONCLUSION: Preceptorship program participants were more likely than both nonparticipants and nonapplicants to select a FM residency.

Trends in rural and urban deliveries and vaginal births: California 1998-2002.

CONTEXT: Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. PURPOSE: Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings. METHODS: Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers. FINDINGS: Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different. CONCLUSIONS: Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

Effects of echinacea on the frequency of upper respiratory tract symptoms: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Upper respiratory tract infection symptoms are a common cause of morbidity. Herbal preparations of the plant Echinacea purpurea have immune-enhancing properties. OBJECTIVE: To compare the frequency of upper respiratory tract symptoms in individuals receiving E. purpurea capsules and those receiving placebo to evaluate the preventive efficacy of echinacea. METHODS: In a randomized, double-blind clinical trial, 90 volunteers recruited from hospital personnel were randomly assigned to receive 3 capsules twice daily of either placebo (parsley) or E. purpurea for 8 weeks during the winter months. Upper respiratory tract symptoms were reported weekly during this period. RESULTS: Fifty-eight individuals were included in the final data analysis: 28 in the echinacea group and 30 in the placebo group. Individuals in the echinacea group reported 9 sick days per person during the 8-week period, whereas the placebo group reported 14 sick days (z = -0.42; P = .67). Mild adverse effects were noted by 8% of the echinacea group and 7% of the placebo group (P = .24). CONCLUSION: Prophylactic treatment with commercially available E. purpurea capsules did not significantly alter the frequency of upper respiratory tract symptoms compared with placebo use.

The missing link: improving quality with a chronic disease management intervention for the primary care office.

Bold steps are necessary to improve quality of care for patients with chronic diseases and increase satisfaction of both primary care physicians and patients. Office-based chronic disease management (CDM) workers can achieve these objectives by offering self-management support, maintaining disease registries, and monitoring compliance from the point of care. CDM workers can provide the missing link by connecting patients, primary care physicans, and CDM services sponsored by health plans or in the community. CDM workers should be supported financially by Medicare, Medicaid, and commercial health plans through reimbursements to physicians for units of service, analogous to California's Comprehensive Perinatal Services Program. Care provided by CDM workers should be standardized, and training requirements should be sufficiently flexible to ensure wide dissemination. CDM workers can potentially improve quality while reducing costs for preventable hospitalizations and emergency department visits, but evaluation at multiple levels is recommended.

Physician perceptions of practice environment and professional satisfaction in California: from urban to rural.

CONTEXT: Few studies have systematically examined the experience of rural practice from the physician's perspective or included physicians from an array of specialties, particularly non-primary care. PURPOSE: To better understand differences between rural and urban physicians in perceptions of their practice environment. METHODS: In 2001-2002, self-administered questionnaires were sent to a probability sample of primary care and specialist physicians identified from the American Medical Association's Physician masterfile in California. Logistic regression was performed to model the effect practice location had on key variables, controlling for physician demographics, specialty, and the insurance profile of the physician's patients. FINDINGS: Completed questionnaires were obtained from 1,365 of 2,240 eligible urban physicians (61%), and 398 of 632 rural physicians (63%). Among primary care physicians, those in rural areas defined as nonadjacent or small non-metropolitan counties were the least likely to report pressures to see more patients, limit referrals, and limit treatment options. In contrast, among specialists, those in rural areas within metropolitan areas (or in large adjacent non-metropolitan counties) were more likely than urban specialists to report practice pressures. Although rural physicians in both primary care and specialist fields were more likely than urban physicians to report difficulty attracting new physicians to their communities, they perceived their overall practice climate to be better. Physicians in the nonadjacent-or-small non-metropolitan category were the most satisfied, but specialists in the nonadjacent-or-small non-metropolitan category were the least satisfied. CONCLUSION: Physicians in rural California appear to have maintained a greater sense of clinical autonomy and higher professional satisfaction compared with their urban counterparts.

Vaginal birth after cesarean in California: before and after a change in guidelines.

PURPOSE: In 1999 the American College of Obstetricians and Gynecologists (ACOG) adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC). This study assesses trends in VBAC in California and compares neonatal and maternal mortality rates among women attempting VBAC delivery or undergoing repeat cesarean delivery before and after this guideline revision. METHODS: The 1996 through 2002 California Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital. RESULTS: Attempted VBAC deliveries decreased significantly from 24% before to 13.5% after guideline revision (P <.001). Neonatal mortality rates per 1,000 live births for attempted VBAC deliveries were not different from repeat cesarean delivery rates among neonates weighing > or =1,500 g in either the study periods 1996 to 1999 or 2000 to 2002. Neonatal mortality rates for attempted VBAC deliveries were higher for repeat cesarean deliveries among neonates weighing <1,500 g in the same periods (attempted VBAC: 1996-1999, 253.2; 95% Poisson confidence interval [CI], 197.7-308.6; 2000-2002, 336.8; CI, 254.3-419.4; repeat cesarean delivery: 1996-1999, 59.1; CI, 48.3-69.9; 2000-2002, 60.5, CI, 48.4-72.5). Maternal death rates per 100,000 live births for attempted VBAC deliveries were similar for both periods (1996-1999, 2.0; CI, 0.1-11.0; 2000-2002, 8.5; CI, 1.0-30.6). CONCLUSIONS: Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years after the ACOG 1999 VBAC guideline revision. Women with infants weighing > or =1,500 g encountered similar neonatal and maternal mortality rates with VBAC or repeat cesarean delivery.

High school census tract information predicts practice in rural and minority communities.

PURPOSE: Identify census-derived characteristics of residency graduates' high school communities that predict practice in rural, medically underserved, and high minority-population settings. METHODS: Cohort study of 214 graduates of the University of California, San Francisco-Fresno Family Practice Residency Program (UCSF-Fresno) from its establishment in 1970 through 2000. Rural-urban commuting area code; education, racial, and ethnic distribution; median income; population; and federal designation as a medically underserved area were collected for census tracts of each graduate's (1) high school address and (2) practice location. FINDINGS: Twenty-one percent of graduates practice in rural areas, 28% practice in areas with high proportions of minority population (high minority areas), and 35% practice in federally designated medically underserved areas. Graduation from high school in a rural census tract was associated with rural practice (P < .01), Of those practicing in a rural site, 32% graduated from a rural high school, as compared with 11% of nonrural practitioners. Graduation from high school in a census tract with a higher proportion of minorities was associated with practice in a proportionally high minority community (P = .01). For those practicing in a high-minority setting, the median minority percentage of the high school census tract was 31%, compared with 16% for people not practicing in a high minority area. No characteristics of the high school census tract were predictive of practice in a medically underserved area. CONCLUSION: Census data from the residency graduate's high school predicted rural practice and practice in a proportionally high minority community, but not in a federally designated medically underserved area.

Why we should reduce family practice training to two years.

Family practice (FP) should consider decreasing its residency training from three years to two years. These are troubling times for FP. The number of U.S. medical students choosing FP has declined, FP physicians have difficulty maintaining the broad range of skills they learned in residency, and salaries have flattened. FP provides the best training for physicians who care for undifferentiated or continuity patients of all ages in an ambulatory setting. The author proposes that FP should focus its training on this large health care niche and develop a two-year curriculum that reduces inpatient and specialty rotations while increasing time in the family health center. At the same time, he recommends a third or even a fourth year of training be used to develop skills in any number of specialty areas. FP salaries are unlikely to be affected by these changes, residents would rack up less debt, and savings in society's contribution to graduate medical education would be realized. Reducing the length of FP training to two years will make FP more nimble, adaptable, and cost-effective.

Are sample medicines hurting the uninsured?

BACKGROUND: Pharmaceutical representatives often give sample medications to physicians for distribution to patients. In chronic conditions such as hypertension, this practice can contribute to unnecessary medication changes, gaps in treatment, and inferior control of disease. The objective of the current study was to explore associations between use of free sample medicine, hypertension, and source of payment for health care. METHODS: Telephone interviews and chart reviews were conducted at two community health centers in California. Adults with hypertension who had at least three clinic visits in the previous year and either had no insurance or had Medicare or Medicaid were included. RESULTS: Seventy-one patients participated. Seventeen had received sample medicines up to three times within the previous year. Lack of insurance (P < .01) was associated with sample medicine use. No group differences were found for medication changes. In multiple regression analysis, uninsured patients who received sample medicines had higher diastolic blood pressure (P = .01). CONCLUSIONS: Lack of insurance was the principle predictor of use of sample medications. Although cross-sectional design and covariance of independent variables limit conclusions, higher diastolic blood pressure was related to sample medication use in patients who did not have insurance.