Validity of the Family APGAR in patients with irritable bowel syndrome.

BACKGROUND: This study explores the validity of the Family APGAR (adaptability, partnership, growth, affection, and resolve), a test of family function, in persons with irritable bowel syndrome (IBS). Previous studies have reported increased stress in persons with IBS in the form of marital and interpersonal relationships. METHODS: The Family APGAR and the MMPI were completed by 198 persons, including 58 who sought care for IBS, 67 with IBS who did not seek care, and 73 who did not have the disorder. Family APGAR scores were compared for the three groups using analysis of variance. Multiple regression analysis was used to compare Family APGAR scores with both IBS group status and MMPI K and L scales. An odds ratio was calculated for the two groups with IBS. RESULTS: Mean Family APGAR scores were in the normal range for all three groups and differed by less than 1 point among the groups. The Family APGAR score did not differentiate among persons with IBS but was strongly related to the MMPI K score, a measure of defensiveness in test taking. CONCLUSIONS: The failure of the Family APGAR to detect the family dysfunction found by psychological interviewing and the strong relationship with the MMPI K scale lead us to question the construct validity of the APGAR. More sophisticated test construction is necessary to measure family dysfunction in patients who may tend to respond defensively.

Dermatologic adverse drug reactions in a family medicine setting.

To determine the prevalence of dermatologic adverse drug reactions in a family medicine outpatient practice setting, identify associated drug classes, and describe associated patient demographics and risk factors, we reviewed the charts of 557 patients in a university-based family medicine center who were diagnosed with a dermatologic condition. The study population included all patients diagnosed during a 1-year period. Thirty-five patients (6.3%) were identified as having dermatologic adverse drug reactions, of which the two most common types were exanthematous eruptions (n = 18 [51.4%]) and generalized erythroderma (n = 6 [17.1%]), with antibiotic use accounting for the majority (n = 21 [60.0%]) of reactions. Patient characteristics most commonly associated with a dermatologic adverse drug reaction were race (African-American), gender (female), and age (70 years and older). These data should provide insight into the types of cutaneous drug reactions commonly seen in community practice. Educational programs in all health-care disciplines, particularly medicine, pharmacy, and public health, that incorporate pharmacoepidemiologic strategies into their curricula are necessary to improve the overall process of monitoring and reporting of adverse drug reactions.

Group screening for cognition disorders in elderly persons.

Prevalence rates of cognitive impairment in persons aged 75 to 85 years are in the range of 10 to 19 percent, and 20 to 47 percent after the age of 85 years. Screening for dementia in persons aged 75 years and older would therefore identify a significant number of impaired persons. When screening for dementia, group testing would be more cost-effective than individual testing. We modified the Folstein Mini-Mental State examination (MMSE) for screening in a group setting. Community volunteers were tested at a geriatric health fair and at a special exercise class for the elderly. Subjects were subsequently tested individually using the standard Folstein MMSE. Analysis using Pearson correlation and a paired t-test indicates a high degree of concurrent validity between the two methods of administering the MMSE. This pilot study suggests that when screening elderly persons for dementia, a group-administered instrument can be a useful method to obtain a preliminary sample of cognitively impaired individuals.

Drug-related admissions to a family medicine inpatient service.

Admissions to a family medicine inpatient service were monitored retrospectively over a one-year period to determine the incidence of drug-related hospitalizations. Of the 293 admissions, 45 (15.4%) were identified as drug related; in 29 admissions (9.9%), a drug-related problem was identified as the primary cause of hospitalization. The two patient characteristics associated with a drug-related admission (DRA) were marital status (divorced) and age (older patients). The two most common types of DRAs were adverse drug reactions (17/45, 37.8%) and drug abuse (14/45, 31.1%), with alcohol being the most commonly abused agent. Adverse drug reactions were most commonly implicated in DRAs for patients over 70 years old, with drug abuse more evenly distributed among age groups. Educational programs that incorporate pharmacoepidemiologic strategies into all health care disciplines are necessary to address this public health issue.

Effect of an educational intervention on oral cephalosporin use in primary care.

The prescribing of oral cephalosporin antibiotics in an ambulatory setting was evaluated before and after an educational intervention. A drug utilization review used previously developed criteria to study the indications, processes, complications, and outcome for oral cephalosporins in the outpatient setting. Baseline data were collected for one year in the initial phase of the study. Only one prescription (1.4%) in the initial phase (0.96% of the total) met the criteria for appropriate use. However, during the year after an educational intervention by a clinical pharmacist explaining the proper use of oral cephalosporins, the prescribing of these agents decreased substantially. Educational strategies in medical schools and residency programs that seek to improve drug-prescribing behavior should combine drug utilization review programs with specific education about the appropriate use of pharmacologic agents.

Effect of case mix on provider continuity.

A random sample of 265 patient charts was selected to assess the degree of provider continuity at the University of North Carolina Family Practice Center from July 1, 1983, to June 30, 1984. Continuity was measured using usual provider continuity, the ratio of the number of visits with the assigned physician divided by total visits. Usual provider continuity rates varied as predicted for three types of visits: acute illness (0.55), chronic illness (0.76), and health maintenance (0.86). The average rate of usual provider continuity was 0.68. Case mix had a statistically significantly effect on provider continuity when comparing acute care with either chronic or health maintenance care (P less than .01). Because case mix is relevant and varies from site to site, a method of rate standardization was suggested using data on case mix from the National Ambulatory Medical Care Survey. Direct rate adjustment, a standard epidemiologic technique, would make continuity rates directly comparable for sites with different case mixes.

A technique for measuring family physician priorities for patient care.

Family physicians frequently choose which elements of patient care to emphasize in order to balance the idealized principles of medical care with the real constraints of medical practice. Colleagues at several residency programs agreed to help us to find out if these choices can be quantified and whether personal characteristics of respondents or the acuteness or chronicity of the patient's illness influence these priorities. Two sets of 15 forced-choice item pairs, one set in reference to chronic illness and one set in reference to acute illness, were used in the study. Responses from 346 family physicians and non-physician colleagues ranked six hypothetical elements of patient care for acute and chronic illness: continuity, comprehensiveness, family orientation, community orientation, coordination and prevention. The data were analyzed using the psychometric scaling technique of paired comparisons. The analysis yielded a set of rankings which showed that these choices were quantifiable and made with a high degree of individual consistency and greater intragroup agreement than would result from chance. Patterns of choice differed for acute and chronic illness in a manner consistent with observed clinical practice.