The quality of emergency room radiograph interpretations.

Primary care physicians often make patient management decisions based in part on their own interpretations of radiographs. This important area of clinical decision making has not been previously analyzed in the literature. In this series of 294 consecutive radiographs from rural practice, interpretative disagreement between primary care providers and backup radiologists occurred 9.2 percent of the time, a discordance rate similar to that seen among radiologists in other studies. Although a majority of the films for which interpretative disagreement occurred had potential implications for influencing patient management, in only seven cases did actual case management vary from appropriate norms. Follow-up of cases where interpretative disagreement occurred revealed that in only two cases did unsatisfactory outcomes occur. Primary care physicians can provide high-quality radiographic interpretations that, when coupled with clinical information, yield extremely low rates of error or potential for poor patient outcomes.

Obstetric consultations during labor and delivery in a university-based family practice.

This study retrospectively examined the use of obstetrical consultants by family medicine residents and faculty at the University of Washington Hospital from July 1, 1980, to June 30, 1981. Of 125 deliveries, 104 (83 percent) were vaginal deliveries, 99 percent of which were performed by the family physician involved. There were 21 (17 percent) cesarean sections. Before the audit began, 13 complications of labor and delivery were established as criteria suggesting the need for consultation. Medical records were retrospectively examined for complications meeting these criteria. Formal consultations occurred in 32 percent of all deliveries. Of the patients with at least one of the 13 complications, 75 percent had consultations obtained. Patients with these complications had intrapartum risk scores that were significantly higher than patients without the listed complications. Apgar scores at 1 and 5 minutes were significantly lower in the group of patients meeting the consultation criteria (7.0 vs 8.0 at 1 minute; 8.3 vs 9.0 at 5 minutes). The criteria successfully identified a group of high-risk patients and could be an appropriate guide for decision making in the specific setting studied. Patients without one of the predetermined complications had a low rate of surgical intervention (cesarean section or midforceps deliveries); the negative predictive value was 98 percent.

Lateral Sims' deliveries: a new application for an old technique.

The left lateral Sims' position is a time-honored but neglected childbirth position. Increasing use of bed deliveries as a part of natural childbirth in birthing rooms makes side deliveries attractive, since the perineum is better visualized and the obstetrician has greater freedom of movement. Impeding widespread adoption of the lateral Sims' position is a lack of experienced personnel to teach the procedure and a lack of suitable descriptions and depictions in the literature. This paper presents the advantages and problems of using this position and provides a detailed description of the technique for those interested in incorporating it into their practices.

Otitis media and learning disabilities: the case for a causal relationship.

Despite an extensive literature suggesting a relationship between otitis media in early childhood and later learning disabilities, controversy still exists as to whether this link is causal. The hallmarks of otitis media, including decreased hearing and delayed language acquisition, and the characteristics of learning disabilities are reviewed. Further analysis of the studies that support a relationship between otitis media and learning disabilities strongly suggests that the relationship is causal in spite of methodologic limitations of some individual studies. If a causal relationship is accepted, then otitis media in early childhood is a disease with significant long-term morbidity that deserves careful follow-up and, when indicated, preventive interventions.

The fetal non-stress test.

The non-stress test has become a widely accepted method of screening for fetal distress in high-risk pregnancies. The procedure is technically simple, noninvasive, and when reactive (negative), a highly reliable predictor of fetal well-being for up to one week. This paper outlines the indications, performance, interpretation, and limits of the non-stress test as a standard evaluative tool for use by family physicians.

Diagnosis clusters: a new tool for analyzing the content of ambulatory medical care.

A clustering method for the analysis of ambulatory morbidity data is presented. This approach reduces spurious variations resulting from idiosyncratic diagnosis labeling and coding habits of physicians and facilitates the analysis of the content of ambulatory medical care through the use of aggregate morbidity data. The clusters provide a tool that allows for the comparison of the content of practice based on different factors such as provider training, practice organization, and patient characteristics. Ninety-two diagnosis clusters were derived using the 1977 and 1978 National Ambulatory Medical Care Survey (NAMCS). These clusters incorporate 86 per cent of all ambulatory visits to office-based physicians in the contiguous United States. The clusters were constructed based on the consensus of a group of clinicians including both generalists, as well as selected subspecialists representing the spectrum of ambulatory medical practice. The diagnosis clusters presented are compatible with the International Classification of Diseases (ICDA-8 and ICD-9-CM) and the International Classifications of Health Problems in Primary Care (ICHPPC and ICHPPC-2). Several applications demonstrating the utility of the method are presented, and directions for future applications are suggested.

The diagnostic content of family practice: 50 most common diagnoses recorded in the WAMI community practices.

Because there are several methodological deficiencies in previously published studies, a prospective study was carried out of the 50 most common diagnoses of community-based family practices in the Pacific Northwest. Age and sex of patients and reliability of data were controlled. The data reported show reasonable concordance with other published accounts for 10 most common diagnostic categories. For less frequent diagnoses, however, high variability in rank order is the rule, both within this study and by comparison with other studies. This suggests that the diagnostic content of family practice is far from universal and that diagnostic idiosyncrasies of physicians, regional differences in rates of disease, practice style, and as yet other unexplained factors may significantly influence the diagnostic content of family practice.

Procedures performed by family physicians, internists, and a Medex in a small group practice.

Encounter forms for all patient visits to a small group practice (two internists, three family physicians, and one Medex) were examined retrospectively for October 1979 and January, April, and July 1980. A total of 5,694 patient encounters (2,327 male, 3,367 female) were recorded during the four months studied. Diagnostic and therapeutic procedures were performed on 592 patients (9.6 percent), 321 male and 271 female. The family physicians performed fewer procedures on their patients (6.1, 7.5, and 8.6 percent of the total patients seen). The Medex did 18.4 percent of all office procedures for that time period. The ten most commonly performed procedures included electrocardiogram (ECG), rhythm strip or ambulatory ECG, splint application, suture removal, pulmonary function test, suturing, exercise treadmill test, wart removal, removal of skin lesion or punch biopsy, application or removal of plaster cast, and application of ace wrap, sling, or collar. The majority of the procedures performed by the family physicians were also done by the Medex; however, the diversity of the procedures performed by the family physicians was comparable with that of the internists. There were large economic differences between groups, with the internists having the highest total billings and the Medex the lowest average charge per procedure performed.

Screening during routine health assessment.

Medical charts of 189 patients receiving routine health examination were reviewed. Of the 15 evaluative procedures included, two (the physical examination and stool for occult blood) were performed by physicians; the remaining 13 were delegated to paramedical personnel and/or outside facilities. A total of 330 of 1,497 (22 percent) were found to be abnormal. Of abnormalities only 144 (44 percent) received follow-up as determined by chart audit. Physician-performed tests yielded 62 of 330 abnormal results. The rate of follow-up for physician-detected abnormalities was 58.1 percent compared to 40 percent for abnormalities found by other providers. To improve follow-up rate it is suggested that only those procedures be performed in which early detection significantly alters morbidity and/or mortality and that a structured definition of follow-up role be established or paramedical personnel.