Screening for microalbuminuria to prevent nephropathy in patients with diabetes: a systematic review of the evidence.

OBJECTIVE: Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is effective according to the criteria developed by Frame and Carlson and those of the US Preventive Services Task Force. STUDY DESIGN: We searched the MEDLINE database (1966-present) and bibliographies of relevant articles. OUTCOMES MEASURED: We evaluated the impact of MA screening using published criteria for periodic health screening tests. The effect of the correlation between repeated tests on the accuracy of a currently recommended testing strategy was analyzed. RESULTS: Quantitative tests have reported sensitivities from 56% to 100% and specificities from 81% to 98%. Semiquantitative tests for MA have reported sensitivities from 51% to 100% and specificities from 21% to 100%. First morning, morning, or random urine sampling appear feasible. Assuming an individual test sensitivity of 90%, a specificity of 90%, and a 10% prevalence of MA, the correlation between tests would have to be lower than 0.1 to achieve a positive predictive value for repeated testing of 75%. CONCLUSIONS: Screening for MA meets only 4 of 6 Frame and Carlson criteria for evaluating screening tests. The recommended strategies to overcome diagnostic uncertainty by using repeated testing are based on expert opinion, are difficult to follow in primary care settings, do not improve diagnostic accuracy sufficiently, and have not been tested in a controlled trial. Although not advocated by the American Diabetes Association, semiquantitative MA screening tests using random urine sampling have acceptable accuracy but may not be reliable in all settings.

Physician perceptions regarding competence of obstetrical providers and attitudes about other issues in obstetrical care.

BACKGROUND: Access to obstetrical care in the United States is unevenly distributed and is limited by provider availability, geography, and finances. Obstetrical care is provided by three distinct groups: obstetricians, family physicians, and certified nurse midwives (CNMs). Outcomes among these groups have not been shown to differ, but the attitudes and perceptions of these groups may impact access to obstetrical care. We examined physicians' perceptions regarding competence of obstetrical providers for low- and high-risk care and attitudes regarding CNMs and malpractice insurance costs. METHODS: We mailed a survey containing twenty value-neutral questions on competency, attitudes, and demographics to a randomized list of 3,000 OB/GYNs and 3,000 FPs obtained from the American Medical Association. Physicians surveyed included obstetricians (OB/GYNs), obstetricians specializing in high-risk (HROBs), family physicians who include obstetrics in their practice (FPOBs), and family physicians who do not do obstetrics (FPs). RESULTS: The response rate was 14.5 percent. All respondent types expressed a high degree of confidence in OB/GYNs to provide low-risk obstetrical care. FPOBs were not perceived to be as competent to provide the same care, but FPOBs have more confidence in their ability to provide low-risk obstetrical care than OB/GYNs have (71.4% versus 43.8%, P = .0001). Attitudes differed among the physicians about malpractice insurance fees paid by OB/GYNs and FPOBs. OB/GYNs strongly supported a similar fee schedule for these two groups and FPs supported differential rates (P = .001). CNMs were generally perceived as competent and were thought to warrant hospital privileges for vaginal deliveries. CONCLUSIONS: Physicians view their own and others' obstetrical competence and outcomes differently, but not necessarily accurately. Malpractice rates are not perceived by OB/GYNs as fair. Specialty societies need to promote cooperation and enhance education of all providers of obstetrics.

Absence of longitudinal changes in rheumatologic parameters after silicone breast implantation: a prospective 13-year study.

There have been numerous questions regarding the association of polysiloxane with connective tissue disease and alteration of host immune response. C-reactive protein, rheumatoid factor, and anti-streptolysin-O titers were measured in 218 patients. These studies are routinely used in the diagnosis of autoimmune disease and mixed connective tissue disease. This prospective study has been in progress since 1985. The first patients were seen in July of 1985, and those individuals willing to participate were followed from 1985 to 1998. The implants included saline-filled elastomer shells and polysiloxane gel-filled elastomer shells. These groups were examined separately and in combination for changes between preoperative and postoperative states. In each instance, there was no statistical increase or decrease. Each patient underwent a physical examination and completed a questionnaire focusing on signs and symptoms of autoimmune and connective tissue diseases. The laboratory data and subjective clinical results demonstrated no significant differences between a nonimplanted group versus the saline group alone, the gel group alone, or the combined groups. The data failed to suggest any causal relationship between implants and autoimmune or connective tissue diseases over the study period of 13 years (since 1985).

Outcomes of an insurance company-sponsored multichannel chemistry screening initiative.

BACKGROUND: The use of serum chemistry panels as screening tests has been studied in a variety of clinical and nonclinical settings. None of the studies, however, has attempted to carefully examine any potential harm done to participants, and none has measured the impact on health-related quality of life. METHODS: Consenting participants in an insurance company-sponsored screening initiative completed a questionnaire before and 6 months after having blood drawn for a 25-item chemistry panel and a lipid profile; for men older than 50, a prostate-specific antigen (PSA) test was also done. The prescreening questionnaire included demographic and health information. The postscreening questionnaire included questions about specific outcomes. Included in both questionnaires were single-item measures of self-rated health and self-rated worry about health, and the 17-item Duke Health Profile (DUKE), a measure of health-related quality of life. Various outcomes were examined, including the numbers of new diagnoses, numbers and types of new treatment recommendations, change in self-reported health and worry, and change in DUKE subscale scores. Participants who were potentially helped and those who were potentially harmed by the serum chemistry panels screening program were identified and further characterized. RESULTS: Of the 2249 subjects who satisfactorily completed both questionnaires, 2012 (89%) had at least one abnormal test result, but only 985 of these (49%) remembered having discussed their test results with a physician. A total of 342 individuals received new treatment advice. However, 29 (10%) of them indicated that they would be "somewhat unlikely" to "very unlikely" to follow it. Following the intervention questionnaire, there were statistically significant average decrements in the General Health, Physical Health, and Pain subscales of the DUKE for participants with abnormal results. Self-rated health status did not change but level of worry about health increased significantly. At least 250 (11%) subjects were potentially helped by the screening initiative, but at least 574 (26%) were potentially harmed by it. CONCLUSIONS: The use of serum chemistry panels as screening tests in nonclinical settings should probably be discouraged, since health-related quality of life is not improved and the intervention may harm more individuals than it benefits.

The cost of medical dictation transcription at an academic family practice center.

BACKGROUND: Very little is known about the volume or cost of medical transcription in primary care. A study of the number of lines and cost of transcription at an academic family practice center was performed to establish the average number of lines and costs of transcription by level of service and type of provider (faculty physician, physician assistant, resident physician, and others). METHODS: Parallel 4-month sets of computerized billing records and computerized transcription summary logs (listing the patient name and identification, the dictator, the number of lines of dictation, and the date for each dictation) were merged and analyzed to compare the cost and volume of dictation by types of service and types of provider. RESULTS: During the study period there were 11,085 patient encounters, 9013 with transcription. The average cost of transcription per encounter using transcription was $3.96 and the median was $3.64. The cost per encounter ranged from $0.39 (3 lines of dictation) to $24.83 (191 lines of dictation). Faculty physicians and physician assistants had the lowest cost, resident physicians were intermediate in cost, and others (such as medical students) had the highest costs for medical transcription. Transcription costs rose with increasing level of service but became a smaller proportion of the collected fee, averaging only 5% for a level 5 encounter. CONCLUSIONS: The cost of transcription as a part of overhead was higher than anticipated. Specific education regarding dictation form and content and ways to decrease these costs is appropriate.

The determination and interpretation of reference intervals for multichannel serum chemistry tests.

BACKGROUND: When interpreting the results of clinical chemistry tests, physicians rely heavily on the reference intervals provided by the laboratory. It is assumed that these reference intervals are calculated from the results of tests done on healthy individuals, and, except when noted, apply to people of both genders and any age, race, or body build. While analyzing data from a large screening project, we had reason to question these assumptions. METHODS: The results of 20 serum chemistry tests performed on 8818 members of a state health insurance plan were analyzed. Subgroups were defined according to age, race, sex, and body mass index. A very healthy subgroup (n = 270) was also defined using a written questionnaire and the Duke Health Profile. Reference intervals for the results of each test calculated from the entire group and each subgroup were compared with those recommended by the laboratory that performed the tests and with each other. Telephone calls were made to four different clinical laboratories to determine how reference intervals are set, and standard recommendations and the relevant literature were reviewed. RESULTS: The results from our study population differed significantly from laboratory recommendations on 29 of the 39 reference limits examined, at least seven of which appeared to be clinically important. In the subpopulation comparisons, "healthy" compared with everyone else, old (> or = 75 years) compared with young, high (> or = 27.1) compared with low body mass index (BMI), and white compared with nonwhite, 2, 11, 10, and 0 limits differed, respectively. None of the contacted laboratories were following published recommendations for setting reference intervals for clinical chemistries. The methods used by the laboratories included acceptance of the intervals recommended by manufacturers of test equipment, analyses of all test results from the laboratory over time, and testing of employee volunteers. CONCLUSIONS: Physicians should recognize when interpreting serum chemistry test results that the reference intervals provided may not have been determined properly. Clinical laboratories should more closely follow standard guidelines when setting reference intervals and provide more information to physicians regarding the population used to set them. Efforts should be made to provide appropriate intervals for patients of different body mass index and age.

Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines.

BACKGROUND: Managed care organizations are focusing on how physicians manage their patients with diabetes mellitus as an indicator of physician compliance with clinical practice guidelines. Assessment of physician compliance with published guidelines may reveal areas of disagreement between physicians and guidelines or between physicians and patients and may show areas for potential improvement of care. Compliance with the diabetes care guidelines was assessed in our clinics to determine physician beliefs and performance and patients' accommodation of recommended practices. METHODS: We interviewed 295 patients with diabetes and surveyed 47 providers at an academic family practice center to assess practices and beliefs regarding the care of patients with diabetes. We also reviewed a 1-year compilation of billing and referral records for physician use of glycosylated hemoglobin (hemoglobin A1c) testing and referral of patients for eye examinations. RESULTS: We found that physician beliefs and practices were divergent and that provider performance of these nationally recommended activities was low. More than 75% of providers said that they recommended hemoglobin A1c testing, but only about 50% of patients had a documented test in the billing system. When questioned, one third of the patients reported that their physicians recommended this test. Similarly, nearly all physicians stated that they recommended annual eye examinations, although only 43% of patients said that their primary care physician recommended this referral. CONCLUSIONS: Physicians can and must improve intervention and patient education in the care of diabetic patients. Patient knowledge, motivation, and practice must be augmented by physician efforts. Lack of compliance with guidelines may indicate deficiencies in physician knowledge, implementation problems, lack of belief in guidelines, or problems in patient compliance. Attention should be directed to all these areas.

Clinical use of decision analysis.

An introduction to the theory and practice of clinical decision analysis, including decision trees and rudimentary cost-effectiveness calculations. A brief review of several published articles is also included.

A glossary of medical decision-making terms.

Many of the terms used in medical decision making are foreign to clinicians. This problem creates a barrier that can prevent physicians from acquiring these new clinical tools. This glossary contains definitions of the most common terms as well as examples of their usage by using Down syndrome as the illustrative condition.

Effectiveness and cost-effectiveness of employer-issued back belts in areas of high risk for back injury.

Back belts have gained popularity under the assumption that their use will reduce low back injuries and thereby decrease the costs. This study sought to examine that hypothesis. A retrospective survey instrument was administered to 1316 workers who perform lifting activities at Tinker Air Force Base, Midwest City, Oklahoma, to identify belt use, lifting requirements, injury, and treatment history. Analysis was also performed on costs applicable to providing the belts, treatment of injury, and lost or limited duty work days. Results show an odds ratio of 1.01 (confidence interval 1.01, 1.02) and P value of .0005 of low back injury with the number and weight of lifts performed in an 8-hour period as well as an odds ratio of 5.56 (confidence interval 3.35, 9.26) with prior history of injury. A protective effect, odds ratio of .65, P value of .019 is noted between lifting and attendance at a back training program. Use of a back belt appears to be marginally effective (odds ratio .60, P value .0508) in reducing injuries when controlling for other related factors. Cost analysis over all diagnoses of low back injury shows less intensive treatment and lower cost per injury for workers injured without a belt versus those injured while wearing a belt. It appears that predictors of low back injury are those expected based on risk assumed (amount of time spent performing lifts, history of injury) and that training programs are effective in prevention of problems. Data suggest that back belts appear to be minimally effective in preventing injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical decision-making following abnormal Papanicolaou smear reports.

OBJECTIVE: Interpretation of abnormal Papanicolaou smear reports and the subsequent management of the patient frequently present significant decision-making problems for clinicians. The purpose of this study was to evaluate family physician clinical decision-making strategies for abnormal cervical cytology reports using simulation techniques. METHODS: One hundred fifteen practicing family physicians evaluated two simulations of women with abnormal cervical cytology, the first with inflammatory cytology and the second with a high-grade squamous intraepithelial lesion. RESULTS: Most physicians (66%) selected an etiology evaluation and specific treatment approach to an inflammatory report, while 26% of respondents chose empiric treatment. For the high-grade squamous intraepithelial lesion simulation, 88% of physicians chose the appropriate management response of colposcopic evaluation. CONCLUSIONS: Practice experience, level of involvement, clinician gender, and type of cervical cytology classification influenced family physician clinical decision-making. The majority of responses to an inflammatory or high-grade squamous intraepithelial lesion report was appropriate based on current scientific data.

Hypertension management: relationship between visit interval and control.

OBJECTIVE: Hypertension is one of the most common diagnoses resulting in an office visit to the physician. We examined the relationship between the variation in the interval between follow-up visits for hypertensive patients and the control of blood pressure. METHODS: The sample consisted of 113 patients who made 399 visits. Data included current medical problems, medications, type of health insurance, and socioeconomic status for each patient. RESULTS: The mean number of days between visits was 70.6 with a standard deviation of 76.3. No significant relationship was found between visit interval and severity of hypertension (p = 0.14). Sample size made it possible to detect a 20% difference with a likelihood of 0.80 at a significance level of 0.05. CONCLUSIONS: Our findings are limited by our focus on patient behavior rather than physician recommendation concerning the interval between visits, and by the distinct possibility that many of the visits were made for reasons other than follow-up of hypertension.

Teaching clinical decision making in a family practice clerkship.

Limited health care resources and other social factors are making clinical decision making (CDM) a necessary subject of study for medical students. However, CDM material is technical and could be perceived by students as arcane. This study evaluated student attitudes toward a CDM module imbedded in a third-year medical student (MSIII) family medicine clerkship. A survey instrument was used for the evaluation and included a within-subject check for response consistency. The results show that MSIIIs feel that technical CDM material is within their grasp and that it is relevant to their day-to-day care of patients.

Transurethral prostatectomy versus transurethral dilatation of the prostatic urethra for benign prostatic hyperplasia: a cost-utility analysis.

Transurethral prostatectomy is the treatment currently preferred for benign prostatic hyperplasia. A new procedure, transurethral dilatation of the prostatic urethra, has lower costs and mortality and complication rates but may be less effective. These two strategies were evaluated by using cost-utility analysis, a form of cost-effectiveness analysis in which the benefit is defined in terms of individual preferences. Under the model assumptions, the cost of transurethral dilatation is less than the cost of transurethral prostatectomy for patients with benign prostatic hyperplasia ($7084 versus $8647) and slightly more effective: 11.787 quality adjusted life years versus 11.766. Thus, transurethral prostatectomy is said to be dominated. Results indicate that if patients are rigorously selected, and if balloon catheters of 30-35mm in size are utilized, transurethral dilatation could be the initial treatment of choice for eligible patients with benign prostatic hyperplasia.

Infection of fetal scalp electrode monitoring sites.

Complications caused by placement of a fetal scalp electrode include trauma, hemorrhage and infection. Infections are usually localized and self-limited, but they can occasionally lead to serious complications, such as osteomyelitis, sepsis and death. The recommended treatment for a scalp abscess is incision and drainage, followed by appropriate antibiotic therapy. If a serious infection is suspected, the infant should be hospitalized, blood cultures obtained and intravenous antibiotic therapy initiated.

Recurrent otitis media: a cost-utility analysis of simulated treatment using tympanostomy tubes vs antibiotic prophylaxis.

Using a cost-utility analysis, the effectiveness of tympanostomy tubes was compared to that of antibiotic chemoprophylaxis in young patients with recurrent otitis media. The tympanostomy approach (T-tubes) consisted of placement of a polyethylene grommet in the tympanic membrane, with systemic and local antibiotics administered for one week. The chemoprophylaxis approach consisted of antibiotics in full doses for seven to ten days, followed by continuous antibiotic chemoprophylaxis for six months. Because the T-tube strategy under the model assumptions was more expensive ($396.44 vs $281.30) and yielded slightly less benefit (net utility of .9325 vs. .9476 for initial antibiotic therapy), the chemoprophylaxis option was preferred. We conclude that the initial treatment for recurrent otitis media should consist of acute antibiotics followed by chemoprophylaxis, with T-tubes reserved for treatment failure. Extreme changes in the baseline probabilities of cure or recurrence with antibiotic therapy or in the cost of antibiotic therapy or tympanostomy surgery were required to alter this conclusion. Varying therapy preference (utility) values did not materially alter the conclusions.

Accuracy of patient encounter and billing information in ambulatory care.

BACKGROUND: This study examined the degree of accuracy of billing data in an academically affiliated family practice. METHODS: The progress notes from 1253 consecutive visits were independently reviewed by two family physicians, and the diagnoses, use of procedures, and level of service were determined for each visit. Discrepancies between the reviewers were resolved by consensus. These data were compared with the data on the corresponding billing form that had been completed by the care providers (ie, physicians on the faculty, physicians in training, family nurse practitioners, and nurses). RESULTS: There was poor agreement between the billing form and progress note on level of service and number of diagnoses (kappa = 0.37 and kappa = 0.28, respectively). The progress note usually indicated that a higher level of service should have been billed for a visit than actually was billed. Underreporting of the number of diagnoses was substantial; the billing forms listed only 69% of the diagnoses identified in the progress notes. In 60% of visits, each diagnosis on the billing form had a matching diagnosis in the progress note. This could be improved to 78% of visits if broad categories of disease were used. Residents were similar to faculty in the accuracy of reported level of service and types of diagnoses, but were more likely to underreport the number of diagnoses. CONCLUSIONS: Ambulatory care data from computerized billing files may not be sufficiently accurate for proper reimbursement of physician services or for use in research.

Circumcision: a decision analysis of its medical value.

Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions.

Relationship between patient race and survival following admission to intensive care among patients of primary care physicians.

This study investigated the existence of racial differences in the survival of patients admitted to intensive care by family physicians and general internists for circulatory illnesses. The study population consisted of 249 consecutive patients admitted by these specialists to an ICU in a tertiary care hospital in Pitt County, North Carolina, during the June 1985 to June 1986 period. Logistic regression was used to specify the unique effect of race on ICU patient survival in-hospital, controlling for potential confounding factors such as disease severity, type of health insurance, and case mix. Black patients were almost three times more likely than white patients to die in-hospital following admission to the ICU (RR = 2.9, 95 percent I = 1.5, 5.6). Most of this difference in survival was explained by racial differences in disease severity.

A classification of developmental activities of academic family medicine supported by federal grants.

Substantial funds have been awarded to academic departments of family medicine through the federal Establishment of Departments of Family Medicine grants program, initiated in 1980 under the Public Health Service Act. In 1989 the authors analyzed the successful grant applications in a sample of 61 institutions variously funded or re-funded for the grant cycles from 1980 through 1986 in order to classify the supported developmental activities. Three dimensions for explicating this activity emerged: (1) the functional area of the activity (e.g., curricular development); (2) the objectives of the activity (e.g., improving relevance of instruction); and (3) the strategies to be used to attain the objectives (e.g., addition of specialized faculty). This classification scheme provides a tentative but useful framework for characterizing departmental development.