Heart failure in primary care: measuring the quality of care.

BACKGROUND: Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure. METHODS: We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status. RESULTS: Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF (91%) than among those with a normal LVEF (62%). Among patients with systolic heart failure taking ACE inhibitors, 87% were at target doses. Adherence measures were low for laboratory evaluation and patient-education criteria. CONCLUSIONS: Heart failure with normal LVEF was as prevalent as systolic heart failure in these primary care practices. Performance profiles for the physicians' prescriptions of ACE inhibitors exceeded those published in the literature. Patients who did not have a documented measure of LVEF, however, received lower quality of care as measured by this disease-specific guideline. This underscores the importance of measuring LVEF.

The pharmacologic treatment of depression.

BACKGROUND: Family physicians often provide the first line of treatment for patients with depression. Many effective drugs are now available for the pharmacologic treatment of depression. METHODS: We searched Medline from 1991-96 under the topics of depressive disorders/treatment and antidepressant medications. Other sources were found by back-referencing from these references and from pharmacology texts. RESULTS: Although antidepressants appear to be equally effective, selective serotonin reuptake inhibitors are frequently the drugs of choice because of their safety profile the less troublesome side effects. CONCLUSIONS: When prescribing antidepressant medications, the clinician must educate patients about potential side effects and about the amount of time that must be allowed for therapeutic efficacy. Drug interactions and concurrent medical conditions are important factors in the choice of an antidepressant.

Bacterial vaginosis: an update.

Bacterial vaginosis is the most common cause of vaginal discharge. Recent studies have confirmed its association with pelvic inflammatory disease and adverse pregnancy outcomes. Bacterial vaginosis is treated with oral metronidazole (given either as a single dose or a seven-day course) or clindamycin. Treatment with topical clindamycin or metronidazole is also effective in returning the vaginal flora to normal but may be less effective in preventing the increased incidence of adverse pregnancy outcomes.

Family physicians' attitudes about and use of clinical practice guidelines.

BACKGROUND: The use of clinical guidelines is one strategy intended to improve health care quality, rein in costs, and standardize medical practice. Clinical guideline development has been prodigious, while less effort has been expended on the guidelines' dissemination and implementation. This study examines family physician attitudes toward and perceived uses of clinical guidelines in practice. METHODS: A survey questionnaire was sent to 978 family physicians in Upstate New York to assess their confidence in clinical guidelines developed or endorsed by organizations and the perceived usefulness of such guidelines in practice. Descriptive analyses, chi-square tests, and comparison of means (one-way ANOVA) were conducted. RESULTS: After two mailings, the response rate was 43%. Most respondents perceived clinical guidelines as effective educational tools that should improve the quality of patient care, but were concerned about their potential regulatory intrusion into practice. Solo practitioners expressed more negative attitudes regarding clinical guidelines than physicians in non-solo practices. Respondents had greater confidence in clinical guidelines developed or endorsed by their professional society, the Centers for Disease Control and Prevention, the United States Preventive Services Task Force, and the National Institutes of Health, but less in those by insurance companies or state health departments. The reported adoption rate of clinical guidelines was low. The most preferred methods for adoption were continuing medical education and practice interventions. CONCLUSIONS: Family physicians found clinical guidelines to be valuable educational tools but were divided on their potential regulatory role. If clinical guidelines are to improve quality in practice, they must be more effectively disseminated and implemented. To broaden physicians' adoption of clinical guidelines, further research into dissemination and implementation methods is warranted, along with wider endorsement of guidelines by those whom family physicians trust.

Using a clinical practice guideline to measure physician practice: translating a guideline for the management of heart failure.

BACKGROUND: Effective clinical practice guidelines should improve clinical outcomes, and measures of physician use of clinical practice guidelines should correlate with improved outcomes. This study translates a clinical practice guideline on heart failure into review criteria to measure physician performance and the effectiveness of the clinical practice guideline. METHODS: A panel of 11 family physicians and 1 cardiologist systematically reviewed the clinical practice guideline for its clinical importance, educational relevance, and evaluative appropriateness. Then a subset of 4 family physicians rigorously applied each recommendation to established criteria for measurability and developed an evaluation tool useful in medical record review. RESULTS: The heart failure clinical practice guideline was found to be an excellent educational tool. Using it to measure physician performance, however, was limited to diagnostic tests and drug prescribing. Of 45 recommendations, 5 fulfilled criteria for measurability; 1 recommendation had A-level evidence, whereas 2 recommendations had B-level and 2 had C-level evidence. CONCLUSION: This study illustrates the logistic issues and challenges in developing a measure of physician adherence to clinical practice guidelines. Medical record review is inadequate to measure many recommendations. Physicians use of this clinical practice guideline must be evaluated as an intermediate step to measuring the effectiveness of clinical practice guidelines based on patient outcomes.

Missed appointments and Medicaid managed care.

OBJECTIVES: To compare the demographic characteristics of patients who miss appointments with those who do not and to identify subgroups who would benefit from specific interventions for improving attendance. DESIGN: Retrospective cohort study of an 18-month period. SETTING: An urban primary care practice. PATIENTS: A random sample (N = 477) of patients who were seen at least twice during the study period. MAIN OUTCOME MEASURES: Number of missed visits and kept visits, insurer, age, sex, race, ZIP code, and diagnoses. RESULTS: Of the established patients, 48% missed 1 or more visits. Patients in managed care programs, private and Medicaid, were likely to have missed more visits during the study period than those not in managed care programs (P < .001). Medicaid managed care patients had also scheduled more visits. Significantly higher rates of missed appointments were found in patients aged 19 to 35 years (P = .02), blacks (P < .001), patients in Medicaid managed care programs (P < .001), and patients who scheduled more visits (P < .001). After adjusting for age, race, and sex, Medicaid managed care insurance remained a significant (P < .01) predictor of rate of missed appointments. CONCLUSIONS: Patients in managed care programs missed more appointments. Patients in Medicaid managed care programs scheduled more appointments and had higher rates of missed appointments than their counterparts in other insurance groups.

Use of wet mount to predict Chlamydia trachomatis and Neisseria gonorrhea cervicitis in primary care.

BACKGROUND AND OBJECTIVES: Cervicitis is associated with salpingitis, infertility, and complications of pregnancy. Universal screening has been recommended for high-prevalence populations but may not be appropriate in the family practice setting. Leukocytes on an endocervical gram stain have been associated with infectious cervicitis due to Chlamydia trachomatis and Neisseria gonorrhea. This study sought to determine whether the finding of leukocytes in a vaginal wet mount could be used to screen for infectious cervicitis in an urban family practice. METHODS: A consecutive sample of 357 women had cultures for C trachomatis and N gonorrhea and a standardized wet mount. RESULTS: All women with infectious cervicitis were under age 35. Thirty-six percent of infected women had more leukocytes than epithelial cells in the wet mount, compared with 23% of women without these organisms. CONCLUSIONS: Wet mount findings did not reliably predict infectious cervicitis. Study of a larger population is needed to confirm these findings.

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Chlamydial cervicitis: complications and new treatment options.

Chlamydial cervicitis has the potential for serious gynecologic complications, including pelvic inflammatory disease, infertility and ectopic pregnancy. In the pregnant patient, this infection is associated with premature rupture of membranes and increased fetal morbidity and mortality. In addition, infants infected by passage through an infected cervix are at risk for respiratory complications and conjunctivitis. Chlamydial cervicitis may, however, be asymptomatic, and no single risk factor has been identified that reliably predicts infection. Current recommendations are to screen all pregnant women and patients in high-risk populations, such as those attending clinics for sexually transmitted diseases. Screening tests for chlamydial cervicitis are limited by expense and technical difficulties in obtaining and handling specimens. Chlamydial cervicitis can be treated effectively with several antibiotics, including doxycycline, ofloxacin and erythromycin. Newer antibiotics such as azithromycin offer the potential of effective single-dose treatment.

Gender of physicians and patients and preventive care for community-based older adults.

BACKGROUND: This study was undertaken to determine whether the gender of patients and physicians is a significant factor in deciding which older adults are offered preventive care. METHODS: A survey of medical records of ambulatory patients older than 60 years was performed in the practices of 210 physicians. Documentation of influenza vaccine, rectal examination, fecal occult blood test, Papanicolaou smear, pelvic examination, breast examination, mammogram, and pneumococcal vaccine was recorded, and rates of compliance were evaluated by sex of patient and physician. RESULTS: The medical records of 3327 patients were surveyed. Men were given influenza and pneumococcal vaccines more frequently than women. Among physicians, women physicians were more likely to give influenza vaccine (P = 0.003) and to check for fecal occult blood (P < 0.001). No significant difference was found between men and women physicians in the frequency of doing Papanicolaou smears, breast examinations, rectal examinations, and mammograms. CONCLUSIONS: While a difference in practice patterns was found between men and women physicians, most of the variance in compliance with preventive care guidelines was unexplained by the gender of physicians and patients. Matching of physician and patient by sex did not predict improved preventive care, indicating that other factors are involved in the failure to provide adequate primary preventive care to the ambulatory elderly.

Body mass and weight as indicators for cholesterol screening.

BACKGROUND: Universal screening of serum cholesterol levels in adults has been recommended but not achieved. We were interested in factors that affected screening rates, and whether obese patients were more likely to have elevated cholesterol levels than other patients in our practice. METHODS: A sequential sample of charts was reviewed for height, weight, race, sex, diagnosis of hypertension or diabetes, and evidence of cholesterol screening. RESULTS: Of 604 adult patients, 32% had serum cholesterol measurements. No correlation was found between weight or body mass index and cholesterol levels. Patients with hypertension or diabetes were more frequently screened. Sex and race did not influence screening rates. CONCLUSIONS: In this population neither weight nor body mass index was associated with elevated serum cholesterol levels, suggesting that screening must be offered without regard to level of obesity in order to find those patients who will benefit from intervention.

New concepts in bacterial vaginosis.

Bacterial vaginosis is a polymicrobial, superficial infection caused by an increase in anaerobic bacteria and a concomitant decrease in lactobacilli. Diagnosis is based on the presence of three of the following findings: a homogeneous vaginal discharge; an amine odor released by the addition of 10 percent potassium hydroxide; the presence of clue cells on wet mount; the absence of lactobacilli on wet mount, and an increase in the pH of vaginal secretions to more than 4.7. Oral metronidazole is the drug of choice for the treatment of bacterial vaginosis, but clindamycin is an effective alternative.