Detecting symptoms of alcohol abuse in primary care settings.

BACKGROUND: Studies on alcohol abuse are frequently based on patients who meet minimum diagnostic criteria, thus ignoring patients with individual symptoms of harmful or hazardous use. Consequently, we are unable to characterize alcohol-abusing patients with sufficient clarity to effectively focus screening for primary prevention. OBJECTIVE: To determine the prevalence of harmful and hazardous use of alcohol, assess screening instruments for detecting alcohol abuse or dependence, and assess the impact of alcohol use on other diagnoses treated in outpatient settings. DESIGN: Survey (cross-sectional study). SETTING: Hospital-based outpatient clinic. PARTICIPANTS: Three hundred randomly selected adults (aged 18 years and older). MAIN OUTCOME MEASURE: Diagnosis of alcohol abuse or dependence based on the Diagnostic Interview Schedule (DIS). RESULTS: About 18% met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria of abuse or dependence while almost 50% had at least one symptom of harmful or hazardous use. The T-ACE questionnaire, a modified version of the CAGE questionnaire, was the most effective screening instrument for both men and women. Selected diagnoses, personal characteristics such as family history of alcohol abuse, and self-reported patterns of alcohol use could identify patients likely to meet diagnostic criteria. CONCLUSIONS: Many symptoms of substance use disorders are not adequately addressed in outpatient practice. Little is known about how alcohol use in varying quantities affects health care utilization and treatment of conditions commonly seen in outpatient medicine. Consequently, we lack a full appreciation of the burden of disease borne by alcohol use and have yet to achieve a universally accepted method of approaching primary and secondary prevention of alcohol-related problems.

Cholesterol testing and management: a national comparison of family physicians, general internists, and cardiologists.

BACKGROUND: We wanted to compare the frequency of cholesterol testing and treatment of hypercholesterolemia in patients cared for by family physicians, general internists, and cardiologists. METHODS: This study was a continuous cross-sectional survey of 1991 ambulatory office visits using a national probability sample of US physicians' office practices (National Ambulatory Care Survey). The physicians surveyed self-reported their specialty as family practice, internal medicine, or cardiology. Records of 33,795 patient visits to 1354 physicians were reviewed to find out whether the physicians reported cholesterol testing, cholesterol counseling, and charting of patient use of lipid-lowering medications. The results were compared among the three specialist groups. RESULTS: During an annual health examination (9.77 million office visits), a cholesterol test was reported by 23.5 percent of family physicians, 43.5 percent of internists, and 13.1 percent of cardiologists (P < 0.01). For all hypercholesterolemic patients (23.52 million office visits), the age- and sex-adjusted percentages of reported cholesterol-reduction counseling during office visits were 38.3 percent for family physicians, 42.4 percent for internists, and 36.5 percent by cardiologists (NS), and percentages of reported lipid-lowering medication prescriptions were 13.4 percent for family physicians, 25.1 percent for internists, and 28.4 percent for cardiologists (P < 0.01). In hypercholesterolemic patients with coronary heart disease (3.47 million office visits), the age- and sex-adjusted percentages of cholesterol reduction counseling reported during office visits were 64.4 percent for family physicians, 47.1 percent for internists, and 35.9 percent for cardiologists (NS) and the age- and sex-adjusted percentages of lipid-lowering medication prescriptions reported were 13.9 percent for family physicians, 62.5 percent for internists, and 34.7 percent for cardiologists (P < 0.01). CONCLUSIONS: Recommended goals regarding cholesterol testing and management were not reached by any physician group. Internists tested for hypercholesterolemia during an annual health examination more frequently and had more patients using lipid-lowering medications than did family physicians or cardiologists. Understanding the reasons for these specialty differences might lead to improvement in the diagnosis and management of hypercholesterolemia and therefore reduction in cardiovascular disease.

Encopresis treatment outcome: long-term follow-up of 45 cases.

Among children diagnosed and treated for encopresis (N = 88) at either of two incontinence clinics between 1986 and 1994, 45 could be assessed for long-term (>12 months) outcome. Measures consisted of retrospective analysis of clinical charts and parent report of child soiling status. At follow-up (mean duration 53 months, range 15 to 99 months), 26 children (58%) were in remission, 13 (29%) were improved, and six (13%) showed no improvement. Logistic regression showed that children who presented with no previous encopresis treatment(s) (odds ratio 5.88, 95% confidence interval 1.61 to 21.55, p < .01) and/or children who presented with fecal retention (odds ratio 17.8, 95% confidence interval 2.70 to 153.37, p < .01) were more likely to be in remission. The interval between treatment and follow-up was significantly longer (mean 62 months, range 26 to 94) for children in remission than for children still soiling (mean 45 months, range 15 to 75) (p < .01). At follow-up 1 year or more after treatment for encopresis, a significant number of children may continue to soil. Previous encopresis treatment(s) and/or nonretentive encopresis may be risk factors for persistent soiling. The chances of complete remission of encopresis tend to increase with the passage of time.

Family history and premature coronary heart disease.

BACKGROUND: We were interested in studying whether a family history of coronary heart disease (CHD) persisted as a significant risk factor for premature coronary heart disease after adjusting for traditional and nontraditional risk factors. METHODS: Ninety-five case patients with documented premature CHD (occurring in a person less than 60 years old and with greater than 50 percent occlusion of a major epicardial vessel or a documented myocardial infarction) and 95 community-based control patients were examined for risk factors including family history, hypertension, diabetes mellitus, sedentary lifestyle, smoking, body mass index, total cholesterol, high-density lipoprotein cholesterol, triglycerides, low-density lipoprotein cholesterol, lipoprotein(a), homocysteine, and fibrinogen. RESULTS: The risk of premature CHD for a positive family history ranged from an odds ratio (OR) of 3.25 for a standard family history of CHD in a first-degree relative, 5.9 for family history of early CHD in a first-degree relative before the age of 45 years, and 6.1 for a strong family history of CHD defined as CHD in at least two first-degree relatives. Family history persisted as a significant risk factor for premature CHD (OR = 3.9, 95 percent confidence interval [CI] 1.8-8.7) in multiple variable models that included traditional and nontraditional risk factors. It was rare, however, for a person with a positive family history not to have at least two other traditional or nontraditional risk factors. CONCLUSIONS: Family history of CHD should not be considered a simple binary risk factor for premature CHD, and a positive family history of CHD indicates that a person is at high risk for premature CHD independent of traditional and nontraditional risk factors.

The effect of high-dose ascorbate supplementation on plasma lipoprotein(a) levels in patients with premature coronary heart disease.

STUDY OBJECTIVE: To determine the efficacy of high-dose ascorbate supplementation in lowering lipoprotein(a) [Lp(a)] levels in patients with premature coronary heart disease (CHD). DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Outpatient clinic. PATIENTS: Forty-four patients with documented premature CHD, defined as confirmed myocardial infarction and/or angiographically determined stenosis of 50% or greater in at least one major coronary artery before age 60 years. INTERVENTIONS: Patients were block randomized on the basis of age, gender, and screening Lp(a) concentrations to receive ascorbate 4.5 g/day or placebo for 12 weeks. MEASUREMENTS AND MAIN RESULTS: High-dose ascorbate was well tolerated and produced a marked elevation in mean plasma ascorbate levels (+1.2 mg/dl; p < 0.001). Multiple linear regression analysis revealed no significant effect of supplementation on postintervention Lp(a) levels (p = 0.39) in a model that included treatment group assignment, and baseline Lp(a) levels. CONCLUSIONS: Our findings do not support a clinically important lowering effect of high-dose ascorbate on plasma Lp(a) in patients with premature CHD.

The plain abdominal roentgenogram in the management of encopresis.

OBJECTIVE: To determine whether fecal retention in encopretic children can be assessed objectively using the plain abdominal roentgenogram and whether roentgenographic evidence of fecal retention is associated with clinical findings on presentation in encopretic children. DESIGN: Retrospective case studies. SETTING: Two pediatric incontinence clinics. PARTICIPANTS: Sixty children (72% male), aged 4 to 18 years (mean, 8 years), who met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for the diagnosis of encopresis. All had a plain abdominal roentgenogram obtained on presentation. INTERVENTIONS: None. RESULTS: Using a systematic assessment tool with good interrater reliability (kappa = 0.65), 78% (47) of the children had fecal retention by roentgenographic criteria on presentation, while 22% (13) did not. Retentive encopretic children were less likely to have a history of difficult toilet training (P = .018) than nonretentive encopretic children. There was no association between fecal retention and several clinical factors, including historical features commonly attributed to fecal retention. Retentive encopretic children were no more likely to have a palpable abdominal mass than nonretentive encopretic children, but they were more likely to have excessive stool on rectal examination (P = .015). Using the plain abdominal roentgenogram as the gold standard, the rectal examination showed a positive predictive value of 84.8% and a negative predictive value of 50% in assessing fecal retention. CONCLUSIONS: Fecal retention in encopretic children can be assessed objectively from a plain abdominal roentgenogram. Most, but not all, encopretic children present with fecal retention. A positive rectal examination is strongly predictive of fecal retention, in which case a roentgenogram is not necessary to make that diagnosis. A negative rectal examination may not rule out fecal retention, in which case an abdominal roentgenogram may be useful to make that diagnosis.

The negative pregnancy test. An opportunity for preconception care.

OBJECTIVE: To identify women who would likely benefit from preconception care. METHODS: A comprehensive preconception risk survey was administered during a structured interview to 136 women who had a negative pregnancy test visit in a family practice residency ambulatory practice. The survey solicited the presence of self-reported risk variables associated with maternal conditions related to poor obstetric outcome, risk factors for poor obstetric outcome, and risks for developing these conditions. RESULTS: Seventy women (51.5%) reported a medical or reproductive risk that could adversely affect pregnancy. In addition, 68 women (50%) reported a genetic risk; 39 (28.7%) reported a risk for human immunodeficiency virus infection, 35 (25.7%) reported an indication for hepatitis B vaccine, and an equal number reported recent use of illegal substances; 23 (16.9%) reported at least one affirmative answer to the CAGE questionnaire; 79 (58.5%) smoked cigarettes; 74 (54.4%) reported a nutrition risk; 126 (92.6%) reported a psychosocial risk; and 39 (28.7%) reported a perceived barrier to ongoing medical care. Even with the psychosocial risk category excluded, 94% of the women still reported at least one factor requiring further evaluation, counseling, or intervention before pregnancy. CONCLUSIONS: We discovered a significant number of women with obstetric risk factors. A negative pregnancy test visit provides an opportunity for preconception risk assessment and counseling. These results will guide us to further develop practical preconception care protocols.

High dose ascorbate supplementation fails to affect plasma homocyst(e)ine levels in patients with coronary heart disease.

Pharmacologic doses of folate, in the absence of clinical folate deficiency, can reduce plasma levels of the putatively atherothrombotic amino acid, homocysteine (H(e)). Data suggesting that H(e) may accumulate in experimental scurvy prompted us to explore the efficacy of high dose ascorbate supplementation as a H(e)-lowering treatment, in the absence of clinical ascorbate deficiency. A randomized, placebo-controlled trial of 12 weeks of high dose (4.5 g/day) ascorbate supplementation was completed by 44 patients with established coronary heart disease. No significant change in mean fasting total plasma H(e) levels was demonstrable despite a marked increase in mean fasting plasma ascorbate levels amongst those patients randomized to active treatment. Ascorbate supplementation to prevent the development of fasting hyperhomocysteinemia may only be relevant at scorbutic levels of plasma ascorbate.

A comparison of primary versus secondary cardiovascular disease prevention in an academic family practice.

BACKGROUND: The risk of mortality from cardiovascular disease (CVD) is much higher in those with preexisting CVD than in those without it. Risk factor modification can reduce these risks. This study was designed to determine whether physicians manage risk factors differently in patients with and without overt CVD. METHODS: Risk factor identification and management strategies after the diagnosis of CVD (secondary prevention) were analyzed by chart audit for 61 patients with premature CVD and 61 age-matched patients free of CVD (primary prevention). All of these patients had entered an academic family practice within 1 year of each other and had at least two physician visits between 1982-1992. RESULTS: In the majority of patients, risk factors for CVD were identified by family physicians. Few differences in counseling and management of risk factors were noted between patients with premature CVD and those free of CVD. Management of hypertension was performed with behavioral and pharmacologic therapy; more than 94% of the patients had at least one posttreatment blood pressure below 140/90. Lipid disorders, however, were managed primarily by diet; only 20% of cases with hyperlipidemia and premature CVD received pharmacologic therapy, and only 2.5% had a controlled blood cholesterol level (below 200 mg/dl). CONCLUSIONS: In an academic family practice, CVD risk factor identification was high but recommended management practices in the secondary prevention of CVD were suboptimal. Management of CVD risk factors was not more aggressive among secondary prevention cases compared to primary prevention controls.

Comparison of primary care residents' confidence and clinical behavior in treating hypertension versus treating alcoholism.

PURPOSE: To compare the self-reported confidence and clinical behaviors of primary care residents in treating alcoholism versus hypertension. METHOD: Eighty-five residents, 36 in family medicine and 49 in primary care internal medicine, representing all years of the three-year training programs at two hospitals affiliated with the Brown University School of Medicine, were surveyed in 1988. Self-report questionnaires elicited demographic data and several responses (ranged on scales of 1, not confident or frequent, to 10, very confident or frequent) about the residents' confidence and frequency of use of clinical behaviors with both alcoholic and hypertensive patients. Paired t-tests were used to compare the responses about hypertension with those about alcoholism. RESULTS: Questionnaires were completed by 54 (63.5%) of the residents. No significant difference was found between the residents' responses by sex or program, but there was a significant difference (p < .0001) between the responses with regard to the two disorders. The residents had more confidence about their management of hypertension (a mean score of 8.81 versus 7.95 for alcoholism). They also reported greater use of appropriate clinical behaviors with hypertensive patients (mean scores in the very confident range of 7.5 to 8.2 compared with means in the moderate range of 4.9 to 7.1 for alcoholism). CONCLUSION: Both the family medicine and the internal medicine residents were significantly more confident in managing all aspects of hypertension than in managing alcoholism, and they reported significantly greater frequency in utilizing appropriate clinical behaviors for hypertension than for alcoholism.

Changing physicians' attitudes, knowledge, and self-efficacy regarding cholesterol screening and management.

The National Cholesterol Education Program (NCEP) has identified a need to convey practical approaches for the management of high blood cholesterol (BC) to physicians. Our study was a joint effort between the Pawtucket Heart Health Program and the Brown University Department of Family Medicine to improve family medicine residents' attitudes, knowledge, self-efficacy, and practices regarding cholesterol screening and management. Thirty-six resident physicians received a BC screening and management training program. This program included training in BC screening using the fingerstick method and a desktop analyzer, diet assessment and counseling, and a management protocol for evaluation and treatment of high BC based on NCEP guidelines. The training program also included evaluation of residents' BC screening activity, incentives, chart audits, and biweekly articles in the departmental newsletter. We administered a survey to residents before and one year after the training program began to assess self-reported knowledge, attitudes, self-efficacy, and practices for BC management. Survey results indicated that the residents significantly improved their reported knowledge and attitudes about BC management. In addition, they significantly increased their reported self-efficacy and practices in dietary counseling and patient education. Residents also indicated that the training program was worthwhile, necessary, and practical and that many would use the materials and protocols in their future practices.

The effect of physician and patient gender on preventive medicine practices in patients older than fifty.

This study examined whether the sex of physicians and patients affected the preventive care of middle-aged and older patients of family physicians. The charts of 61 male and 75 female patients older than 50 years, whose primary physicians were third-year family practice residents, were reviewed to determine whether tests to screen for colorectal, breast, and cervical cancer had been offered to them in the previous 18 months by their primary physicians. Male residents had offered rectal examinations significantly more frequently than female residents to male patients older than 70. Female residents had offered mammograms, pelvic exams, and Pap smears significantly more frequently to women older than 50 than had male residents. Female residents had significantly higher rates of offering pelvic exams and Pap smears to women between the ages of 50 and 70, but this difference was not significant for women over 70. There were no significant differences in the number of refusals by male or female patients to male or female residents. Results suggest that the sex and age of the patient and the sex of the physician may play a role in differential rates of cancer screening.

The provision of physical activity to hospitalized elderly patients.

Physical activity has been recognized as an important aspect of patient care for nearly 50 years. Yet, deconditioning and functional decline of hospitalized elderly patients continue to be reported. Such outcomes suggest that a good system for providing activity in hospitals is lacking. In this retrospective study we assessed the provision of physical activity to 500 elderly patients (100 in each of five hospitals) during the first 7 days of hospitalization. No activity order was in effect on 13% of the 3500 patient days reviewed. When activity was ordered, patient activity was different from the activity permitted by the physician orders on 41% of the days. Patients who remained in bed or in a chair rarely received physical therapy, never had physician orders for exercises, and never performed exercises with the nurses. These findings demonstrate that the current practices for the provision of physical activity in hospitals are ineffective.

A successful physician training program in cholesterol screening and management.

METHOD: Thirty-six resident physicians received a blood cholesterol training program which included training in blood cholesterol screening using a fingerstick method and a desktop analyzer, diet assessment and counseling, and a management protocol for follow-up diet and drug treatment. The program also included feedback to residents about their blood cholesterol screening activity, incentives, and biweekly articles in the department newsletter. RESULTS: Between 1986-1987 (baseline) and 1987-1988 (intervention), the percentage of the target patient population (ages 20-65 years, nonpregnant, not screened in the previous year) that was screened for hypercholesterolemia in this primary care practice increased from 16.2 to 23.2% [rate difference (RD) = 7.0; 95% confidence interval (CI) = 4.75-9.25]. The mean value of the screening tests decreased from 5.36 mmol/liter (207.2 mg/dl) to 5.08 mmol/liter (196.6 mg/dl; t = 2.98, P = 0.003) and the percentage of the population screened needing further evaluation decreased from 36.8 to 27.6% (RD 9.2; CI = 2.00-14.00). In the intervention year, compared with the baseline year, patients with a borderline blood cholesterol and cardiovascular risk factors were more likely to have a follow-up test (28.8% vs 11.9%, RD = 16.9; 95% CI = 0.80-33.00) and the low-density lipoprotein cholesterol test was used less for screening (8.2% vs 19.4%, P less than 0.0001). Conclusion. We conclude that this program was effectively integrated into a busy primary care practice, leading to improvement in blood cholesterol screening and management practices.

A follow-up survey of family physicians' interest in and knowledge of nutrition.

Forty-two practicing family physicians completed a questionnaire about 33 nutrition topic areas. They were among 71 physicians who, over an eight-year period (1980-1988), completed an identical questionnaire upon entry to their first postgraduate year in the family practice residency program at Brown University/Memorial Hospital of Rhode Island. Specific topic areas were grouped into five scales. Perceived knowledge of these topics significantly increased (p less than .0001) in all areas except nutritional biochemistry. There was significantly less (p less than .0001) interest in learning more about nutrition. One major exception was that the physicians wanted to learn more about nutrition counseling. Another exception was that nutrition in the life cycle remained an area about which they wanted to learn more. The physicians rated nutritional skills as less relevant on the second questionnaire than on the first. The authors conclude that more emphasis on nutrition counseling skills and nutrition in the life cycle may be appropriate in medical education.