Estimating health literacy in family medicine clinics in metropolitan Detroit: a MetroNet study.

OBJECTIVE: Assessing health literacy during the clinical encounter is difficult. Many established instruments are lengthy and not practical for use in a busy practice setting. Our objective was to compare the performance of 3 health literacy screening questions against the Short Test of Functional Health Literacy for Adults (S-TOFHLA) in an urban, ethnically diverse primary care practice-based research network. METHODS: A convenience sample of patients in clinics in the Detroit area were recruited to complete a questionnaire that included the S-TOFHLA and 3 items similar to the Chew screening questions. Area under the receiver operating characteristic (AUROC) curves compared the test characteristics of the screening questions to the S-TOFHLA. RESULTS: The participation rate was 92% (N = 599). Most participants were women (65%) and African American (51%); 51.8% had a household annual income of <$20,000. Almost all (96.7%) had an adequate score on the S-TOFHLA. The screening question with the largest AUROC (0.83; 95% CI, 0.70-0.95) was "How often do you have someone help you read instructions, pamphlets or other written materials from your doctor or pharmacy?"; the AUROC for all 3 questions was 0.90 (95% CI, 0.85-0.95). CONCLUSIONS: Self-administration of the 3 screening questions demonstrated high performance compared with the 36-item S-TOFHLA interview instrument. These screening questions should help providers identify patients who may need extra support to follow health prescriptions.

Using the Guidelines for Adolescent Preventive Services to estimate adolescent depressive symptoms in school-based health centers.

BACKGROUND AND OBJECTIVES: The study objective was to understand the relationship between depressive symptoms and demographic, behavioral, and environmental risk variables among adolescents attending school-based health centers (SBHCs) using the Guidelines for Adolescent Preventive Services (GAPS) questionnaires. METHODS: Using GAPS questionnaires, we conducted a retrospective medical record review of 672 adolescents attending two Detroit-area school-based health clinics. Bivariate and multivariate analyses were conducted to determine which factors were associated with depressive symptoms while adjusting for other relevant factors. RESULTS: Overall, 26.5% of adolescents reported depressive symptoms. Bivariate analysis revealed associations between depressive symptoms and female gender, older age, disordered eating, lack of physical activity, sexual activity, poor school performance, substance use of all types, violence, law trouble, and an abuse history. Multivariate regression models revealed that female gender, sexual activity, weapon carrying, law trouble, poor physical activity, and a history of abuse were most strongly related to self-reported depressive symptoms. Substance use was not a significant factor after controlling for potential confounders. CONCLUSIONS: Targeting the above factors during routine adolescent examinations may help providers at SBHCs and other clinics identify those at highest risk for depression and provide appropriate interventions.

Comparison of point of care and laboratory HbA1c analysis: a MetroNet study.

BACKGROUND: Evaluating new technology in clinical practice is an important component of translating research into practice. We considered the feasibility of using a Clinical Laboratory Improvement Amendments (CLIA)-waived point of care (POC) glycohemoglobin (HbA1c) methodology in busy family medicine centers by comparing the results of POC HbA1c and laboratory analysis results. METHODS: Recruited from 5 MetroNet practices, the participants were adult diabetic patients having blood samples drawn for laboratory analysis of HbA1c. Each agreed to provide a capillary blood sample for POC testing. RESULTS: With data on 99 paired samples, the POC method yielded a mean HbA1c of 7.38%, which was equivalent to the mean of 7.53% produced with all combined standard laboratory analyses. The Pearson correlation between POC and the laboratory analysis test results was 0.884 (P < .001). POC test sensitivity was 81.8% and specificity was 93.2%. Eighteen percent of patients with an HbA1c > = 7% by laboratory analysis were not identified as such by the POC test. CONCLUSIONS: Before adopting a POC methodology, practices are encouraged to review its feasibility in the context of the office routine, and also to conduct periodic comparisons of the accuracy of POC test results compared with those from laboratory analysis.

Effects of implementation of a team model on physician and staff perceptions of a clinic's organizational and learning environments.

BACKGROUND AND OBJECTIVES: Although teamwork is widely promoted by the Institute of Medicine, the American Academy of Family Physicians, and the Future of Family Medicine project, the health care literature does not provide clear direction on how to create or maintain high-functioning teams in ambulatory residency education. In 2004, we reorganized the clinical operation of our family medicine residency clinic into teams, each consisting of faculty, residents, and nursing and administrative staff. We hypothesized that operating within teams would have a positive effect on employees' job satisfaction and perceptions of our clinic's organizational and learning environments. METHODS: We administered a confidential survey to faculty, residents, and staff annually over 5 years (2002-2006). Using questionnaire data from 2002-2003 as a baseline and data from 2004-2006 as a post-intervention measurement, we performed Mann-Whitney tests to assess the effect of the implementation of teams on employees' ratings of job satisfaction, individual autonomy, organizational commitment, goal attainment, physical characteristics and personnel arrangements within the clinic, learning opportunities for residents, teaching behaviors of faculty, roles of staff, and learning organization characteristics. RESULTS: After the implementation of teams, there was an improvement in ratings of learning opportunities and quality of teaching, job satisfaction, employee autonomy, staff roles, and staff attitudes toward residents. CONCLUSIONS: Implementing a team approach in a residency clinic can improve measures of physician and staff satisfaction and organizational function.

Effect of antibiotics on vulvovaginal candidiasis: a MetroNet study.

PURPOSE: Vulvovaginal candidiasis (VVC) is believed common after systemic antibiotic therapy, yet few studies demonstrate this association. In this pilot study, we evaluate the effect of short-course oral antibiotic use on VVC. METHODS: Nonpregnant women aged 18 to 64 years who required >or=3 days oral antibiotics for nongynecological diseases were recruited from a family medicine office. Age-matched (+/-5 years) women seen in the same clinic for noninfectious problems were recruited as controls. The main outcomes are incidence of symptomatic VVC and prevalence of positive vaginal Candida culture 4 to 6 weeks after antibiotics. RESULTS: Eighty (44 in antibiotic group) women were recruited; 14 of 79 (95% CI, 0.11-0.28) had asymptomatic vaginal Candida cultures positive at baseline. During follow-up, 10 of 27 (95% CI, 0.22-0.56) women in antibiotic group were Candida culture positive. In contrast, 3 of 27 (95% CI, 0.04-0.28) women in the control group were Candida culture positive (relative risk, 3.33; P = .03). Meanwhile, 6 of 27 (95% CI, 0.11-0.41) women in antibiotic group developed symptomatic VVC whereas none (95% CI, 0-0.12) of the women in the control group developed vaginal symptoms (relative risk, infinity; P = .02). Baseline Candida culture did not predict subsequent symptomatic VVC after antibiotics. CONCLUSION: In this pilot study, the use of short courses of oral antibiotics seems to increase prevalence of asymptomatic vaginal Candida colonization and incidence of symptomatic VVC. Larger cohort studies are needed to confirm these findings.

Primary care of overweight children: the importance of parent weight and attitudes about overweight: a MetroNet study.

PURPOSE: The purpose of this study was to identify the association of parents' weight and attitude about their child's weight with the child's body mass index (BMI) status. DESIGN: Cross-sectional, clinic-based study in a practice-based research network. METHODS: One hundred seventy-one parents or adults accompanying children aged 5 to 17 years to a primary care visit in 4 family medicine centers completed a questionnaire. Parent/adult overweight status and attitudes were compared with child overweight status. RESULTS: Forty-eight percent of children were overweight or obese (BMI >or= the 85th percentile) as were 56% of mothers and 77% of fathers (BMI >or= 25 kg/m(2)). Child and parent overweight were significantly associated, as were mother overweight and beliefs about child overweight status. Children aged 5 to 13 years were more likely to be overweight than those aged >or=14 years. CONCLUSIONS: Parents of overweight children are often overweight and many do not recognize that their children are overweight. Suggestions are made for primary care physicians to engage parents of overweight children in family weight control efforts.

Mammography screening among Arab American women in metropolitan Detroit.

Mammography screening behavior has not been well studied among Middle Eastern immigrant women. We conducted a telephone survey of 365 Arab American women residing in metropolitan Detroit, home to one of the largest populations of Middle Eastern immigrants in the US, to determine prevalence of factors associated with mammography, and attitudes and beliefs regarding mammography screening. Of 365 participants, only five were born in the US. Mean age was 53.2 years (SD 10.8). Two hundred twelve (58.1%) reported having mammogram every 1-2 years; 70% ever had mammogram. Age 50-64 years, having health insurance, married status, being in the US over 10 years, and being Lebanese were associated with mammography every 1-2 years. After adjusting for demographic factors, perceived seriousness of disease, general health motivation, and having fewer barriers were associated with more frequent screening. Appropriate mammography screening is decreased in this group. Targeted outreach regarding screening is appropriate for this population; however, lack of insurance may prevent adequate follow-up.

Racial similarities in response to standardized offer of influenza vaccination. A MetroNet study.

BACKGROUND: Despite known benefits of influenza vaccination and coverage by Medicare Part B, elderly minority patients are less likely to receive influenza vaccination than whites. OBJECTIVES: To test whether a nonphysician-initiated standardized offer of influenza vaccination to all elderly primary care patients would result in similar proportions of African-American and white patients accepting vaccine. DESIGN: In 7 metropolitan Detroit primary care practices during the 2003 influenza vaccination season, medical assistants assessed influenza immunization status of all patients 65 years and older and collected limited demographic data. Eligible patients were offered vaccination. MEASUREMENTS: Proportion of patients accepting influenza vaccination by race and predictors of vaccine acceptance. RESULTS: Four hundred and fifty-four eligible patients with complete racial information were enrolled: 40% African American, 52% white, 8% other race/ethnicity. Similar proportions of African Americans and whites had already received the 2003 vaccine (11.6% and 11.0%, respectively) or stated vaccination as the reason for visit (23.8% and 30.5%, respectively). Among the remainder, there also were similar proportions who accepted vaccination: 68.9% white and 62.1% African-American patients. History of previous vaccination was the only statistically significant predictor of vaccine acceptance (odds ratio [OR] 8.64, 95% confidence interval [CI] 4.17, 17.91, P<.001). After adjusting for history of previous vaccination, age, gender, and education, the odds of vaccine acceptance were no different for whites and African Americans (OR 1.20, 95% CI 0.63, 2.29, P=.57). CONCLUSIONS: Vaccination acceptance differed little between African-American and white elderly patients. Using nonphysician personnel to identify and offer influenza vaccine to eligible patients is easily accomplished in primary care offices and has the potential to eliminate racial disparities in influenza vaccination.

Exploring physician and staff perceptions of the learning environment in ambulatory residency clinics.

BACKGROUND AND OBJECTIVES: Investigations of teaching quality in ambulatory clinics have generally focused on faculty and medical student perspectives. We investigated the association of learning and organizational environment variables with faculty, resident, and nursing staff perceptions of quality of teaching and with a measure of resident learning in ambulatory residency clinics. METHODS: Annually over 5 years (1998-2002), we distributed learning and organizational environment surveys to faculty, residents, and staff in three ambulatory clinics of the Wayne State University Department of Family Medicine. We assessed internal reliability of the surveys' 11 scales and then compared responses of employee groups across sites. We then conducted a multiple regression analysis to determine the association of learning and organizational environment variables with faculty, resident, and staff perceptions of quality of teaching. We also compared the mean change in residents' In-training Examination (ITE) scores at our clinic teaching sites over the years of the study. RESULTS: Nine of 11 survey scales demonstrated acceptable internal reliability. Staff views were significantly lower than residents' views on all scales and were significantly lower than faculty's on all but one scale. Opinions about availability of learning opportunities for residents explained the most variance (35.2%) in the overall assessment of teaching quality. The addition of job satisfaction brought the explained variance up to 46.4%. The mean change in ITE scores was higher for residents at the site with higher learning and organizational environment assessment scores but not significantly so. CONCLUSIONS: Nine learning and organizational environment scales were found internally reliable and useful to measure faculty, resident, and staff perspectives on ambulatory teaching sites. Two areas of focus for improvement were found. First, learning opportunities should be structured so that residents are oriented to the ambulatory clinic, have their knowledge assessed regularly, are helped to meet individual goals, are given appropriate levels of responsibility, and see an adequate number, mix, and continuity of patients. Second, prioritizing efforts to improve job satisfaction for all employees is important because of the association between job satisfaction and employee perceptions of quality of teaching. We recommend that research into the educational climate in ambulatory clinics include perspectives of the full range of clinic personnel who can contribute to resident learning.

Synchronous distance learning as an effective and feasible method for delivering residency didactics.

BACKGROUND AND OBJECTIVES: Providing effective multisite didactic teaching in residency programs remains a challenge. There is limited evidence regarding the educational equivalency of the traditional and distance learning methods for delivery of didactics. We introduced a synchronous two-way audio and video Internet-transmitted distance learning methodology in two sites. The study assessed both residents' satisfaction and knowledge gain at the face-to-face lecture site as compared with the distance learning site. METHODS: The study was conducted over 1 year at the Wayne State University family medicine residency program, involving all 36 residents. Seventeen distance learning sessions were conducted, and the results from the lecture and distance learning sites were evaluated. RESULTS: The didactic sessions were rated highly by both groups, with no significant differences on the resident satisfaction survey. The distance learning method was received positively by learners. The residents in both groups scored higher on posttests compared to the pretests, and there was no statistical difference in knowledge gain between the lecture and the distance learning group. CONCLUSIONS: Synchronous interactive instructor-led distance learning is an effective method for delivering residency didactics at more than one site. The new technology is well accepted by learners and is a promising approach to multi-site education.

Correlation of same-visit HbA1c test with laboratory-based measurements: a MetroNet study.

BACKGROUND: Glycated hemoglobin (HbA1c) results vary by analytical method. Use of same-visit HbA1c testing methodology holds the promise of more efficient patient care, and improved diabetes management. Our objective was to test the feasibility of introducing a same-visit HbA1c methodology into busy family practice centers (FPC) and to calculate the correlation between the same-visit HbA1c test and the laboratory method that the clinical site was currently using for HbA1c testing. METHODS: Consecutive diabetic patients 18 years of age and older having blood samples drawn for routine laboratory analysis of HbA1c were asked to provide a capillary blood sample for same-visit testing with the BIO-RAD Micromat II. We compared the results of the same-visit test to three different laboratory methods (one FPC used two different laboratories). RESULTS: 147 paired samples were available for analysis (73 from one FPC; 74 from the other). The Pearson correlation of Micromat II and ion-exchange HPLC was 0.713 (p < 0.001). The Micromat II mean HbA1c was 6.91%, which was lower than the 7.23% from the ion-exchange HPLC analysis (p < 0.001). The correlation of Micromat II with boronate-affinity HPLC was 0.773 (p < 0.001); Micromat II mean HbA1c 6.44%, boronate-affinity HPLC mean 7.71% (p < 0.001). Correlation coefficient for Micromat II and immuno-turbidimetric analysis was 0.927 (p < 0.001); Micromat II mean HbA1c was 7.15% and mean HbA1c from the immuno-turbidimetric analysis was 7.99% (p = 0.002). Medical staff found the same-visit measurement difficult to perform due to the amount of dedicated time required for the test. CONCLUSION: For each of the laboratory methods, the correlation coefficient was lower than the 0.96 reported by the manufacturer. This might be due to variability introduced by the multiple users of the Micromat II machine. The mean HbA1c results were also consistently lower than those obtained from laboratory analysis. Additionally, the amount of dedicated time required to perform the assay may limit its usefulness in a busy clinical practice. Before introducing a same-visit HbA1c methodology, clinicians should compare the rapid results to their current method of analysis.

Patient-clinician agreement on signs and symptoms of 'strep throat': a MetroNet study.

BACKGROUND: Despite substantial use of the telephone in health care, only a few studies have formally evaluated the appropriateness of telephone-based management for acute medical problems. The accuracy of patients' report of signs and symptoms remains unknown. OBJECTIVE: We compared the agreement between patient self-assessment and clinician assessment on the typical signs and symptoms of group A beta-haemolytic Streptococcus (GABHS) to investigate the potential difficulties of using patient self-report to triage sore throat patients. METHODS: In this cross-sectional study, each of 200 adult pharyngitis patients was instructed to examine him/herself and to record the symptoms and physical findings. Two clinicians independently interviewed and examined each patient and recorded their findings. Each patient then had a rapid GABHS antigen test, the results of which were blinded to both clinicians and patients. Each patient self-assessment was compared with the findings of each clinician, and the agreement and disagreement between them computed. RESULTS: We found varying levels of agreement (kappa=-0.05 to 0.71) between patients and clinicians on sore throat history and physical assessments. Importantly, there was fair to substantial agreement (kappa=0.20-0.71) on the key signs and symptoms used in GABHS clinical prediction rules. As expected, history items had the highest agreement (kappa=0.52-0.71). Patients were more likely than clinicians to report rather than deny a specific physical sign. CONCLUSION: Adult sore throat patients may reliably report their symptoms, but may not be able to assess and report accurately on relevant physical signs of pharyngitis. Patients have a tendency to over-report physical signs. This study indicates the potential difficulties associated with telephone triage of sore throat patients, or other illnesses that require assessment of physical signs.

Pharyngitis clinical prediction rules: effect of interobserver agreement: a MetroNet study.

OBJECTIVE: Pharyngitis clinical prediction rules improve Group A beta-hemolytic streptococcus (GABHS) diagnosis and decrease unnecessary antibiotic use, yet few studies have addressed clinician variability in assessment of sore throat signs and symptoms. STUDY DESIGN AND SETTING: We conducted a cross-sectional study in which two clinicians examined each of 200 adult sore throat patients. Each patient had a rapid GABHS antigen test. Clinicians were blinded to each other's assessment and to the rapid antigen result. Interobserver agreement was estimated using a kappa coefficient. Effect of agreement on sensitivity, specificity, and hypothetic rapid antigen testing and antibiotic prescribing was determined for two clinical prediction rules. RESULTS: We found moderate inter-rater reliability on sore throat history and physical assessments. Clinician agreement was associated with significantly fewer hypothetic rapid antigen tests performed. CONCLUSION: Interobserver agreement enhances the utility of pharyngitis clinical prediction rules. Medical school and residency training should focus on correct assessment of history and physical examination components used in GABHS clinical prediction rules. Correct assessment will result in less GABHS testing and antibiotic prescriptions for sore throat patients.

Medical journals' conflicts of interest in the publication of book reviews.

The purpose of the study was to assess medical journals' conflicts of interest in the publication of book reviews. We examined book reviews published in 1999, 2000, and 2001 (N = 1,876) in five leading medical journals: Annals of Internal Medicine, British Medical Journal (BMJ), Journal of the American Medical Association (JAMA), Lancet, and New England Journal of Medicine. The main outcome measure was journal publication of reviews of books that had been published by the journal's own publisher, that had been edited or authored by a lead editor of the journal, or that posed another conflict of interest. We also surveyed the editors-in-chief of the five journals about their policies on these conflicts of interests. During the study period, four of the five journals published 30 book reviews presenting a conflict of interest: nineteen by the BMJ, five by the Annals, four by JAMA, and two by the Lancet. These reviews represent 5.8%, 2.7%, 0.7%, and 0.7%, respectively, of all book reviews published by the journals. These four journals, respectively, published reviews of 11.9%, 25.0%, 0.9%, and 1.0% of all medical books published by the journals' publishers. Only one of the 30 book reviews included a disclosure statement addressing the conflict of interest. None of the journals had a written policy pertaining to the conflicts of interest assessed in this study, although four reported having unwritten policies. We recommend that scientific journals and associations representing journal editors develop policies on conflicts of interest pertaining to book reviews.