Trends in patient encounters: implications for family medicine clerkships.

BACKGROUND AND OBJECTIVES: Adequate and equivalent clinical experience is related to the number and diagnoses of patients encountered and should provide students with experiences similar to community practice. This study compares the distribution of diagnoses family medicine clerkship students encountered at a Midwest medical school during 2009-2011 with both 1997-1999 data and the 2010 National Ambulatory Medical Care Survey (NAMCS) samples of family physicians and all physicians. METHODS: Electronically submitted encounter data (2009-2011) were compared to logbook data (1997-1999) and to the 2010 NAMCS data listing primary diagnoses at office visits in the United States by major disease category. RESULTS: Of the 15 diagnoses with ≥150 encounters, seven increased and eight decreased between the two time periods. The relative percent ratio of clerkship diagnoses distribution to the NAMCS family physician distribution revealed that diagnoses ratios were ≤100% in eight categories (clerkship experiences

A model for estimating the economic impact of secondhand smoke exposure: a study in Indiana.

OBJECTIVE: This study estimated the economic cost of health services and premature loss-of-life costs from secondhand smoke (SHS) exposure in Indiana. DESIGN AND SETTING: Costs of SHS-related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to SHS exposure both for adults and children. Estimated direct costs included hospital inpatient costs, loss-of-life costs, and ambulatory care costs where available, based on the most currently available Indiana hospital discharge data, vital statistics, census data, and nationally published research. PARTICIPANTS: Attributable risk values were applied to the number of deaths and hospital discharges in Indiana in 2008 and 2010, respectively, to estimate the number of individuals impacted by SHS exposure. All cost estimates were adjusted to 2010 US dollar values. RESULTS: The direct cost of health care and premature loss of life in Indiana attributed to SHS was estimated to be $1.3 billion in 2010--$237.8 million in health care costs and $879.0 million in premature loss of life for adults and $89.4 million in health care costs and $98.6 million in premature loss of life for children. The estimated population for Indiana in 2010 was 6 483 802 resulting in SHS-related costs of $201 per capita. DISCUSSION: This study demonstrated a model that could be used to estimate the costs of health care and premature mortality from exposure to SHS at a state or local level. These data may be used to support the education of the public, community leaders, and state policy makers regarding the magnitude of the problem and the compelling need to implement interventions to better protect the health of citizens and their economic prosperity.

Effect of personal characteristics on individual support for indoor smoke-free air laws, Indiana, 2008.

INTRODUCTION: Policy makers should understand the attitudes and beliefs of their constituents regarding smoke-free air legislation. The purpose of this study was to evaluate the effect of selected personal characteristics on attitudes and beliefs about secondhand smoke in Indiana and on support for smoke-free air laws. METHODS: Data were obtained from the 2008 Indiana Adult Tobacco Survey of 2,140 adults and included 11 sociodemographic variables. Chi-square and multiple logistic regression analyses were used to test for significant associations between sociodemographic characteristics and support for statewide or community smoke-free air legislation. RESULTS: Most respondents (72.3%) indicated that they supported laws making work places smoke-free. After adjusting for the effects of the other variables, 3 were found to be significant predictors of support: being a never or former smoker, being female, and being aware of the health hazards of secondhand smoke. Age, race/ethnicity, income, urban or rural county of residence, employment status, and having children in the household were not significant when adjusting for the other characteristics. CONCLUSION: Most Indiana residents support smoke-free air legislation for workplaces. The support was constant among most groups across the state, suggesting policy makers would have the backing of their constituents to pass such legislation. The results of this study suggest that efforts to gain support for smoke-free air laws should focus on men, people unaware of the health hazards from secondhand smoke, and smokers and former smokers.

Dietary behaviors associated with fruit and vegetable consumption, Marion County, Indiana, 2005.

INTRODUCTION: Eating inadequate amounts of fruits and vegetables is associated with diminished health, and most Americans fall short of the Centers for Disease Control and Prevention's recommendation to eat at least 2 servings of fruit and 3 servings of vegetables each day. This study assessed behaviors associated with fruit and vegetable consumption in adults. METHODS: A cross-sectional, random-digit-dialed telephone survey of 4,784 adults living in Marion County (Indianapolis), Indiana, measured demographic characteristics, personal health data, food consumption, food label use, and other eating habits. Multivariate logistic regressions were used to assess the association between selected dietary behaviors and fruit and vegetable consumption, controlling for demographic characteristics. RESULTS: Behaviors associated with adequate versus inadequate consumption of fruits and vegetables were frequent snacking on healthy foods (odds ratio [OR], 2.54), eating meals at home (OR, 2.09), using nutrition labels when making purchases (OR, 1.52), and using "heart healthy" symbols and other food information labels when ordering from restaurants (OR, 1.41). Frequent red meat consumption was negatively associated with adequate consumption of fruits and vegetables (OR, 0.64). CONCLUSION: Healthful snacking, food label use, and eating meals prepared at home may improve dietary quality. Our measure of adequacy may also be useful in future studies assessing dietary behavior and diet composition.

The effect of pregnancy intention on important maternal behaviors and satisfaction with care in a socially and economically at-risk population.

This study examined the association of pregnancy intention with maternal behaviors and the woman's perceived satisfaction with her prenatal and delivery care. Face-to-face interviews with 478 primarily Medicaid eligible women in Indianapolis, Indiana during their postpartum hospital stay were conducted to assess their degree of satisfaction with prenatal care and pregnancy intention, stratified into wanting to be pregnant now, later or never. Behaviors and characteristics influencing utilization of prenatal care were obtained from linked birth certificate data. A greater proportion of younger women (15-29) wanted to be pregnant later, a greater proportion of African-Americans never wanted to be pregnant, a greater proportion of divorced and never married women wanted to be pregnant later or never, and as parity increased the percentage of women never wanting to be pregnant increased. Multivariate analyses found that women never wanting to be pregnant were twice as likely to underutilize prenatal care, twice as likely to smoke while pregnant, half as likely to utilize WIC services and half as likely to recommend their providers to pregnant friends or relatives compared to women with a planned pregnancy, controlling for confounding variables. Finally, women wanting to be pregnant later were half as likely to rate their overall hospital care and prenatal care provider as high. Providers assessing their patients' pregnancy intention could better identify those women needing additional support services to adopt healthier behaviors and improve satisfaction with care. This study also demonstrated the value of more specific definitions of pregnancy intention.

Effects of personal characteristics on African-American women's beliefs about breast cancer.

PURPOSE: This study measured the effect of demographic and clinical characteristics on health and cultural beliefs related to mammography. DESIGN: Cross-sectional study. SETTING: Interviews were conducted during 2003 and 2004 in a Midwestern urban area. SUBJECTS: Subjects were 344 low-income African-American women 40 years and older who had not had mammography within the previous 18 months. MEASURES: The instrument measured personal characteristics, belief and knowledge scales, and participants' mammography experience and plans. ANALYSIS: Multiple regression analysis assessed the effect of specific demographic and clinical characteristics on each of the scale values and on subjects' stages of readiness to change. RESULTS: The subjects' levels of education significantly affected six of the 12 belief and knowledge scales. Higher-educated women felt less susceptible to breast cancer, had higher self-efficacy, had less fear, had lower fatalism scores, were less likely to be present-time oriented, and were more knowledgeable about breast cancer. Older women felt they were less susceptible to breast cancer, had higher fatalism scores, were more present-time oriented, and were less knowledgeable about breast cancer. CONCLUSIONS: The findings suggest that mammography promotion programs for African-Americans should consider the education levels and ages of the target women to be most effective.

Trends in adult attitudes toward secondhand smoke in Indiana, 2002-2007: the impact of smoking status.

PURPOSE: As more research has been distributed through the media about the negative health impact of exposure to secondhand smoke (SHS), the public's support for smoke-free policies has increased. The purpose of this study was to evaluate trends in knowledge and attitudes about SHS exposure among Indiana adults by smoking status. METHODS: Study data were from four cross-sectional studies previously conducted by the Indiana Tobacco Prevention and Cessation Agency using the Adult Tobacco Survey protocol between the years 2002 and 2007. RESULTS: Eighteen questions were identified as addressing SHS, 16 of which were available for more than 1 year and were evaluated for time trends. Significant overall trends toward increased awareness of SHS's health effects and support for smoking bans were noted in 10 of the 16 questions analyzed. No significant overall change, positive or negative, occurred in the remaining six questions. When responses were analyzed by smoking status, never smokers and former smokers consistently exhibited higher rates of anti-SHS sentiments and knowledge of SHS than did current smokers. CONCLUSIONS: In general, the trends are encouraging to public health efforts to raise awareness about SHS, but there remains much room for improvement, particularly among current smokers.

Measuring mammography and breast cancer beliefs in African American women.

Although intervention trials have demonstrated significant improvement in mammography adherence for African American women, many of the current measurement tools used in these interventions have not been assessed for validity and reliability in ethnic minorities. This study assessed the validity and reliability of Health Belief Model (HBM) variables that are often the target of mammography interventions. Scale validity and reliability was assessed for HBM scales in a sample of 344 low-income African American women. Validity was supported through exploratory factor analysis and theoretical prediction of relationships. Internal consistency reliability was .73 or above for all scales.

Comparison of three interventions to increase mammography screening in low income African American women.

BACKGROUND: Low-income African American women are more likely to die of breast cancer than their Caucasian counterparts, and at least part of the difference in mortality results from differential screening adherence. The purpose of this study was to identify more efficacious methods of promoting routine mammography screening in underserved populations. METHODS: A prospective randomized intervention study of 344 low income African American women compared the impact of three interventions on mammography adherence and stage of readiness: (1) pamphlet only; (2) culturally appropriate video; and (3) interactive computer-assisted instruction program. RESULTS: The interactive computer intervention program produced the greatest level of adherence to mammography (40.0%) compared to the video group (24.6%) and the pamphlet group (32.1%). When subjects in the pamphlet and video groups were combined to form a non-interactive group, this group had a significantly lower adherence than the group who received the interactive computer intervention (27.0% versus 40.0%). There was also significantly more forward movement in mammography stage of readiness among participants in the computer group (52.0%) compared to those in the pamphlet group (46.4%) or the video group (31.3%). When combining the non-interactive technology (pamphlet and video) there was also more forward movement in mammography stage of readiness for those in the interactive intervention group (52.0% moved 1 or 2 stages) compared to those in the non-interactive group (36.2%). CONCLUSIONS: These data indicate that tailored approaches are more effective than targeted messages either in print or video format. Another finding of this study is that interactive interventions are more effective than non-interactive interventions in increasing adherence and moving African American women forward in their mammogram stage of readiness.

Use of herbal remedies by Hispanic patients: do they inform their physician?

PURPOSE: This study measured the knowledge and use of herbs among Hispanics and assessed their experiences when discussing herb use with their physician. METHODS: Self-administered questionnaires were collected from 620 Hispanic patients seeking treatment in urban health centers. RESULTS: Most (80.3%) reported using herbs. Herb users were more comfortable speaking Spanish (91.9% vs 80.2%) and had been in the United States less than 5 years (47.0% vs 29.4%). More users considered herbs as drugs (60.5% vs 39.6%). Users were more aware that herbs could harm a baby if taken during pregnancy (56.4% vs 36.0%). The majority did not know the English name for 23 of the 25 herbs. A majority indicated their physician was unaware of their herb use. Few (17.4%) responded that their physicians asked about herb use. Only 41.6% thought their physician would understand their herb use, and 1.8% believed their physician would encourage continued use. There were no significant differences between herb users and nonusers in their perception of patient-physician communication levels. CONCLUSION: Primary care physicians need to be aware that most Hispanic patients are likely to use herbs. It is important to initiate and encourage discussion of their patient's interest in and use of these therapies.

Antitobacco media awareness of rural youth compared to suburban and urban youth in Indiana.

PURPOSE: This study examined the awareness and impact of antitobacco media messages among rural, suburban, and urban youth. METHOD: Self-administered questionnaires were received from 1,622, 1,059, and 1,177 middle school (sixth, seventh, and eighth grade) students in rural, suburban, and urban locations, respectively. Logistic regression compared media awareness and impact among the groups, controlling for grade, gender, race, and smoking behavior. RESULTS: Compared to rural youth, suburban youth were more likely to recall media messages about the dangerous health effects of tobacco use (odds ratio [OR] = 1.94) and have their personal choice to use tobacco affected by the messages (OR = 1.85). Suburban and urban youth more often recalled antitobacco messages (OR = 2.00 and 2.15), reported that the messages made them think about the dangers of tobacco use (OR = 2.02 and 1.47), believed that these ads prevent youth from initiating tobacco use (OR = 3.21 and 1.46) and stop youth from using tobacco (OR = 2.25 and 1.47), and recalled seeing specific campaign television ads (OR = 3.72 and 3.57). Urban youth were more likely to recall specific campaign messages on the radio (OR = 1.58). Neither suburban nor urban youth differed from the rural youth on whether the campaign-specific radio and television ads made them think about not using tobacco. CONCLUSIONS: The results support the need for targeting antitobacco media announcements to youth, based on their residence.

Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience.

BACKGROUND: State-legislated trauma systems have been enacted in an attempt to improve trauma care. Blunt splenic injury incidence without a legislated trauma system was examined for changes in care with a hypothesis that a voluntary system may perform equally with a legislated system. METHODS: Data from a statewide discharge database for the years 1993 to 2002 were examined. RESULTS: There were 276,425 trauma admissions overall, with blunt splenic injury occurring in 1.76%. Average Injury Severity Score (ISS) increased in trauma centers and decreased in the community. Trauma centers (TC) had more multisystem injuries. Splenic injury diagnosis increased 44% in TC between the early and late periods but only 7% in community facilities. Splenectomies increased 16% in TC but declined 16% in community hospital. Splenic salvage rate improved at both types of facilities. CONCLUSIONS: Splenic salvage rates improved over time in hospitals with no formal trauma system. Community hospitals cared for more than 50% of splenic injuries but transferred complex multisystem injuries, including splenic injuries, suggesting evolving care. Non-invasive imaging has increased the recognition of splenic injuries in both community hospitals and TC. Splenectomies are performed less, but have increased in TC with increasing ISS scores.

An incentive compensation system that rewards individual and corporate productivity.

INTRODUCTION: An economically mature health care market has led to increased cost competition. Subsequently, a perceived need for productivity-based physician compensation has developed. While some institutions have rewarded individual productivity based on specific facets of academic responsibility, such as teaching, research, and patient care, we chose to develop an incentive compensation system that rewards both individual and group productivity. PROGRAM DEVELOPMENT: We developed a physician incentive compensation system that rewards individual and group productivity by capturing multiple aspects of work activity. Faculty members are given compensation value points for clinical productivity, scholarship activities, teaching activities, service activities, and achievement of the department's goals. The system was implemented in a graduated fashion in the Department of Family Medicine at Indiana University beginning July 1, 2000. PROGRAM EVALUATION: In April 2003, all faculty physicians (n=18) participated in a survey about the compensation system. The majority of faculty view the system as a necessity for the department (72.2%); 35.2% were satisfied with the system overall; 35.3% were neutral; and 27.4% were dissatisfied or not sure of their overall satisfaction. CONCLUSIONS: A comprehensive physician incentive compensation system incorporating department goals can be designed and implemented in an academic setting.

Estimating the economic impact of secondhand smoke on the health of a community.

PURPOSE: This study provides a model to estimate the health-related costs of secondhand smoke exposure at a community level. MODEL DEVELOPMENT: Costs of secondhand smoke-related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to secondhand smoke exposure for adults and children. Estimated costs included ambulatory care costs, hospital inpatient costs, and loss of life costs based on vital statistics, hospital discharge data, and census data. APPLICATION OF THE MODEL: The model was used to estimate health-related costs estimates of secondhand smoke exposure for Marion County, Indiana. Attributable risk values were applied to the number of deaths and hospital discharges to determine the number of individuals impacted by secondhand smoke exposure. RESULTS: The overall cost of health care and premature loss of life attributed to secondhand smoke for the study county was estimated to be $53.9 million in 2000-$10.5 million in health care costs and $20.3 million in loss of life for children compared with $6.2 million in health care costs and $16.9 million in loss of life for adults. This amounted to $62.68 per capita. CONCLUSIONS: This method may be replicated in other counties to provide data needed to educate the public and community leaders about the health effects and costs of secondhand smoke exposure.

A cost-effectiveness comparison of three tailored interventions to increase mammography screening.

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, adherence to recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of three combinations of tailored telephone and mailed intervention strategies for increasing adherence to mammography. METHODS: There were 1044 participants who were randomly assigned to one of four groups. A logistic regression model with adherence as the dependent variable and group as the independent variable was used to test for significant differences, and a ratio of cost/improvement in mammogram adherence evaluated the cost-effectiveness. RESULTS: All three of the interventions (tailored telephone, tailored mail, and tailored telephone and mail) had significantly better adherence rates compared with the control group (usual care). However, when also considering costs, one emerged as the superior strategy. The cost-effectiveness ratios for the three interventions show that the tailored mail (letter) was the most cost-effective strategy, achieving 43.3% mammography adherence at a marginal cost of dollar 0.39 per 1% increase in women screened. The tailored mail plus telephone achieved greater adherence (49.4%), but at a higher cost (dollar 0.56 per 1% increase in women screened). CONCLUSIONS: A tailored mail reminder is an effective and economical intervention to increase mammography adherence. Future research should confirm this finding and address its applicability to practice in other settings.

Impact of the life skills training curriculum on middle school students tobacco use in Marion County, Indiana, 1997-2000.

Evaluation of school-based tobacco prevention and control programs have yielded mixed results. This study assessed the impact of the Life Skills Training curriculum on Marion County, Ind., middle school students' knowledge, attitudes, and ability to make good lifestyle decisions. From 1997 to 2000, students in grades six to eight in the study schools received the Life Skills Training curriculum. Survey data (n = 1,598) were used to compare tobacco use behavior, attitudes, and knowledge of those exposed with those not exposed to the program. Of the students surveyed, 12.5% were currently smoking. There were significantly fewer current smokers, and more students exposed to the program indicated they intended to stay smoke-free. Fewer of those participating in the program "hung out" with smokers and more said they could easily refuse a cigarette if offered one. Students completing the Life Skills Training curriculum were more knowledgeable about the health effects of smoking. Program effects were different for male and female students as well as for White and Black students.

The cost effectiveness of 5 interventions to increase mammography adherence in a managed care population.

OBJECTIVE: To determine the cost effectiveness of 5 combinations of strategies for increasing adherence to mammography recommendations in a population of women between the ages of 50 and 85 years enrolled in a large midwestern health maintenance organization. STUDY DESIGN: A randomized control trial comparing interventions believed to increase mammography adherence. PATIENTS AND METHODS: Intervention strategies included 5 combinations of physician recommendation, telephone, and in-person counseling. A total of 652 participants were randomly assigned to 1 of 6 intervention groups and 628 (95.9%) were available at 6-month follow-up. A logistic regression model with adherence as the dependent variable and group as the independent variable was used to test for significant differences between groups. A ratio of cost to improvement in mammogram adherence evaluated the cost effectiveness at 6 months. RESULTS: All 5 interventions resulted in significantly higher rates of adherence compared to no intervention. However, when considering costs, only 1 emerged as the superior strategy for the overall study population. In-person counseling was the most cost-effective strategy overall, followed closely by in-person counseling and physician's letter intervention. For women contemplating mammography, the telephone contact and physician's letter combination was the most cost-effective intervention. For women not contemplating mammography, the physician's letter was superior. The physician's letter worked best with women who had previous mammograms. For women with no mammogram history, the in-person counseling and physician's letter combination was clearly superior. CONCLUSIONS: The cost effectiveness of mammography screening interventions varies based on women's prior history of mammograms and their future intent. Further, managed care organization member characteristics can be used to determine the most cost-effective mammography screening intervention based on individual readiness.

Preparticipation Screening of Athletic Officials: SEC Football Referees at Risk.

UNLABELLED: Although preparticipation screening for athletes is commonplace, few studies have addressed the issue for those officiating at games. OBJECTIVES: To review current data on physiologic stress on sports officials, to obtain prevalence data on health parameters for football officials, and to determine the outcomes when screening criteria are applied in preseason exams. METHODS: A protocol was established using health history questionnaires and physical exams with laboratory screening to assess the health of all football officials working in the Southeastern Conference (SEC) from 1997 to 2000. The main outcome measure was the prevalence of cardiac risk factors as determined by American College of Sports Medicine guidelines. RESULTS: Initial screening of 102 football officials revealed that 10.1% of SEC referees had elevated systolic blood pressure, 13.9% had elevated diastolic blood pressure, and 3.8% had resting tachycardia. Average body mass index (BMI) was 28.6 kg/m2, with 87.3% having a BMI that exceeded 25 (overweight). About one-third (31.6%) had a BMI greater than 30 (obese). Total fasting cholesterol exceeded 200 mg/dL in 44.2%, HDL levels were below 35 mg/dL in 34.3%, and LDL levels were above 120 mg/dL in 62.3%. Compared with age-adjusted national data, there were more overweight and more obese officials, but they had lower systolic and diastolic blood pressures and lower mean total cholesterol levels. Using the Framingham Study prediction model to estimate coronary heart disease (CHD) risk, analysis revealed that referees had a lower risk than the national 10-year CHD risk but a higher risk compared with that of the low-risk population. CONCLUSIONS: These data reveal a greater need for graded exercise testing. The higher rates of obesity among officials will promote further screening for CHD risk factors.

If electronic medical records are so great, why aren't family physicians using them?

OBJECTIVE: The chasm theory of marketing states that fundamental differences exist between early adopters of technology and the mainstream marketplace, making it difficult for technology to transition to the mainstream market. We investigated possible differences in attitudes and beliefs about electronic medical records (EMRs) between current EMR users (early market) and nonusers (mainstream market). STUDY DESIGN: Cross-sectional mail survey. POPULATION: Active members in the Indiana Academy of Family Physicians 2000-2001 membership database (N = 1328). OUTCOMES MEASURED: Differences in attitudes, beliefs, and demographic characteristics of EMR users and nonusers. RESULTS: The overall return rate was 51.7%; 14.4% of respondents currently use an EMR. Electronic medical record users were more likely to practice in urban areas or to be hospital-based and reported seeing fewer patients. Nonusers were less likely to believe that (1) physicians should computerize their medical records; (2) current EMRs are a useful tool for physicians; (3) EMRs improve quality of medical records and decrease errors; and (4) it is easy to enter data into current EMRs. Nonusers were more likely to believe that paper records are more secure and more confidential than EMRs. Both users and nonusers believed that current EMRs are too expensive. CONCLUSIONS: A chasm exists between EMR users and nonusers regarding issues that affect EMR implementation, including necessity, usefulness, data entry, cost, security and confidentiality. To reach full implementation of EMRs in family medicine, organizations should use these data to target their research, education, and marketing efforts.

Medical students' experience with musculoskeletal diagnoses in a family medicine clerkship.

Many US medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses the students experience. This study examines patients encountered with musculoskeletal diagnoses using quantitative data collected by family practice clerkship students. Over a two-year period, 445 students completed 7,202 patient encounter forms for patients with a musculoskeletal diagnosis, noting their confidence level and responsibilities. Of the 78,854 diagnoses presented, 7,850 were for musculoskeletal conditions. Students reported a lower level of confidence in diagnosing and treating musculoskeletal patients when compared with their confidence level in dealing with non-musculoskeletal patients. They are generally more actively involved with musculoskeletal patients by observing, seeing the patient before the preceptor, taking a history, suggesting treatment and discussing the case with the preceptor. At the study school, this fact may reflect that formal curricular teaching in orthopedics occurs in the fourth year, after students have completed their family medicine clerkship. It is concluded that by using a relatively simple computerized database, areas of need for curricular change can be identified. Our study verifies that additional training is needed in the area of musculoskeletal diagnoses.