Referrals by general internists and internal medicine trainees in an academic medicine practice.
(41/8459)
Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed. (+info)
Healthcare utilization among women with eating disordered behavior.
(42/8459)
This study was designed to explore relationship between self-reported eating disordered behavior (without formally established eating disorder diagnoses) and healthcare utilization among women in a primary care setting. Through a self-report questionnaire, 150 participants between the ages of 17 and 49 were asked if they had ever vomited, starved themselves, or abused laxatives in a manner that was intentional and self-harming (i.e., eating disordered behavior identified as pathologic by the participant). Participants who reported a history of disordered eating (n = 17) exhibited higher scores on two of five measures of healthcare utilization (mean number of telephone contacts and mean number of specialist referrals) compared with participants without eating disorders (n = 133). These data suggest that eating disordered behavior may be a predictor of increased healthcare utilization among women in primary care settings. (+info)
Effect of home blood glucose monitoring on the management of patients with non-insulin dependent diabetes mellitus in the primary care setting.
(43/8459)
The purpose of the study was to determine whether blood glucose monitoring strips influence the management of patients with non-insulin dependent diabetes (NIDDM) in the primary care setting. The medical records of 115 patients with NIDDM taking a sulfonylurea drug (oral hypoglycemic agent) during the review period were randomly selected for review. Patients were divided into two groups: those who did not receive a prescription for blood glucose monitoring strips during 1995 and 1996 and those who did for the same 2 years. The main outcome measures were hemoglobin A1c, blood sugar, number of laboratory tests ordered, and number and type of treatment interventions. No statistically significant differences between groups were noted for any measured parameter. Glucose control was independent of number of strips dispensed. Home glucose monitoring strips did not affect the management of patients with NIDDM taking a sulfonylurea agent in the primary care setting. (+info)
The neonatologist as primary care physician.
(44/8459)
Although trained first as pediatricians, neonatologists are not typically viewed as primary care physicians. However, given their particular training and expertise, patient population, and interaction with families as the newborn's first physician in many settings, neonatologists may rightly be viewed as the most appropriate primary care physician for newborns with medical or surgical problems. We review the fundamental underpinnings of primary care medicine with particular attention to how the neonatologist functions in such capacities. Neonatologist can contribute greatly to ensuring continuity of care for the sick newborn, the comprehensive nature of that care, and the coordination of care. Neonatologists' interactions with elements of the community to which the newborn will be discharged are an asset, as is their ability to work as part of a team. Given recent changes in practice management, the availability of neonatologists in the United States, and the desire for full-service mother and infant care capabilities in community hospitals, the primary care role of neonatologists bears recognition and support in today's changing healthcare marketplace. (+info)
Evaluation of "solitary" thyroid nodules in a community practice: a managed care approach.
(45/8459)
Evaluation of thyroid nodules remains a challenge for primary care physicians. To include or exclude the presence of malignancy in a thyroid nodule, radioisotope scan, ultrasound, and fine-needle aspiration biopsy of the thyroid generally are used. The objectives of this study were to determine the utility and cost effectiveness of fine-needle aspiration biopsy of solitary thyroid nodules in a community setting; to compare the cost of fine-needle aspiration biopsy with that of radioisotope scan and ultrasound; and to determine whether the practice of obtaining radioisotope scans and ultrasound has changed in the 1990s compared with the 1980s. Patients were referred by community physicians to university-based endocrinologists for evaluation of thyroid nodules. Many of the patients had previously undergone radioisotope scans and ultrasound scans at the discretion of their primary care physicians. All patients underwent fine-needle aspiration biopsy. The biopsy results were evaluated prospectively, and the practice of community physicians' obtaining radioisotope scans and ultrasound scans was compared for the 1980s and 1990s. Eighty-three patients underwent 104 biopsies. In 20 biopsies the specimens were inadequate; the others showed 70 benign, 9 suspicious, and 4 malignant lesions. All four patients with biopsy findings read as malignant were found to have malignant growth at surgical procedures. Two benign biopsy findings were false-negative results. Malignant growth was correctly diagnosed later for one patient at a second biopsy and for the other because of growth of the nodule. The cost of 104 biopsies was $20,800. The cost of radioisotope scans was $22,400, and the cost of ultrasound scans was $10,640. The frequency of obtaining radioisotope scans (84.5% vs 77%) and ultrasound scans (65% vs 45%) was slightly higher in the 1990s compared with the 1980s. Fine-needle aspiration biopsy is a safe and cost effective initial evaluation modality for smaller community-based centers, as it is at large tertiary centers. The cost incurred ($33,040) in obtaining the radioisotope scans and ultrasound scans could have been saved if fine-needle aspiration biopsy had been used as the initial diagnostic procedure for evaluation of these nodules. Although radioisotope scan and ultrasound scan are of little diagnostic help in the evaluation of thyroid nodules, they continued to be obtained at a high frequency during the last decade. (+info)
Assessing local health needs in primary care: understanding and experience in three English districts.
(46/8459)
BACKGROUND: Assessing the health needs of a local population has been promoted as a key component in effective targeting of healthcare services and quality improvement. The understanding and experience of assessing health needs in general practice were investigated in three English districts. AIM: To identify the issues surrounding the potential for assessing health needs in primary care. METHOD: Postal survey of 347 general practices in three health authorities. Telephone interviews with a random stratified sample of 35 general practitioners. RESULTS: Although most practices identified assessing health needs as important, it is clear that this identification was typically based on an understanding of assessing needs as primarily focused on individual patient care, based on clinical priorities and involving practice held data. Most practices had not undertaken local consultation, whatever their understanding of assessing health needs. The few practices which had completed population oriented, proactive assessment of needs considered it to have led to tangible improvements in clinical or practice management. Overall, there was apparent confusion over the nature and purpose of assessing needs, although the principled aims and objectives of a population oriented, proactive component to primary care were generally upheld. The need for additional resources and support was identified. In four out of the five cases where specifically population based assessment of health needs had been undertaken, the local public health department had been involved. CONCLUSION: The value of the concept of assessing health needs in primary care holds considerable uncertainty and ambivalence. The findings from this study show that any attempts to promote assessing needs into primary care which focus either primarily or exclusively on the provision of "education" are unduly simplistic. More fundamental questions about the perceived relevance and opportunities for assessing health needs should be considered if primary care groups are to meet future commissioning challenges. (+info)
Indicators of the appropriateness of long-term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability.
(47/8459)
OBJECTIVES: To develop valid, reliable indicators of the appropriateness of long-term prescribing in general practice medical records in the United Kingdom. DESIGN: A nominal group was used to identify potential indicators of appropriateness of prescribing. Their face and content validity were subsequently assessed in a two round Delphi exercise. Feasibility and reliability between raters were evaluated for the indicators for which consensus was reached and were suitable for application. PARTICIPANTS: The nominal group comprised a disciplinary mix of nine opinion leaders and prominent academics in the field of prescribing. The Delphi panel was composed of 100 general practitioners and 100 community pharmacists. RESULTS: The nominal group resulted in 20 items which were refined to produce 34 statements for the Delphi exercise. Consensus was reached on 30, from which 13 indicators suitable for application were produced. These were applied by two independent raters to the records of 49 purposively sampled patients in one general practice. Nine indicators showed acceptable reliability between raters. CONCLUSIONS: 9 indicators of prescribing appropriateness were produced suitable for application to the medical record of any patient on long term medication in United Kingdom general practice. Although the use of the medical record has limitations, this is currently the only available method to assess a patient's drug regimen in its entirety. (+info)
Mental disorders in the primary care sector: a potential role for managed care.
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This activity is designed for leaders and managers of managed care organizations and for primary care physicians involved in evaluating, treating, and caring for patients with mental disorders. GOAL: To provide a better understanding of primary care patients' needs for mental health services and how managed care companies might best address these needs. OBJECTIVES: 1. Describe problems in detection of mental disorders 2. Discuss the specific ways in which treatments can be improved for mental disorders under managed care systems. (+info)