Attitudes and behavioral intentions regarding managed care: a comparison of academic and community physicians.
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Physicians' attitudes toward managed care and the impact of these attitudes on behaviors that affect patient care are important factors in managed care reform. In addition, the attitudes of academic physicians may influence their willingness to reform medical education in an effort to prepare students to practice under managed care. Although it is a conventional opinion that the academic health center and its academic physicians are antagonistic toward managed care, there has not been a direct comparison of the attitudes of these physicians to those of practicing community physicians. We used a self-administered questionnaire to assess attitudes toward managed care and behavioral intentions regarding practices related to managed care; a sample of academic physicians (n = 129) was compared with a sample of community physicians (n = 307). Community physicians were less negative in their evaluations of the quality of care in a managed care environment, but no differences were identified between the two groups with regard to the cost-effectiveness, inevitability, or need to adapt to managed care. Academic specialists were more likely than academic primary care physicians to rate managed care as something to which they needed to adapt. Community physicians were less likely to report a willingness to change their referral patterns. Aggregating across practice type, we also uncovered systematic differences between primary care and specialist physicians. The data suggest that opinions about quality and cost-containment in managed care are significant correlates of intentions to change practice behaviors. (+info)
Resolution and resurgence of schistosoma haematobium-induced pathology after community-based chemotherapy in ghana, as detected by ultrasound.
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Community-based treatment is recommended for endemic populations with urinary schistosomiasis; however, the optimal target group for treatment and retreatment interval have not been established. Using ultrasound, this study identified subpopulations whose lesions were most likely to respond to treatment and characterized resurgence of pathology. Ultrasound examination of 1202 infected patients was followed by chemotherapy with praziquantel. A sample of 698 patients was followed for 18 months after treatment. Nearly all types of bladder pathologies resolved after treatment, regardless of patient's age or intensity of initial infection. However, many patients' upper urinary tract pathologies (62.5%) did not resolve. During the 18-month follow-up period, reappearance of severe bladder pathologies was rare, and <10% of persons had resurgence of mild bladder pathologies. For this population, retreatment is not needed annually but might be cost effective if given several years later. Confirmation from other areas is required before general policies can be formed. (+info)
A pilot study of community-based training of hospital obstetric senior house officers.
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Most senior house officer (SHOs) posts have little relevance to general practice. This problem was addressed in a pilot community teaching placement, of up to one session per week over four to six months that was set up to learn community-based obstetrics from primary health care teams. The nine participating SHOs were interviewed; qualitative analysis revealed seven themes that were important to the SHOs that should help guide further community-based teaching. Such sessional release for improving the practice-based component of vocational training merits evaluation in a larger study. (+info)
A randomized, community-based trial of the effects of improved, centrally processed complementary foods on growth and micronutrient status of Ghanaian infants from 6 to 12 mo of age.
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BACKGROUND: Koko, a fermented maize porridge used as the primary complementary food in Ghana, has been implicated in the high prevalence of child malnutrition. Weanimix, a cereal-legume blend developed by the United Nations Children's Fund and the Ghanaian government, has been promoted as an alternative. OBJECTIVE: We evaluated the effect of feeding Weanimix and 3 other locally formulated, centrally processed complementary foods on the nutritional status of 208 breast-fed infants. DESIGN: Infants were randomly assigned to receive 1 of 4 foods from 6 to 12 mo of age: Weanimix (W), Weanimix plus vitamins and minerals (WM), Weanimix plus fish powder (WF), and koko plus fish powder (KF). Dietary and anthropometric data were collected regularly. Blood was collected at 6 and 12 mo of age to assess iron, zinc, vitamin A, and riboflavin status. Before and after the intervention, cross-sectional data on the anthropometric status of infants not included in the intervention (NI; n = 464) were collected. RESULTS: There were no significant differences between intervention groups in weight or length gain or in hemoglobin, hematocrit, transferrin saturation, plasma zinc, or erythrocyte riboflavin values between 6 and 12 mo of age. From 9 to 12 mo of age, z scores were lower in NI infants than in the combined intervention groups [at 12 mo: -1.71 +/- 0.90 compared with -1.19 +/- 0.93 for weight and -1.27 +/- 1.02 compared with -0.63 +/- 0.84 for length (P < 0.001 for both), respectively]. The percentage of infants with low ferritin values increased significantly between 6 and 12 mo of age in groups W, WF, and KF but not in group WM. Change in plasma retinol between 6 and 12 mo of age was significantly greater in group WM than in the other 3 groups combined (0.14 +/- 0.3 compared with -0.04 +/- 0.3 micromol/L, P = 0. 003). CONCLUSIONS: All 4 foods improved growth relative to the NI group. Infants fed WM had better iron stores and vitamin A status than those fed nonfortified foods. (+info)
Community nephrology: audit of screening for renal insufficiency in a high risk population.
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BACKGROUND: The rate of acceptance onto dialysis programmes has doubled in the past 10 years and is steadily increasing. Early detection and treatment of renal failure slows the rate of progression. Is it feasible to screen for patients who are at increased risk of developing renal failure? We have audited primary care records of patients aged 50-75 years who have either hypertension or diabetes, and are therefore considered to be at high risk of developing renal insufficiency. Our aim was to see whether patients had had their blood pressure measured and urine tested for protein within 12 months, and plasma creatinine measured within 24 months. METHODS: This was a retrospective study of case notes and computer records in 12 general practices from inner and greater London. A total of 16,855 patients were aged 50-75 years. From this age group, 2693 (15.5%) patients were identified as being either hypertensive or diabetic, or both. RESULTS: Of the 2561 records audited, 1359 (53.1%) contained a plasma creatinine measured within 24 months, and 11% of these (150) had a value > 125 micromol/l. This equates to a prevalence of renal insufficiency of > 110,000 patients per million in this group. Forty two patients (28%) had been referred to a nephrologist. Of records audited, 73% contained a blood pressure measurement and 29% contained a test for proteinuria within 12 months. CONCLUSIONS: There is a high prevalence of chronic renal insufficiency in hypertensive and diabetic patients. It is feasible to detect renal insufficiency at a primary care level, but an effective system will require computerized databases that code for age, ethnicity, measurement of blood pressure and renal function, as well as diagnoses. (+info)
Measuring community-oriented attitudes towards medical practice.
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BACKGROUND: The measurement of attitude and attitudinal changes regarding community-oriented primary care (COPC) and the community-oriented principles of family medicine from the College of Family Physicians of Canada was a key component of this study involving family medicine residents. The Department of Family and Community Medicine at the Toronto Hospital initiated a new COPC curriculum in July 1997 for its first-year residents which was designed to teach the principles of family medicine which are community oriented. OBJECTIVE: This study was developed to provide an analysis and summary of the attitude and attitudinal changes of residents exposed to the programme and those of two cohort groups who were not exposed. METHODS: A quasi-experimental design was used. A 20-item questionnaire was administered pre- and post-intervention. Qualitative data were also collected from focus group sessions with the residents exposed to the programme. RESULTS: The questionnaire was found to have good reliability, with an alpha coefficient of 0.8. No significant differences were observed between the study and control groups pre- and post-intervention. Within the study group, two items from the questionnaire yielded significant differences (P < 0.05). These items dealt with lack of funding and impracticality issues of applying COPC in medical practice. They were also the prevalent themes generated from the focus group session analysis. CONCLUSIONS: The qualitative data corroborated the findings of the survey. These findings have helped in the evolution of the curriculum. Longitudinal studies to measure attitudes and the practice of COPC and community-oriented principles of family medicine after residency are recommended. (+info)
Frequency doubling perimetry and the detection of eye disease in the community.
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PURPOSE: Frequency Doubling Technology (FDT) perimetry is a novel perimetric test that provides rapid screening (45 to 60 seconds) and full-threshold (4 to 5 minutes) testing for detection of vision loss. The purpose of this study was to determine the specificity and sensitivity of FDT perimetry for the detection of ocular disease. METHODS: A total of 130 participants (257 eyes of 42 men and 88 women) recruited from the community completed FDT perimetry, standard achromatic automated perimetry (SAP), anterior segment biomicroscopy, tonometry, and dilated ophthalmoscopy. FDT results were considered abnormal if 1 point was abnormal (depressed below the 5% level on the screening protocol C-20-5). SAP was considered abnormal if the glaucoma hemifield test or pattern standard deviation was outside normal limits (P < .05) or a hemifield cluster of 3 depressed points on the pattern deviation probability plot (P < .05) was present. An abnormal eye examination was defined as the presence of an abnormality in the anterior segment, lens, or posterior segment that was likely to cause a visual field defect or the presence of glaucomatous or other optic neuropathy. RESULTS: The mean age (+/- SD) of participants was 55.5 years (+/- 10.3). Ethnic groups, as reported by participants, included 77 (59%) African Americans, 40 (31%) Caucasians, and 13 (10%) in other groups. On clinical examination, 116 eyes (45%) were normal, 9 eyes (3.5%) had a cataract with best corrected visual acuity worse than 20/30, 16 eyes (6%) had open-angle glaucoma, and 17 eyes (7%) had retinal findings or lesions that were likely to cause a visual field defect. For FDT perimetry, 22 (8.6%) of 257 tests were unreliable, and for SAP, 65 (25.3%) of 257 tests were unreliable. The sensitivity and specificity of FDT perimetry for detecting an abnormal clinical examination were 55% and 90% and for detecting an abnormal examination that included an abnormal SAP, 64% and 86%. CONCLUSIONS: FDP demonstrated reasonable discriminatory power for detecting eye disease. (+info)
Antimicrobial resistance: a plan of action for community practice.
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Antibiotic resistance was once confined primarily to hospitals but is becoming increasingly prevalent in family practice settings, making daily therapeutic decisions more challenging. Recent reports of pediatric deaths and illnesses in communities in the United States have raised concerns about the implications and future of antibiotic resistance. Because 20 percent to 50 percent of antibiotic prescriptions in community settings are believed to be unnecessary, primary care physicians must adjust their prescribing behaviors to ensure that the crisis does not worsen. Clinicians should not accommodate patient demands for unnecessary antibiotics and should take steps to educate patients about the prudent use of these drugs. Prescriptions for targeted-spectrum antibiotics, when appropriate, can help preserve the normal susceptible flora. Antimicrobials intended for the treatment of bacterial infections should not be used to manage viral illnesses. Local resistance trends may be used to guide prescribing decisions. (+info)