Biomedical subjects

D S Main

Publications and source records attributed to D S Main.

16 recordsLinked to original sources

PubMed1996

Toward optimal laboratory use. Problems in laboratory testing in primary care.

OBJECTIVE: To examine the frequency and characteristics of problems in laboratory testing in primary care physicians's offices and their impact on health care. DESIGN: Prospective descriptive study in which participating office-based primary care clinicians reported each occurrence of any laboratory incident during a 6-month study. Each identified problem was reported on a structured data collection instrument with an open-ended description of the problem. SETTING: Primary care physicians' offices in North America. PARTICIPANTS: One hundred twenty-four primary care clinicians in 49 practices of the Ambulatory Sentinel Practice Network (ASPN). MAIN RESULTS: A total of 180 problems were reported, yielding a crude rate of 1.1 problems per 1000 patient visits. Problems involving test ordering and specimen handling were the most common (56%), while those attributable to the test analysis itself accounted for 13% of the total. In the judgment of the practice staff, 27% of the reported problems had an impact on patient care. Of the 24 cases for which the specific impact was known and reported, half of the impacts were minor and about half were significant, as judged by whether or not the diagnosis and/or treatment of the patient was measurably affected. CONCLUSIONS: Clinically apparent problems with laboratory testing in primary care were found at a rate of 1.1 problems per 1000 patient visits. Of the laboratory problems that occurred in this study, 27% were judged by the physician to have an effect on patient care.

Clinical Laboratory Techniques↗

PubMed1995

Human immunodeficiency virus seroprevalence in community-based primary care practices, 1990-1992. A report from the Ambulatory Sentinel Practice Network.

OBJECTIVE: To estimate the seroprevalence of human immunodeficiency virus type 1 (HIV-1) infection in primary care practices. METHODS: Fifty-four practices in the United States participated in an anonymous, unlinked HIV seroprevalence study between January 1990 and December 1992. Residual blood samples drawn for routine clinical tests from patients 15 to 49 years of age were centrally tested for the HIV-1 antibody for 1 month of each quarter. Information about patient demographics, clinician-recognized risk factors, the known HIV status of the patient, and whether the blood was drawn for HIV testing was recorded with each specimen. RESULTS: Of 21,998 specimens collected, 99 (0.45%) were seropositive. Of these 99 seropositive persons, 31.3% (a seroprevalence of 0.15%) were not suspected by their clinicians of being infected with HIV. Seroprevalences in men (0.96%) exceeded those in women (0.22%), and rates in rural practices (0.18%) were lower than in urban practices (0.71%). Among patients with unsuspected HIV infection, however, the gender differences, especially in rural areas, were less pronounced. Risk factors for HIV infection were infrequently noted. There was an increase in the overall seroprevalence during the 1990 to 1992 study period (0.36% to 0.53%); however, this trend was not statistically significant. CONCLUSIONS: Within a 3-year period, clinicians in at least two of five primary care practices can expect to encounter patients infected with HIV, regardless of practice location. Also, nearly one third of the patients with HIV infection will not be suspected of having this condition by their clinician.

Adolescent↗

PubMed1994

Preventing HIV infection among adolescents: evaluation of a school-based education program.

BACKGROUND: This article reports the results of the impact of a school-based HIV prevention intervention on students' knowledge, attitudes, and behavior related to HIV infection. METHODS: Seventeen schools within six Colorado school districts were assigned to either intervention or comparison conditions. Students in 10 schools received a 15-session, skills-based HIV prevention curriculum implemented by trained teachers. A total of 2,844 students completed at least one survey during the study period; surveys were matched using demographic questions, yielding a cohort of 979 students who had baseline and 6-month follow-up data. RESULTS: Intervention students exhibited greater knowledge about HIV and greater intent to engage in safer sexual practices than the comparison students. Among sexually active students at the 6-month follow-up, intervention students reported fewer sexual partners within the past 2 months, greater frequency of using condoms, and greater intentions to engage in sex less frequently and to use a condom when having sex. Intervention students were also more likely to believe that teens their age who engage in HIV risk behaviors are vulnerable to infection. The intervention neither delayed the onset nor decreased the frequency of sexual intercourse and the frequency of alcohol and other drug use before sex by the 6-month follow-up assessment. CONCLUSIONS: The results suggest that skills-based risk reduction programs can have an effect on student behavior. Among sexually active students, evidence suggests that school-based interventions can reduce behavior associated with risk of HIV infection.

Adolescent↗

PubMed1993

The role of primary care clinician attitudes, beliefs, and training in the diagnosis and treatment of depression. A report from the Ambulatory Sentinel Practice Network Inc.

OBJECTIVE: To examine the relation between primary care clinicians' attitudes, beliefs, and training and their perceptions of the importance and frequency of depression. DESIGN: A 56-item questionnaire was mailed to 226 clinicians in the Ambulatory Sentinel Practice Network Inc (ASPN), a primary care research network. SETTING: The ASPN, consisting of 69 primary care practices in the United States and Canada, cares for approximately 350,000 patients. MAIN OUTCOME MEASURE: The degree to which clinician training in depression and clinician attitudes and beliefs about treating depression predict their perceptions of the importance of depression in their primary care practices. RESULTS: Results of path analysis indicate that clinician training in depression, beliefs about the burden and discomfort associated with diagnosing and treating depression, perceptions of their patients' discomfort, and self-efficacy in diagnosing and treating depression are all significantly related to clinician perceptions of whether depression was an important and frequent primary care problem. Further analysis indicates that actual prevalence of depression accounted for little variability in clinicians' beliefs and attitudes about depression. CONCLUSIONS: What clinicians think their patients feel about issues on depression and how they view their own abilities may profoundly influence the degree to which they recognize depression in primary care. Understanding these factors may help explain and subsequently decrease clinician variability in the recognition of depression in primary care.

Attitude of Health Personnel↗

PubMed1993

Frequency of exercise and dropouts in a work-site program. Correlates of 6-month activity patterns.

Exercise professionals have little information concerning expected levels of exercise for new participants. This study examined the frequency of exercise of 949 employees during their first 6 months of membership in a work-site health promotion facility, using automated check-in data. Overall, the frequency of exercise declined, the proportion of frequent exercisers declined, and the proportion of employees who dropped out increased. Men exercised more frequently and were less likely to drop out than were women (P < .01). Younger employees exercised more frequently than did older employees. Employees in the middle salary level exercised more frequently than did employees in the lower or upper levels (P < .01). The employee groups that started out with a lower frequency of exercise remained at a lower frequency throughout the 6 months. By their 6th month, women were 50% more likely to drop out and 50% less likely to exercise regularly than were men. These figures provide a basis for comparison with other programs to document expected exercise behavior.

Adult↗

PubMed1993

Factors influencing mammogram ordering at the time of the office visit.

BACKGROUND: Breast cancer is the second most common cause of cancer death in women, with mammographic screening the only modality shown to decrease the death rate. However, only 17% to 41% of women have ever been screened, and multiple barriers to screening have been identified. This study examined physician and patient factors at a single encounter to explore components influencing mammography ordering. METHODS: Ten family physicians in a primary care research network completed daily data cards on encounters with women presenting for annual examinations, chronic problems, or breast-related complaints. Information collected included patient age, personal or family history of breast cancer, physician's perception of expected compliance, previous mammogram results, breast examination, physician's perception of need for a mammogram, whether the mammogram was ordered, and the patient's method of payment for the test. RESULTS: Eight hundred thirty-nine patients were entered into the study, and 277 mammograms were ordered. Mammograms were ordered for a greater percentage of patients with insurance (36%) than for those without insurance (26%) (P < .001). A multivariate analysis indicated that several factors helped to correctly classify 90% of mammogram ordering: the patient was making a first visit, a breast-related visit, or a visit for an annual examination; the patient had had a previous mammogram; had a breast examination at the current visit or within the past year; and the physician believed the patient would comply and believed that a mammogram was indicated. CONCLUSIONS: Factors unique to a physician-patient visit influence the physician with regard to ordering a mammogram, including the type of visit, whether the physician believes a mammogram is indicated, and the cost.

Adult↗

PubMed1992

Patients presenting to family physicians after a fall: a report from the Ambulatory Sentinel Practice Network.

BACKGROUND: Patients who fall present a diagnostic challenge to family physicians. The diagnostic workup of these patients must be thorough enough to detect and treat important causes of the fall yet not subject patients to unnecessary tests. Previous studies have provided only limited guidance for primary care physicians because in general they occurred in settings other than primary care and focused on a single age group. METHODS: The Ambulatory Sentinel Practice Network (ASPN) conducted a 6-month study of primary care patients of all ages presenting after a fall, or with medical problems resulting from a fall. ASPN clinicians collected information about the history, physical examination findings, and follow-up of these patients. Causes of falls were grouped into three categories: external reasons for falling, internal reasons related to gait, and internal reasons unrelated to gait. RESULTS: Participating clinicians identified 431 patients who had falls out of the 256,680 seen for any reason during the study period. The patients ranged in age from 1 to 94 years. The rate of falls for patients increased rapidly after age 65 years. Most falls occurred for reasons external to the patient, but internal reasons, both nonlocomotor and locomotor, increased after age 65 years. No nonlocomotor causes for a fall were found in patients younger than 65 years of age. Also, the rate of hospitalization of patients seen for falls was greater in the geriatric age group. CONCLUSIONS: The results highlight the need for further research about falls, particularly those occurring in pediatric and young adult patients. Furthermore, correcting environmental hazards and modifying gait problems in the elderly by increasing lower extremity and truncal strength could decrease the risk of falling.

Accidental Falls↗

PubMed1988

Children's preference for challenge: the role of perceived competence and control.

This research tested the hypothesis that children's perceptions of academic competence and their personal control over school-related performance affects subsequent intrinsic interest and preference for challenge in an evaluative setting. In a correlational study, children's self-reported perceptions of academic competence and personal control were found to relate positively to their intrinsic interest in schoolwork and preference for challenging school activities. A subset of this sample was exposed to varying levels of a controlling directive, and preference for challenge was assessed behaviorally during a free-choice period in which subjects were unaware that they were being observed. As predicted, the data indicated that when given the evaluative, controlling directive, children who had high perceptions of academic competence and control preferred a greater challenge than did children whose perceptions were low on these measures. No difference between groups in terms of preference for challenge was evident when no controlling directive was presented. These findings are discussed in terms of theories of intrinsic motivation and potential processes that underly these effects.

Achievement↗

PubMed1986

Enhancing interest in peer interaction: a developmental analysis.

Using an intrinsic motivation paradigm, the effects of providing different reasons for interacting with a peer were examined in terms of children's subsequent interest in playing with the other child. Children (5 1/2, 7, and 9 years old) were randomly assigned to 1 of 3 conditions and provided with identical information about a child presented on a television monitor (that he was nice and had a new Lego game). In the experimental conditions, children were then asked if they wanted to play with the peer either "because he has a new game" (situational information) or "because he's real nice" (dispositional information). The results indicated that, for the 9-year-olds, the dispositional/intrinsic information enhanced subsequent intrinsic interest in the peer relative to the control condition, while the situational information undermined later interest. In contrast, for the younger age groups, the situational information increased interest in peer interaction for the younger age groups in comparison to the control condition, while the dispositional information did not differ from control. The findings are discussed in terms of potential processes underlying these effects.

Child↗

PubMedDate not supplied

Practice style differences between family physicians and internists.

BACKGROUND: Because an estimated 70 percent of all medical care expenditures are generated by physicians, evaluation of specialty practice styles is essential to learn what changes in policies governing physician training, service delivery, and patterns of medical practice would promote cost containment. METHODS: We examined the 1981 and 1985 National Ambulatory Medical Care Survey for seven primary care diagnoses to compare practice style differences between family physicians and internists and to look for changes in family physicians' practice styles between 1981 and 1985. RESULTS: Family physicians referred fewer patients in 1985 and spent 3 to 10.5 minutes less per patient encounter than internists. Clinical laboratory testing, electrocardiogram (ECG) ordering, and radiographic examinations differed significantly between the two groups in 1981 and 1985 for some diagnoses. In 1981, family physicians did Papanicolaou smears 2.2 times more often than internists during general medical examinations; however, in 1985, there was no difference. Between 1981 and 1985, family physicians ordered significantly more laboratory tests and ECGs for some diagnoses but had no change in the number of radiographs ordered or referrals. For six diagnoses, they spent more time with a patient encounter in 1985 than in 1981. CONCLUSIONS: Family physicians and internists appear to be more alike in practice style, but significant differences remain. These differences, as well as changing practice styles of family physicians, have implications for training and health care resource distribution.

Clinical Laboratory Techniques↗

PubMedDate not supplied

Measuring health: guidelines for reliability assessment.

In the area of health measurement, few guidelines exist for the health professional interested in understanding the concept of reliability. Yet, often there is a need to construct, modify, or select a reliable instrument that will satisfy a particular research or clinical need. This article reviews the concept of reliability and presents a few of the more common techniques used to calculate the reliability of health assessment instruments. Practical guidelines for questionnaire construction and administration are also discussed.

Data Collection↗

PubMedDate not supplied

The contraceptive implant and the injectable: a comparison of costs.

A comparison of the relative costs of the injectable contraceptive (depot medroxyprogesterone acetate) and the hormonal implant (Norplant) indicates that the implant is a less costly contraceptive option when it is used for its full five-year lifespan. Over a five-year period, the implant costs $107 annually, compared with $140 per year for the injectable. However, if a woman discontinues the implant before she has used it for at least four years, the injectable becomes the less costly option. Relatively high continuation rates--around 95% annually--are necessary to make the implant the more cost-effective contraceptive method.

Cost-Benefit Analysis↗

PubMedDate not supplied

Measuring physician readiness to change cancer screening: preliminary results.

Our objective was to describe the development and validation of an instrument for measuring physician readiness to change cancer screening and counseling. We designed a cross-sectional survey of primary care physicians. Participants were 745 enrollees in the Copic Insurance Company, a physician liability insurer of more than 80% of Colorado's physicians. A large percentage of physicians do not perceive a need to change their screening patterns for eligible patients in both mammography and Pap tests. Approximately one third of the physicians are contemplating screening more of their patients within the next six months for sigmoidoscopy, clinical skin, and oral cavity exams and counseling more of their patients on skin protection and dietary fat. Few physicians are planning significant changes in cancer screening and counseling within the next month. Scales of readiness to change screening and counseling, as well as an overall readiness-to-change scale, had high internal consistency: .81, .65, .84, for screening, counseling, and overall, respectively. We conclude that readiness to change may be a useful construct for determining if and when physicians may be willing to make behavior changes. Moreover, the assessment of physician readiness to change may facilitate the tailoring of interventions designed to foster physician behavior change and improve patient care.

Attitude of Health Personnel↗

PubMedDate not supplied

Comparison of HIV-risk behaviors and demographics of adolescents tested or not tested for HIV infection.

In a survey of 2,548 adolescents, 11.5 percent reported ever having had the human immunodeficiency virus (HIV) antibody test. Those who had been tested were significantly more likely to be male, black, and to reside in metropolitan areas than those who had not been tested. Tested adolescents were more than three times as likely to report having injected drugs and were more than twice as likely to have had sexual intercourse, had sexual intercourse at earlier ages, and with multiple partners. More than half of adolescents who had been HIV-tested had no reported risks for HIV infection. More than one-quarter of adolescents not tested reported at least one HIV risk factor. These data suggest the importance of discussing the HIV testing and counseling process within any HIV education program directed to adolescents.

Adolescent↗

PubMedDate not supplied

Appropriateness of hospital use by family physicians.

BACKGROUND: Reducing inappropriate hospital admissions could lead to lower total health care costs without compromising the quality of care. Research suggests that a sizeable portion of hospital admissions are inappropriate. Other studies indicate that family physicians use health care resources, including hospitalizations, less often than other primary care physicians. To gain additional insight into family physicians' decisions to admit patients, we performed an exploratory study using the Appropriateness Evaluation Protocol, a validated, clinically based utilization review instrument. METHODS: We assessed admissions by community-based and residency-based family physicians to a single university-affiliated hospital during calendar year 1988. A total of 905 patients were admitted to the hospital by family physicians during the study period. Of these, 889 records had complete data. Each was reviewed for appropriateness of admission. We calculated percentages of inappropriate admissions and used logistic regression to ascertain variables that were significant predictors of inappropriateness. RESULTS: Overall, 5.4 percent of admissions were categorized as inappropriate. Omitting obstetric cases, the rate was 10.5 percent. Inappropriate admissions did not cluster around a small number of diagnoses or diagnosis-related groups. Using logistic regression, we found that urgency of admission, patient insurance status, and residency-based physician admission versus community-based physician admission were significant predictors of inappropriate hospital use. Of the inappropriate admissions, 70 percent were so rated because diagnostic procedures or treatments could have been performed on an outpatient basis. CONCLUSIONS: In contrast with other studies for which physician specialty was not controlled, family physicians less frequently admitted patients inappropriately. Predictors of inappropriateness differed from those found in other studies. Changes in hospital systems, in addition to educational efforts directed toward individual physicians, hold promise as a strategy for reducing inappropriate hospital use.

Adult↗

PubMedDate not supplied

Continuation rates among injectable contraceptive users.

Few published data exist on the ongoing use of depot medroxyprogesterone acetate, the injectable contraceptive. Women who obtained the injectable from Planned Parenthood of the Rocky Mountains between January 1993 and March 1995 were followed to ascertain continuation rates for the method. Of the 5,178 women who received an initial injection, only 57% returned for a second administration; 63% of those who returned for their second injection went on to receive a third. The overall one-year continuation rate was 23%. No significant differences in continuation rates were found based on age, race or payment type.

Adolescent↗