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Biomedical subjects

Elizabeth G Baxley

Publications and source records attributed to Elizabeth G Baxley.

10 recordsLinked to original sources
PubMed2006

Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years.

OBJECTIVES: Estimate the prevalence of medically unnecessary Emergency Medical Services (EMS) transports among children. METHODS: We linked EMS and emergency department (ED) billing records for all EMS-to-hospital transports of children originating in three counties in South Carolina between January 1, 2001 and March 31, 2003. EMS responses resulting in no transport, transports to destinations other than the ED, or multiple trips for the same child in a single day could not be linked to ED data and were excluded. Medically unnecessary transports were identified with an algorithm using pre-hospital impressions, ED diagnoses and ED procedures. After exclusions, 5,693 transports of children between 0 and 17 years were available for study. RESULTS: Sixteen percent (16.4%) of all transports were medically unnecessary. Among children through age 12, upper respiratory and viral problems were the most common diagnoses associated with medically unnecessary transports; among older children, behavioral problems such as conduct disturbance or drug abuse were common. In multivariable analysis, the odds of an unnecessary transport were higher among younger children, non-white children, rural children, and children insured by Medicaid. CONCLUSIONS: The proportion of EMS transports which may be medically unnecessary is relatively modest compared to previous studies. However, many questions remain for future research. Further investigation should include examination of primary care availability and occurrence of unnecessary EMS use, existence of race-based disparities, and transports involving conduct disturbance and other behavioral conditions among children.

Adolescent↗
PubMed2006

Rural-urban differences in depression prevalence: implications for family medicine.

BACKGROUND AND OBJECTIVES: Rural populations experience more adverse living circumstances than urban populations, but the evidence regarding the prevalence of mental health disorders in rural areas is contradictory. We examined the prevalence of depression in rural versus urban areas. METHODS: We performed a cross-sectional study using the 1999 National Health Interview Survey (NHIS). In face-to-face interviews, the NHIS administered the Composite International Diagnostic Interview Short Form (CIDI-SF) depression scale to a nationally representative sample of 30,801 adults, ages 18 and over. RESULTS: An estimated 2.6 million rural adults suffer from depression. The unadjusted prevalence of depression was significantly higher among rural than urban populations (6.1% versus 5.2% ). After adjusting for rural/urban population characteristics, however, the odds of depression did not differ by residence. Depression risk was higher among persons likely to be encountered in a primary care setting: those with fair or poor self-reported health, hypertension, with limitations in daily activities, or whose health status changed during the previous year. CONCLUSIONS: The prevalence of depression is slightly but significantly higher in residents of rural areas compared to urban areas, possibly due to differing population characteristics.

Adolescent↗
PubMed2005

Update: health insurance and utilization of care among rural adolescents.

CONTEXT: Adolescence is critical for the development of adult health habits. Disparities between rural and urban adolescents and between minority and white youth can have life-long consequences. PURPOSE: To compare health insurance coverage and ambulatory care contacts between rural minority adolescents and white and urban adolescents. METHODS: Cross-sectional design using data from the 1999-2000 National Health Interview Survey, a nationally representative sample of US households. Analysis was restricted to white, black, and Hispanic children aged 12 through 17 (8,503 observations). Outcome measures included health insurance, ambulatory visit within past year, usual source of care (USOC), and well visit within past year. Independent variables included race, residence, demographics, facilitating/enabling characteristics, and need. RESULTS: Across races, rural adolescents were as likely to have insurance (86.8% vs 87.7%) but less likely to report a preventive visit (60.1% vs 65.5%) than urban children; residence did not affect the likelihood of a visit or a USOC. Minority rural adolescents were less likely than whites to be insured, report a visit, or have a USOC. Most race-based differences were not significant in multivariate analysis holding constant living situation, caretaker education, income, and insurance. Low caretaker English fluency, limited almost exclusively to Hispanics, was an impediment to all outcomes. CONCLUSIONS: Most barriers to care among rural and minority youth are attributable to factors originating outside the health care system, such as language, living situation, caretaker education, and income. A combination of outreach activities and programs to enhance rural schools and economic opportunities will be needed to improve coverage and utilization among adolescents.

Adolescent↗
PubMed2004

Shoulder dystocia.

Shoulder dystocia can be one of the most frightening emergencies in the delivery room. Although many factors have been associated with shoulder dystocia, most cases occur with no warning. Calm and effective management of this emergency is possible with recognition of the impaction and institution of specified maneuvers, such as the McRoberts maneuver, suprapubic pressure, internal rotation, or removal of the posterior arm, to relieve the impacted shoulder and allow for spontaneous delivery of the infant. The "HELPERR" mnemonic from the Advanced Life Support in Obstetrics course can be a useful tool for addressing this emergency. Although no ideal manipulation or treatment exists, all maneuvers in the HELPERR mnemonic aid physicians in completing one of three actions: enlarging the maternal pelvis through cephalad rotation of the symphysis and flattening of the sacrum; collapsing the fetal shoulder width; or altering the orientation of the longitudinal axis of the fetus to the plane of the obstruction. In rare cases in which these interventions are unsuccessful, additional management options, such as intentional clavicle fracture, symphysiotomy, and the Zavanelli maneuver, are described.

Birth Weight↗
PubMed2003

Management of gestational diabetes mellitus.

Gestational diabetes mellitus is a common but controversial disorder. While no large randomized controlled trials show that screening for and treating gestational diabetes affect perinatal outcomes, multiple studies have documented an increase in adverse pregnancy outcomes in patients with the disorder. Data on perinatal mortality, however, are inconsistent. In some prospective studies, treatment of gestational diabetes has resulted in a decrease in shoulder dystocia (a frequently discussed perinatal outcome), but cesarean delivery has not been shown to reduce perinatal morbidity. Patients diagnosed with gestational diabetes should monitor their blood glucose levels, exercise, and undergo nutrition counseling for the purpose of maintaining normoglycemia. The commonly accepted treatment goal is to maintain a fasting capillary blood glucose level of less than 95 to 105 mg per dL (5.3 to 5.8 mmol per L); the ambiguity (i.e., the range) is due to imperfect data. The postprandial treatment goal should be a capillary blood glucose level of less than 140 mg per dL (7.8 mmol per L) at one hour and less than 120 mg per dL (6.7 mmol per L) at two hours. Patients not meeting these goals with dietary changes alone should begin insulin therapy. In patients with well-controlled diabetes, there is no need to pursue delivery before 40 weeks of gestation. In patients who require insulin or have other comorbid conditions, it is appropriate to begin antenatal screening with nonstress tests and an amniotic fluid index at 32 weeks of gestation.

Blood Glucose↗
PubMed2002

Rural-urban differences in visits to primary care physicians.

BACKGROUND AND OBJECTIVES: Our study explored ambulatory practice differences between rural and urban primary care physicians. Because most rural practitioners are not educated through special rural tracks, all primary care medical educators need to ensure that training prepares physicians for the demands of rural sites. METHODS: Visits to family, general practice, internal medicine, and pediatric physicians from the 1996 and 1997 National Ambulatory Medical Care Surveys were analyzed. "Rural" was defined as outside a metropolitan statistical area. RESULTS: Family physicians handled the majority of rural visits, even among pediatric populations. Acute injuries represented 6.1% of rural visits versus 5.0% of urban visits. Conditions likely to be associated with pain (degenerative joint disease, low-back pain, myalgias, headaches, and bursitis) were higher among rural visits (8.5% versus 5.4% urban). Preventive counseling and services and anticipatory guidance for children were provided less frequently in rural visits. CONCLUSIONS: Physicians entering rural primary care practice need training in acute injury and chronic pain syndromes, as well as ample exposure to care for children. Research is needed to explain the less-frequent provision of clinical preventive services in rural areas. Given clinical similarities between rural and urban visit content, subtle differences in provision of acute care and preventive services may provide important clues to training needs among physicians preparing to enter rural practice.

Adolescent↗
PubMedDate not supplied

Use of ED diagnosis to determine medical necessity of EMS transports.

OBJECTIVE: To examine interrater agreement for classifying emergency medical services transports as medically unnecessary using emergency department diagnosis as the sole determining factor. METHODS: Three emergency physicians and two family medicine physicians classified 913 International Classification of Diseases, Ninth Revision (ICD-9) codes as medically necessary, unnecessary, or uncertain. Overall agreement, interrater agreement, and agreement within 17 major disease categories were measured using kappa statistics in SAS. RESULTS: Physicians rated between 25% and 65% of diagnoses codes as medically unnecessary. Overall agreement was fair (kappa = 0.31). Agreement within specialties was higher among family medicine-trained physicians than among emergency physicians (kappa = 0.52 and kappa = 0.22, respectively). Agreement across all raters was highest for diseases classified as symptoms, signs, and ill-defined conditions (kappa = 0.40) and lowest for diseases of the blood and blood-forming organs (kappa = -0.17). Agreement was observably better between physicians with more experience. CONCLUSIONS: Considerable doubts about the utility of emergency department diagnosis as a criterion are raised from study findings. Further development of Neely Conference criteria is needed. Priority should be given to testing and validation of criteria as well as exploration of differences in judgment between specialists representative of the medical director profession.

Consensus↗