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Biomedical subjects

Janusz Kaczorowski

Publications and source records attributed to Janusz Kaczorowski.

At least 37 records · Page 2Linked to original sources
PubMed2003

Randomizing patients by family practice: sample size estimation, intracluster correlation and data analysis.

BACKGROUND: Cluster randomized controlled trials increasingly are used to evaluate health interventions where patients are nested within larger clusters such as practices, hospitals or communities. Patients within a cluster may be similar to each other relative to patients in other clusters on key variables; therefore, sample size calculations and analyses of results require special statistical methods. OBJECTIVE: The purpose of this study was to illustrate the calculations used for sample size estimation and data analysis and to provide estimates of the intraclass correlation coefficients (ICCs) for several variables using data from the Seniors Medication Assessment Research Trial (SMART), a community-based trial of pharmacists consulting to family physicians to optimize the drug therapy of older patients. METHODS: The study was a paired cluster randomized trial, where the family physician's practice was the cluster. The sample size calculation was based on a hypothesized reduction of 15% in mean daily units of medication in the intervention group compared with the control group, using an alpha of 0.05 (one-tailed) with 80% power, and an ICC from pilot data of 0.08. ICCs were estimated from the data for several variables. The analyses comparing the two groups used a random effects model for a meta-analysis over pairs. RESULTS: The design effect due to clustering was 2.12, resulting in an inflation in sample size from 340 patients required using individual randomization, to 720 patients using randomization of practices, with 15 patients from each of 48 practices. ICCs for medication use, health care utilization and general health were <0.1; however, the ICC for mean systolic blood pressure over the trial period was 0.199. CONCLUSIONS: Compared with individual randomization, cluster randomization may substantially increase the sample size required to maintain adequate statistical power. The differences in ICCs among potential outcome variables reinforce the need for valid estimates to ensure proper study design.

Aged↗
PubMed2003

Prospective evaluation of colposcopic features in predicting cervical intraepithelial neoplasia: degree of acetowhite change most important.

OBJECTIVE.: To prospectively evaluate the contribution of three colposcopic features-degree of acetowhite change, blood vessel pattern, and lesion margin-to the diagnosis of cervical intraepithelial neoplasia. MATERIALS AND METHODS.: A total of 301 women, who participated in two randomized controlled trials and a cross-sectional study of human papillomavirus testing and who were referred to a regional colposcopy center, were studied. Women were examined by colposcopists, who prospectively scored all abnormal transformation zones using three features. The site with the highest score (the most abnormal site) was biopsied and histology reviewed by two pathologists. RESULTS.: In multivariate analysis, degree of acetowhite change was the only feature significantly associated with cervical intraepithelial neoplasia. CONCLUSIONS.: Grading lesion severity using degree of acetowhite change alone gave comparable results to grading using the three combined features.

Journal Article↗
PubMed2003

Regional distribution of antibodies to herpes simplex virus type 1 (HSV-1) and HSV-2 in men and women in Ontario, Canada.

This study estimated the regional and age- and gender-specific seroprevalences of herpes simplex virus type 1 (HSV-1) and HSV-2 in Ontario, Canada. Stored serum specimens from subjects aged 15 to 44 years, including men (n = 979), women not under prenatal care (n = 638), and women under prenatal care (n = 701) submitted for routine viral serology were randomly selected according to regional population size from public health laboratories. HSV-1 and HSV-2 testing was done with the MRL enzyme immunoassay (EIA) (Focus Technologies), and HSV-2 was also tested by the Gull/Meridian EIA. Specimens discordant for HSV-2 antibodies between the two EIAs were resolved by a recombinant immunoblot assay (Focus Technologies). The overall age- and gender-standardized seroprevalences of HSV-1 and HSV-2 were 51.1% (95% confidence interval [CI], 50.1 to 52.1) and 9.1% (95% CI, 8.6 to 9.7), respectively. The seroprevalence of HSV-1 antibodies increased from 26.9 to 54.7% in men between 15 to 16 and 40 to 44 years of age, from 32.0 to 88.7% in women not under prenatal care, and from 55.2 to 69.2% in women under prenatal care. The seroprevalence of HSV-2 increased from 3.8 to 21.3% in men between 15 to 16 and 40 to 44 years of age, from 0 to 18.9% in women not under prenatal care, and from 3.4 to 23.1% in women under prenatal care. HSV-2 results were discordant for 3.3% (76 of 2,318) of specimens. Both types of HSV antibodies appeared to be acquired earlier among women under prenatal care than among men and women not under prenatal care. Antibodies were more prevalent among people in northern Ontario (72.9% of subjects [range, 68.4 to 77.4%] for HSV-1 and 13.7% of subjects [95% CI, 10.2 to 17.2%] for HSV-2) than elsewhere.

Adolescent↗
PubMed2003

Prenatal HIV tests. Routine testing or informed choice?

OBJECTIVE: To examine how prenatal care providers responded to a new provincial policy of offering HIV testing to all prenatal patients, and to determine factors associated with self-reported high testing rates. DESIGN: Cross-sectional mailed survey. SETTING: Outpatient practices in three Ontario health-planning regions. PARTICIPANTS: Prenatal care providers: 784 family physicians, 200 obstetricians, and 103 midwives were sent questionnaires and were eligible to participate. MAIN OUTCOME MEASURES: Self-reported testing of 80% or more prenatal patients ("high testers") and associated practice characteristics, attitudes, and counseling practices. RESULTS: Response rate was 57% (622/1087): 43% of respondents were high testers. Family physicians were most likely and midwives least likely to be high testers. High testers tended to report that they had adequate knowledge of HIV testing, that HIV risk among their patients warranted testing all of them, and that testing should be routine. Encouraging women to test and not providing written information or choice were independently associated with high testing rates. CONCLUSION: Strongest predictors of high prenatal HIV testing rates were attitudes and practices that favoured a routine approach to testing and that placed little emphasis on informed consent.

AIDS Serodiagnosis↗
PubMed2002

Does delivery volume of family physicians predict maternal and newborn outcome?

BACKGROUND: The number of births attended by individual family physicians who practice intrapartum care varies. We wanted to determine if the practice-volume relations that have been shown in other fields of medical practice also exist in maternity care practice by family doctors. METHODS: For the period April 1997 to August 1998, we analyzed all singleton births at a major maternity teaching hospital for which the family physician was the responsible physician. Physicians were grouped into 3 categories on the basis of the number of births they attended each year: fewer than 12, 12 to 24, and 25 or more. Physicians with a low volume of deliveries (72 physicians, 549 births), those with a medium volume of deliveries (34 physicians, 871 births) and those with a high volume of deliveries (46 physicians, 3024 births) were compared in terms of maternal and newborn outcomes. The main outcome measures were maternal morbidity, 5-minute Apgar score and admission of the baby to the neonatal intensive care unit or special care unit. Secondary outcomes were obstetric procedures and consultation patterns. RESULTS: There was no difference among the 3 volume cohorts in terms of rates of maternal complications of delivery, 5-minute Apgar scores of less than 7 or admissions to the neonatal intensive care unit or the special care unit, either before or after adjustment for parity, pregnancy-induced hypertension, diabetes, ethnicity, lone parent status, maternal age, gestational age, newborn birth weight and newborn head circumference at birth. High- and medium-volume family physicians consulted with obstetricians less often than low-volume family physicians (adjusted odds ratio [OR] 0.586 [95% confidence interval, CI, 0.479-0.718] and 0.739 [95% CI 0.583-0.935] respectively). High- and medium-volume family physicians transferred the delivery to an obstetrician less often than low-volume family physicians (adjusted OR 0.668 [95% CI 0.542-0.823] and 0.776 [95% CI 0.607-0.992] respectively). Inductions were performed by medium-volume family physicians more often than by low-volume family physicians (adjusted OR 1.437 [95% CI 1.036-1.992]. INTERPRETATION: Family physicians' delivery volumes were not associated with adverse outcomes for mothers or newborns. Low-volume family physicians referred patients and transferred deliveries to obstetricians more frequently than high- or medium-volume family physicians. Further research is needed to validate these findings in smaller facilities, both urban and rural.

Adolescent↗
PubMed2002

Optimizing the hybrid capture II human papillomavirus test to detect cervical intraepithelial neoplasia.

OBJECTIVE: To estimate the optimal relative light unit ratio, and correspondingly viral load, of the hybrid capture II oncogenic human papillomavirus deoxyribonucleic acid test for detecting cervical intraepithelial neoplasia (CIN). METHODS: Women with abnormal cytology were referred for colposcopy, and a cervical swab or brush specimen was obtained for human papillomavirus testing. Sensitivities, specificities, and likelihood ratios of different relative light unit ratio cutoffs were calculated using a reference standard of colposcopy or biopsy of either CIN II+ (CIN II, III, or carcinoma), or CIN I+ (CIN I, CIN II+). The receiver operating characteristic curve was used to estimate optimal test-positive cutoff points for the hybrid capture II test. RESULTS: CIN II+ was found in 18.7% (98 of 524) and CIN I in 10.5% (55 of 524) of the women. The optimal relative light unit ratio was 15.56, giving a sensitivity and specificity of 82.7% and 73.2% for CIN II+, and 74.2% and 77.8% for CIN I+. In a stratified analysis, a higher relative light unit cutoff (15.19) optimized sensitivity and specificity for CIN II+ (sensitivity 81.8%, specificity 51.5%) for women with low-grade squamous intraepithelial lesions cytology, whereas the optimal cutoff was 2.36 (sensitivity 100%, specificity 73.0%) for women with atypical squamous cells of undetermined significance, yielding referral rates of 53.3% and 28.7%, respectively. Use of a swab or brush was not associated with the level of human papillomavirus detected (P >.05). CONCLUSION: Use of a higher cutoff for the relative light unit ratio (higher viral load) of the hybrid capture II test may improve the management of women, especially those with low-grade squamous intraepithelial lesions cytology.

Adolescent↗
PubMed2002

Recruiting family physicians and patients for a clinical trial: lessons learned.

BACKGROUND: The randomized controlled trial (RCT) is the most definitive tool for evaluating an intervention. However, methodological deficiencies may limit the internal or external validity of the RCT. OBJECTIVE: Our aim was to describe the tactics used and the resources required randomly to select and recruit family physicians (FPs) and their patients aged 65 and older (seniors) for a community-based cluster RCT in primary care. METHODS: We randomly selected 48 FPs in 24 urban and rural sites in Southern Ontario, and 889 of their community-dwelling seniors (approximately 20 per FP) taking five or more medications daily. To accomplish this, the principal investigator (an FP) contacted the eligible FPs. The participating FPs' office staff then generated and contacted the roster of eligible seniors, with support provided by the research staff. RESULTS: Of the 163 randomly selected FPs telephoned, 94 were ineligible and 48 (69.6%) of the remaining 69 participated. The rosters were generated with the assistance of the research staff (taking 1.5-8.0 hours) in each of the 48 practices, using electronic appointment records (n = 26), electronic billing records (n = 17), electronic medical records (n = 2) or written charts or file cards (n = 3). Of the 2078 seniors approached, 799 were ineligible and 889 (69.5%) of the remaining 1279 participated. Seniors' refusal rates among practices ranged from 4.8 to 62.3%. CONCLUSIONS: Recruitment of a representative sample and generalizability of results are possible in RCTs in primary care. Involvement of an FP in physician recruitment and clinical research nurses who provided assistance to office staff were keys to success.

Aged↗
PubMed2002

Comparing the characteristics and attitudes of physicians in different primary care settings: The Ontario Walk-in Clinic Study.

BACKGROUND: In Canada, walk-in clinics (WICs) are a focus for debate about access to and the costs and quality of primary care. While WICs may offer patients easier access through longer hours and shorter waits, it has been argued that they may also lead to unnecessary utilization, duplication of services, lack of continuity of care, decreased quality and increased costs. OBJECTIVES: The main objectives were to analyse the characteristics and attitudes of physicians working in different family practice types including WICs. METHODS: We analysed the results of a 1998 survey of 728 primary care physicians in Ontario to compare physicians working in WICs with those working in solo and group family practices. RESULTS: Our survey found that few physicians worked most or all of their hours in WICs; most worked in WICs and other family practice types. Compared to family physicians in solo and group practices, physicians working in WICs saw more patients who were not their regular patients, patients without appointments and children. They reported slightly higher frequencies of problems such as backlogs (patient queues) and patients who had sought care from other doctors for the same problem. WIC physicians were less satisfied than other physicians with their relations with patients. They were, however, more satisfied with the availability of consultation, support staff, hours, income, and vacation coverage. Further, WIC physicians assessed the quality of care in WICs to be neither better nor worse than that in other family practices. CONCLUSIONS: We conclude that there are important similarities as well as differences, between physicians in WICs and those in more conventional family practices. The assessments of primary care physicians do not support the generally negative reputation of WICs. Instead, greater consideration should be given to the system-level issues which produce demand for WICs.

Ambulatory Care Facilities↗
PubMed2002

Urinary incontinence in Canada. National survey of family physicians' knowledge, attitudes, and practices.

OBJECTIVE: To determine current knowledge, attitudes, and management of urinary incontinence among family physicians in Canada. DESIGN: Cross-sectional mailed survey. SETTING: Family physicians in Canada. PARTICIPANTS: A random sample of 1500 members of the College of Family Physicians of Canada. MAIN OUTCOME MEASURES: Self-assessed knowledge, self-reported attitudes, and rating of various tests and treatments in the investigation and management of incontinence. RESULTS: The overall unadjusted response rate was 43.3% (650/1500). Although most respondents reported that urinary incontinence was common in their practices, less than half (46.0%, 284/617) indicated that they clearly understood incontinence and just 37.9% (232/612) had an organized plan for incontinence problems. Only 35.0% (214/612) of respondents felt very comfortable dealing with incontinence. Physical examination, urodynamic studies, urinalysis, and testing blood sugar levels were all considered important investigations by more than 90% of respondents. CONCLUSION: There are wide variations in knowledge, attitudes, practices, and comfort level among family physicians dealing with urinary incontinence.

Adult↗
PubMed2002

Who provides walk-in services? Survey of primary care practice in Ontario.

OBJECTIVE: To compare walk-in clinics with other primary care settings on characteristics associated with best practices in primary care. DESIGN: A mailed self-administered questionnaire asked about organizational and clinical characteristics of primary care practices located in major urban and suburban areas in Ontario. SETTING: Four types of fee-for-service group practices: walk-in and urgent-care clinics (WICs), mixed practices (MPs), after-hours clinics (AHCs), and group family practices (GFPs). PARTICIPANTS: A physician or a staff member involved in practice administration. MAIN OUTCOME MEASURES: The four practice types were compared on organizational characteristics and measures of access, continuing care, comprehensiveness, coordination, and mechanisms for monitoring quality of care. RESULTS: Walk-in clinics, MPs, and AHCs were open more hours during evenings and weekends and were more likely to see patients without appointments; GFPs were more likely to have on-call arrangements. Group family practices saw a larger proportion of patients for whom they provided ongoing care; WICs and MPs reported that more than 60% of their visits were with "regular" patients. Walk-in clinics were less likely to provide preventive services and psychological counseling than were GFPs and MPs. A few WICs, MPs, and GFPs had procedures to support coordination of care or to monitor quality of care. CONCLUSION: Although WICs, MPs, and AHCs provided walk-in services to Ontario patients, WICs and MPs also provided a substantial amount of ongoing care and preventive services. Independent AHCs appeared to most closely fit the "walk-in clinic" stereotype.

Adolescent↗
PubMed2002

Medical abortion and family physicians. Survey of residents and practitioners in two Ontario settings.

OBJECTIVE: To determine the knowledge, attitudes, and interest in providing medical abortion reported by family physicians and residents in rural and urban settings. DESIGN: A self-administered mailed survey using the modified Dillman method. SETTING: Hamilton and Thunder Bay County in Ontario. PARTICIPANTS: Family medicine residents (n = 93) and physicians (n = 234) in predominantly urban (Hamilton) and rural (Thunder Bay) settings. All faculty family physicians at McMaster University practising general family medicine and all family physicians in Thunder Bay County were surveyed. MAIN OUTCOME MEASURES: Knowledge of, attitudes toward, and interest in providing medical abortion. RESULTS: Overall response rate to the survey was 62.7% (n = 327); 74.2% (69/93) of residents responded; 58.1% (136/234) of physicians responded. Physicians and residents rated their knowledge about medical abortion as poor, but most were interested in receiving more information and training in this area. Many (83.1%, 157/189) reported that medical abortion was an acceptable procedure for family physicians to perform, and 52.0% (64/123) of the physicians would consider providing medical abortions for their patients. Residents training in the more rural Thunder Bay program were less likely to support first-trimester abortions for both medical and nonmedical reasons than those training in Hamilton (P < .05). Male respondents were significantly less supportive of abortion for nonmedical reasons and were less likely to consider providing medical abortions for their patients (P < .05). CONCLUSION: Most family physicians and residents showed interest in receiving more information about and training in medical abortion.

Abortion, Induced↗
PubMed2002

In for the long haul. Which family physicians plan to continue delivering babies?

OBJECTIVE: To compare characteristics of family physicians planning to discontinue or stay in intrapartum care. DESIGN: Self-administered questionnaire. SETTING: Department of Family Practice at Children's and Women's Health Centre of British Columbia. PARTICIPANTS: Ninety-five family physicians who attended at least one birth at the Health Centre between April 1997 and August 1998. MAIN OUTCOME MEASURES: Intention to leave or stay in family practice maternity care, physician characteristics and beliefs. RESULTS: Forty-five percent (43/95) of family physicians planned to leave maternity care within the next 5 years. Physicians planning to leave had more negative attitudes about the alternative birthing centre, doulas, and practising in free-standing settings without on-site obstetricians; were more likely to report missing personal events because they had put their maternity patients first; were less likely to make housecalls during women's labour; and were more likely to be paid through fee-for-service. CONCLUSION: Being paid by fee-for-service, having negative attitudes toward non-traditional maternity care, and conflict between maternity care and personal life were associated with intention to leave intrapartum care.

Adult↗
PubMed2002

Incontinence Quality of Life Instrument in a survey of primary care physicians.

OBJECTIVE: To assess the performance of the Incontinence Quality of Life (I-QOL) Instrument in measuring the impact of urinary incontinence on the quality of life of family medicine patients. STUDY DESIGN: Postal survey. Multiple imputations of missing answers. Linear regression analysis of I-QOL predictors. Comparison by receiver operating characteristic of the I-QOL and the Short Form 12 (SF-12). POPULATION: Women 45 years or older attending either of 2 family medicine clinics. Response rate was 605 (61%) of 992. OUTCOMES MEASURED: Prevalence of stress, urge, and mixed incontinence. Scores on the I-QOL and SF-12 instruments. RESULTS: Of the 605 respondents, 310 (51%) reported urinary incontinence in the month before the survey. One or more items were missing on 19% of the I-QOL scales and scores were imputed. The relation between I-QOL and the number of leakage episodes was nonlinear. I-QOL scores decreased with the number of episodes, the amount of leakage, and poorer general health. There was no association between the I-QOL and age, education, or type of incontinence. The I-QOL was more sensitive than the SF-12 to the statement, "urinary incontinence is a problem." CONCLUSIONS: The I-QOL is a useful instrument for the investigation of incontinence-related quality of life in the community setting.

Aged↗
PubMedDate not supplied

Collaboration between community pharmacists and family physicians: lessons learned from the Seniors Medication Assessment Research Trial.

OBJECTIVES: To learn about the experiences of specially trained expanded role pharmacists (ERPs) and family physicians in a program in which they worked together to optimize drug therapy for elderly patients (aged 65 and older) and to identify shortcomings of the program, obstacles to its implementation, and strategies to overcome these obstacles. DESIGN: Qualitative opinion analysis. PARTICIPANTS: Six family physicians and six community-based ERPs who had participated in a randomized controlled trial (Seniors Medication Assessment Research Trial [SMART]). INTERVENTION: In-depth interviews. MAIN OUTCOME MEASURES: Themes that emerged from the interviews regarding the strengths and weaknesses of and ways to improve the program. RESULTS: ERPs and physicians differed in their perceptions of appropriate roles for ERPs. ERPs saw the program as an opportunity to take on new professional roles. Physicians appreciated the information they received from ERPs about their patients' adherence and use of nonprescription medications, but they did not want ERPs to directly counsel their patients. Some physicians questioned the value of the program for some patients, since the inclusion criteria for patients were broad and not all patients meeting the criteria needed intense interventions by ERPs. Both ERPs and physicians identified the need to refine the referral process and to work out professional role relationships and ongoing collaboration more fully. If the program were to be implemented as a routine service, physicians were concerned about the demands on their staff and office space and the need for an external compensation mechanism. CONCLUSION: Issues to be addressed for future programs include clarification of the roles of pharmacist and physician when the professionals work together, targeting of appropriate patients for the program, identification of a more efficient way to deliver recommendations, and development of an appropriate compensation mechanism.

Aged↗
PubMedDate not supplied

Prenatal HIV testing in Ontario: knowledge, attitudes and practices of prenatal care providers in a province with low testing rates.

OBJECTIVE: To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing. METHODS: A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire. RESULTS: Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians. CONCLUSION: Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.

AIDS Serodiagnosis↗