Biomedical subjects

K Fiscella

Publications and source records attributed to K Fiscella.

33 records · Page 2Linked to original sources

PubMed1998

Does child abuse predict adolescent pregnancy?

OBJECTIVE: To determine whether sexual and nonsexual childhood abuse are risk factors for early adolescent sexual activity and pregnancy. DESIGN; Cross-sectional study. SETTING: Prenatal clinic within an inner-city teaching hospital from June 1990 to August 1991. POPULATION: One thousand twenty-six primiparous, African-American women enrolled in a randomized clinical trial of nurse home visitation. MAIN OUTCOME MEASURES: Four measures of child abuse were used: sexual abuse, incidents of physical abuse, any major physical abuse, and emotional abuse. The outcome measures were age of first consensual coitus and age of first pregnancy. RESULTS: After adjustments for household income, parental separation, urban residence, age of menarche, and teen smoking, sexual abuse during childhood was associated with younger age at first coitus (7.2 months; 95% confidence interval [CI], 2.6 to 11.7 months) and younger age at first pregnancy (9.7 months; 95% CI, 3.0 to 16.3 months). Incidents of physical abuse showed minimal effect on age at first coitus (1.2 days per incident; 95% CI, 0.5 to 1.9 days) and no effect on age of first pregnancy. A history of major physical abuse or emotional abuse showed no effect on age of first coitus or first pregnancy. CONCLUSION: Child sexual abuse, but not child physical or emotional abuse, seems to be a risk factor for earlier pregnancy among African-American adolescents.

Adolescent↗

PubMed1998

Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience.

BACKGROUND: The advent of managed care has resulted in considerable debate regarding the relative effects of specialist and primary care on patient outcomes and costs. Studies on these subjects have been limited to a disease-focused orientation rather than a patient-focused orientation inherent in primary care management. We examined whether persons using a primary care physician have lower expenditures and mortality than those using a specialist as their personal physician. METHODS: Using data on a nationally representative sample of 13,270 adult respondents tot he 1987 National Medical Expenditure Survey reporting as their personal physician either a primary care physician (general practitioner, family physician, internist, or obstetrician-gynecologist) or a specialist, we examined total annual health care expenditures and 5-year mortality experience. RESULTS: Respondents with a primary care physician, rather than a specialist, as a personal physician were more likely to be women, white, live in rural areas, report fewer medical diagnoses and higher health perceptions and have lower annual healthcare expenditures (mean: $2029 vs $3100) and lower mortality (hazard ratio = 0.76, 95% confidence interval [CI], 0.64-0.90). After adjustment for demographics, health insurance status, reported diagnoses, health perceptions, and smoking status, respondents reporting using a primary care physician compared with those using a specialist had 33% lower annual adjusted health care expenditures and lower adjusted mortality (hazard ratio = 0.81; 95% CI, 0.66-0.98). CONCLUSIONS: These findings provide evidence for the cost-effective role of primary care physicians in the health care system. More research is needed on how to optimally integrate primary and specialty care.

Economics, Medical↗

PubMed1997

Poverty or income inequality as predictor of mortality: longitudinal cohort study.

OBJECTIVE: To determine the effect of inequality in income between communities independent of household income on individual all cause mortality in the United States. DESIGN: Longitudinal cohort study. SUBJECTS: A nationally representative sample of 14,407 people aged 25-74 years in the United States from the first national health and nutrition examination survey. SETTING: Subjects were followed from initial interview in 1971-5 until 1987. Complete follow up information was available for 92.2% of the sample. MAIN OUTCOME MEASURES: Relation between both household income and income inequality in community of residence and individual all cause mortality at follow up was examined with Cox proportional hazards survival analysis. RESULTS: Community income inequality showed a significant association with subsequent community mortality, and with individual mortality after adjustment for age, sex, and mean income in the community of residence. After adjustment for individual household income, however, the association with mortality was lost. CONCLUSIONS: In this nationally representative American sample, family income, but not community income inequality, independently predicts mortality. Previously reported ecological associations between income inequality and mortality may reflect confounding between individual family income and mortality.

Adult↗

PubMed1997

Does psychological distress contribute to racial and socioeconomic disparities in mortality?

Being black or poor are powerful predictors of mortality. Although psychological distress has been proposed as mediating the effects of race and socioeconomic status on mortality, this hypothesis has not been previously directly tested. We used data from the National Health and Nutrition Examination I (NHANES I), a nationally representative sample from the U.S, and the NHANES I Epidemiological Follow-up Survey (NHEFS) of subsequent mortality to test this hypothesis. Both black race and lower family income were associated with significantly higher psychological distress as measured at the time of the initial survey by reports of hopelessness, depression, and life dissatisfaction. Black race and low income in addition to each of the measures of psychological distress were associated with higher mortality at follow-up. In a series of Cox proportional hazards models that controlled for the effects of age and gender, additional adjustment for hopelessness, depression, or life dissatisfaction had little effect on the relationship between either African American race or family income and subsequent all-cause mortality. We conclude that the effects of both race and income on mortality are largely independent of psychological distress. These findings do not support the hypothesis that psychological distress is a significant mediator of the effects of race or class on health.

Adult↗

PubMed1997

'Being a foreigner, I may be punished if I make a small mistake': assessing transcultural experiences in caring for patients.

BACKGROUND: Emotionally charged issues that arise during graduate medical education often are unrecognized and consequently not addressed by training programmes. Little attention has been given to the emotional challenges encountered by international medical graduates (IMG) in caring for patients transculturally. OBJECTIVES: We aimed to examine the value of qualitative approaches to assessing the transcultural experiences of IMG residents during primary care training. METHODS: Two qualitative research techniques (the critical incident and the focus group) were used to assess the transcultural challenges in caring for patients of IMG and American medical graduates (AMG) resident in a primary care residency programme. Each resident wrote a narrative describing a challenging experience and facilitators then conducted a focus group to discuss these experiences. Key themes were identified from the written narratives and from the transcript of the videotaped focus group. RESULTS: Previously unacknowledged feelings emerged during the assessment. Themes of struggles for acceptance, fear of rejection, and fear of disappointing patients were identified from analysis of the written narrative, while themes of struggle to express caring transculturally were identified from the focus group transcript. Based on these findings, significant changes were made to the residency training curriculum. CONCLUSIONS: Qualitative methods are useful for assessing the transcultural experiences of IMG residents and for informing curricular changes in residency training. These methods may help other training programmes to identify the particular needs of their trainees in addressing emotionally laden experiences.

Attitude of Health Personnel↗

PubMed1997

Perceived family criticism and primary care utilization: psychosocial and biomedical pathways.

We explored the relationship of perceived family criticism to subsequent healthcare utilization in patients attending a family medicine center. We examined: a) the relationship of perceived criticism to subsequent utilization for biomedical and psychosocial/somatic problems; b) the mediating effects of self-rated mental health and physical function; and c) the mediating effects of social support. The analyses were adjusted for age, sex, race, education, health insurance, and martial status. Higher perceived criticism predicted more psychosocial/somatic and biomedical visits. The relationship of perceived criticism with psychosocial/somatic visits was entirely mediated through self-rated mental health. The relationship of perceived criticism with biomedical visits was partly mediated through self-rated physical function and, in part, independent. Social support played no role in explaining these relationships. Further research is needed to determine whether lowering perceived family criticism lowers primary care utilization.

Family↗

PubMed1996

Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counseling.

OBJECTIVE: To determine the incremental cost-effectiveness of the transdermal nicotine patch. DESIGN: Decision analytic model that evaluated the incremental cost-effectiveness of the addition of the nicotine patch to smoking cessation counseling. Costs were based on physician time and the retail cost of the nicotine patch, and benefits were based on quality-adjusted life years (QALYs) saved. PATIENTS: Male and female smokers aged 25 to 69 years receiving primary care. INTERVENTION: Addition of the nicotine patch to physician-based smoking cessation counseling. MAIN OUTCOME MEASURE: Costs (1995 dollars) per QALYs save discounted by 3% annually. RESULTS: The use of the patch produced 1 additional lifetime quitter at a cost of $7332. The incremental cost-effectiveness of the nicotine patch by age group ranged from $4390 to $10 943 per QALY for men and $4955 to $6983 per QALY for women. A clinical strategy involving limiting prescription renewals to patients successfully abstaining for the first 2 weeks improved the cost-effectiveness of the patch by 25%. CONCLUSIONS: The findings provide support both for the routine use of the nicotine patch as an adjunct to physicians' smoking cessation counseling and for health insurance coverage of nicotine patch therapy.

Administration, Cutaneous↗

PubMed1996

Race, perinatal outcome, and amniotic infection.

Racial differences in rates of amniotic infection were examined through a review of the literature. Following a computerized and manual search of the literature from 1966 to 1994, studies were selected that reported the prevalence by race of presumed markers of amniotic infection. These markers included: amniotic infection syndrome, histologic chorioamnionitis, clinical chorioamnionitis, premature rupture of the membranes, and early neonatal mortality from sepsis. With the exception of overall rates of histologic chorioamnionitis, black women showed higher rates of the all the conditions examined. Insofar as amniotic infection is a risk factor for poor perinatal outcomes, the finding of higher rates of markers of amniotic infection among black women suggests that such infections may contribute to racial disparities in perinatal outcome.

Black or African American↗

PubMed1996

Family involvement in routine health care: a survey of patients' behaviors and preferences.

BACKGROUND: The purpose of this study was to assess the behavior and preferences of patients regarding family involvement in their routine health care visits. METHODS: A self-administered questionnaire was given to a convenience sample of patients visiting a family medicine center for an appointment. RESULTS: Thirty-nine percent of patients came to the physician's office with a family member or friend. Married patients and those with higher emotional involvement scores were significantly more likely to come to the office with someone. Two thirds of accompanied patients reported that this person came into the examination room with them. One third of the accompanied patients, however, thought that their physician was unaware that someone had accompanied them to the office. The majority (55%) of patients indicated that they would prefer to have a friend or family member in the examination room with them for some of their visits. No patient indicated that they never wanted a family member or friend to come into the examination room. CONCLUSIONS: Patients prefer direct family involvement in their health care more often than what occurs in practice. Physicians can easily address this discrepancy by asking patients whether and in what way they would like others to be involved in their health care.

Adult↗

PubMed1995

Does prenatal care improve birth outcomes? A critical review.

OBJECTIVE: To evaluate evidence that prenatal care improves birth outcomes. DATA SOURCES: The MEDLINE data base was searched for appropriate studies for the years 1966-1994; a review of published studies was also conducted. METHODS OF STUDY SELECTION: Published observational and experimental studies of prenatal care that met specified criteria were selected. DATA EXTRACTION AND SYNTHESIS: Studies were graded based on the system used by the United States Preventive Services Task Force. Data were assessed using established criteria for the evaluation of prenatal interventions: temporal relationship, biologic plausibility, consistency, alternative explanations, dose-response, strength of association, and cessation effects. Current evidence did not satisfy the criteria. CONCLUSION: Prenatal care has not been demonstrated to improve birth outcomes conclusively. However, policymakers deciding on funding for prenatal care must consider these findings in the context of prenatal care's overall benefits and potential cost-effectiveness. Cost-effective reductions in low birth weight deliveries may be beyond the statistical powers of detection of current studies.

Bias↗

PubMedDate not supplied

Patients and community together. A family medicine community-oriented primary care project in an urban private practice.

BACKGROUND: There has been considerable discussion in the literature regarding the value and feasibility of community-oriented primary care (COPC), but relatively few published real-world examples. OBJECTIVE: To examine the effect of a practice-based COPC project on rates of preventive health interventions within an inner-city family medicine practice. METHODS: A newly created community advisory board called Patients and Community Together (PACT) and the medical director of the practice in Rochester, NY, collaborated on all phases of the COPC project. Papanicolaou smear and mammography screening, childhood immunizations, diabetes control, and smoking cessation were targeted for intervention. A practice/community awareness campaign was instituted and individual and group incentives were developed. Progress was monitored through a computerized medical record that included all active patients in the practice. RESULTS: Rates of annual Papanicolaou smears increased from 46% to 71%; annual mammography for women older than age 50 years, from 56% to 86%; completed childhood immunizations when younger than 6 years, from 78% to 97%; and performance of semiannual glycosylated hemoglobin, from 85% to 92%. Rates of patients with glycosylated hemoglobin values under 10% improved from 56% to 77%. There were 5 smokers who successfully quit. CONCLUSION: This project illustrates how practice-based COPC can be successfully implemented within a private practice setting. It also shows how COPC principles can be used to achieve the goals for Healthy People 2000 within inner-city practices.

Adult↗

PubMedDate not supplied

Racial and ethnic disparities in perceptions of physician style and trust.

CONTEXT: While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly. OBJECTIVE: To assess whether a person's race or ethnicity is associated with low trust in the physician. DESIGN, SETTING, AND PARTICIPANTS: Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32,929). MAIN OUTCOME MEASURE: Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules. RESULTS: After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites. CONCLUSIONS: Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed. Arch Fam Med. 2000;9:1156-1163

Adolescent↗

PubMedDate not supplied

Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: a randomized controlled trial.

BACKGROUND: Clinic appointments in which patients do not appear (no-show) result in loss of provider time and revenue. Previous studies have shown variable effectiveness in telephone and mailed reminders to patients. METHODS: We conducted a randomized controlled trial of telephone reminders 1 day before the scheduled appointments in an urban family practice residency clinic. Patients with appointments were randomized to be telephoned 1 day before the scheduled visit; 479 patients were telephoned and 424 patients were not telephoned. RESULTS: The proportions of patients not showing up for their appointments were 19% in the telephoned and 26% in the not-telephoned groups (P = .0065). Significantly more cancelations were made when telephoning patients before their visit, 17% compared with 9.9%. The opened scheduling slots were used for appointments for other patients. This additional revenue offset the cost of telephone intervention in our cost analysis. CONCLUSION: Reminding patients by telephone calls 1 day before their appointments yields increased cancelations that can be used to schedule other patients. Telephone reminders provide substantial net revenue, but the results may be population specific.

Adolescent↗

PubMedDate not supplied

Relationship of weight change to required size of vaginal diaphragm.

Health care providers are instructed to counsel diaphragm users to return for a re-fitting of the device if there is a change in the patient's weight. Texts on contraception do not give a rationale for this rule. In an effort to explore the effect of weight change on the required size of diaphragm, the charts of 80 diaphragm users were reviewed. All women had at least two visits for diaphragm fitting. A table was constructed with weight and diaphragm size for each subject at each visit. The subjects ranged in age from mid-tens to early forties and all were patients at the same clinic. Chi-square analysis of the data revealed no correlation between weight change and change in diaphragm size.

Adolescent↗

PubMedDate not supplied

Racial disparities in preterm births. The role of urogenital infections.

OBJECTIVES: To evaluate the impact of urogenital infections on the racial gap between black and white women in preterm birth rates. METHODS: A computer-assisted search of the medical literature was conducted through MEDLINE aided by a manual bibliographic search of published articles and relevant books. Estimates of the relative risk for preterm birth were extracted from published studies for the following infections: N. gonorrhea, syphilis, trichomoniasis, Chlamydia trachomatis, Group B streptococcal vaginal colonization, asymptomatic bacteriuria, genital mycoplasmas, and bacterial vaginosis. Estimates of the prevalence among black and white women by race for each of these infections were extracted from published studies. The attributable risk for preterm birth for selected infections was then calculated for the black and white populations and the impact on the racial gap in preterm births was estimated. RESULTS: Only bacterial vaginosis and bacteriuria appear to be established risk factors for preterm births. Significantly higher rates of bacterial vaginosis among black women may account for nearly 30% of the racial gap in preterm births. Higher rates of bacteriuria among black women may account for roughly 5% of the gap. CONCLUSION: Although these findings are limited by the reliability of published estimates of prevalence and relative risk for these infections, treatment of infections during pregnancy, particularly bacterial vaginosis, offers hope for reducing the racial gap in preterm births.

Bacteriuria↗