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Biomedical subjects

Kevin Fiscella

Publications and source records attributed to Kevin Fiscella.

At least 19 recordsLinked to original sources
PubMed2006

The effect of polycarbophil gel (Replens) on bacterial vaginosis: a pilot study.

OBJECTIVE: To determine if use of intravaginal polycarbophil gel (Replens) for 1 month will: (1) lower vaginal pH; (2) improve signs of bacterial vaginosis (BV). STUDY DESIGN: Seventeen women with BV self-administered polycarbophil gel every third day for 4 weeks in an open-label, prospective pilot study. Primary outcome measures included vaginal pH, presence of amines and Nugent scores. RESULTS: At week 4, there was improvement in Nugent scores, vaginal odor and clue cell count (p<0.05). Eleven women converted from amine positive to negative (73+/-20%). There was no significant change in vaginal pH. CONCLUSIONS: Polycarbophil gel is associated with improved signs of BV, although not vaginal pH.

Acrylic Resins↗
PubMed2006

Does the content of primary care visits differ by the racial composition of physicians' practices?

PURPOSE: The study compared the content of primary care visits between physicians with larger and smaller African American practices. METHODS: We compared the content of primary care adult visits between physicians with larger and smaller African American practices using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey 1997 to 2002. Larger African American practice (>14% of primary care visits by African Americans) was empirically defined to conform with previous studies. RESULTS: Larger African American practices comprised 24% of all practices but accounted for 80% of all visits by African American patients. In adjusted analyses, physicians with larger African American practices were less likely to refer patients to specialists (adjusted odds ratio 0.77; 95% confidence internal 0.61-0.98) and marginally less likely to perform rectal examinations (adjusted odds ratio 0.84; 95% confidence interval 0.56-1.00) but were more likely to schedule a return appointment (adjusted odds ratio 1.25; 95% confidence interval, 1.02-1.52). However, there were no other significant differences in the reported content of the office visits. Results were not altered when different cutoffs for larger African American practices were used or when obstetricians-gynecologists were excluded from the analyses. CONCLUSION: There are few differences in the content of office visits between physicians with larger and smaller African American practices.

Adult↗
PubMed2005

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators.

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Adult↗
PubMed2005

Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Communication↗
PubMed2005

Emotion language in primary care encounters: reliability and validity of an emotion word count coding system.

OBJECTIVES: To develop a reliable and valid computer coded measure to assess emotional expression from transcripts of physician-patient interactions. METHODS: Physician encounters with two standardized patients (SPs) were audiotaped. Fifty patients from each physician (n = 100 primary care physicians) completed surveys that assessed patients' perceptions of their relationships with physicians. Audio-recordings of 193 patient-physician encounters were transcribed and computer-coded to derive a percent emotion words, and research assistants completed the Measure of Patient-Centered Communication (MPCC). RESULTS: After adjustment for potential confounders, regression analyses revealed physicians' use of emotion words and the MPCC contribute independently to patients' and SPs' perceptions of their relationship with physicians. CONCLUSIONS: The computerized coding of emotion words shows promise as a reliable, valid, and simple method to code transcript data of physician-patient interactions. This method may be expanded to examine other aspects of physician language and does not require coder training.

Attitude of Health Personnel↗
PubMed2005

Racial disparity in surgical complications in New York State.

OBJECTIVE: To examine the relationship between race and surgical complications. SUMMARY BACKGROUND DATA: Blacks have been reported to experience higher rates of surgical complications than whites, but the reasons are not known. METHODS: The effect of the black race on risk of any surgical complication (from the Agency for Healthcare Research and Quality's patient safety indicators) was examined using New York State (NYS) hospital discharge data from 1998 to 2000. Sequential, hierarchical analyses controlled for: 1) patient age and gender, 2) morbidity length of stay, 3) individual social factors, 4) hospital characteristics, and 5) ecologic factors (region of state, percent black and Medicaid annual discharges, and mean income of admitted patients). RESULTS: Following adjustment for patient age and gender, blacks had 65% higher odds for a surgical complication. Further adjustment for comorbidity and length of stay (LOS) reduced the odds substantially to 1.18. Additional adjustment for American Hospital Association hospital characteristics essentially eliminated the risk. Final adjustment for hospital ecologic variables reduced the odds to 1.0. CONCLUSIONS: Higher rates of surgical complications among blacks than whites in NYS are primarily explained by differences in comorbidity LOS and the hospital where the surgery occurred.

Black People↗
PubMed2005

Racial disparities in the content of primary care office visits.

BACKGROUND: Little is known about racial disparities in primary care at the level of the office visit. OBJECTIVE: To assess racial disparities in the receipt of commonly performed/recommended procedures during routine primary care office visits and examine trends in disparities over time. DESIGN, SETTING, AND PATIENTS: The sample included 88,303 visits by adults to 3,260 primary care physicians in office-based practices in the National Ambulatory Medical Care Surveys, 1985, 1989, 1990, 1991, 1992, and 1995 to 2001. MEASUREMENTS: Adjusted odds for receipt or recommendation of commonly performed office procedures. RESULTS: During the years 1985 to 2001, African Americans, compared with whites, had lower odds of receiving a Pap test (odds ratio (OR) 0.81; 95% confidence interval (CI) 0.70 to 0.93), rectal exam (OR 0.67; 95% CI 0.56 to 0.80), smoking cessation counseling (OR 0.80; 95% CI 0.66 to 0.96), and mental health advice (OR 0.51; 95% CI 0.38 to 0.69), but had higher odds for visual screening (OR 1.38; 95% CI 1.08 to 1.77), weight advice counseling (OR 1.27; 95% CI 1.13 to 1.44) and receiving a follow-up appointment (OR 1.45; 95% CI 1.29 to 1.64). These findings were not appreciably altered by adjustment for physician practice characteristics including percent African American or Medicaid patients. Disparities disfavoring African Americans in cholesterol testing and smoking cessation observed during 1985 to 1992 were not observed in 1995 to 2001. CONCLUSIONS: The findings suggest that race is associated with the type of primary care received by patients, at least for selected procedures, with evidence that some disparities have diminished over time.

Black or African American↗
PubMed2005

Management of opiate detoxification in jails.

Little is known about how jails manage opiate withdrawal among arrestees and inmates. We conducted a national survey of 500 jails in the United States. We specifically asked about assessment and management opiate dependency among arrestees and use of standardized protocols. Among the 245 jails that responded, more than half (56%) reported they routinely assessed arrestees for opiate dependency and most (59%) reported using standardized detoxification protocols. Fifty percent of jails used clonidine for detoxification. Very few jails (1%) used methadone or other opiates (2%) for detoxification. Half of all jails (49%) failed to use clonidine, methadone or other opiates for detoxification. These results show that many jails fail use recommended opiate detoxification procedures and highlight the need for uniform national standards for jail management of opiate dependence.

Acute Disease↗
PubMed2005

Is patient HMO insurance or physician HMO participation related to racial disparities in primary care?

OBJECTIVE: To examine the relationship between racial disparities in common primary care procedures and patient HMO membership and physician level of HMO participation. DESIGN: Cross-sectional analysis. METHODS: Data were obtained from a nationally representative sample of primary care office visits documented in the National Ambulatory Medical Care Survey for 1985, 1989-1992, and 1997-2000. Patient HMO membership was assessed based on reports by primary care physicians (defined as family physicians/general practitioners, internists, or obstetrician-gynecologists). Physician HMO participation was assessed based on the proportion of the physician's patients who were in an HMO. Patient characteristics (age, sex, race, insurance, diagnoses) and office procedures or interventions were determined by examining the physician report. Patients were adults aged 19 years or older. RESULTS: In adjusted analyses, African Americans, compared with whites, had lower odds of receiving a Pap test (adjusted odds ratio [AORI = 0.76; 95% confidence interval [CI] = 0.65, .90), a rectal exam (AOR = 0.67; 95% CI = 0.54, 0.84), smoking cessation advice (AOR = 0.72; 95% CI = 0.58, 0.91), and mental health advice (AOR = 0.46; 95% CI = 0.29, 0.72), but had higher odds of receiving advice on diet and weight, and a follow-up appointment. Notably, there were no significant interactions between either patient HMO membership or physician level of HMO participation, patient race, and receipt of primary care services. CONCLUSION: Neither patient HMO membership nor physician level of HMO participation is substantially associated with racial disparities in primary care.

Adult↗
PubMed2005

Race, genes and preterm delivery.

High rates of preterm delivery (PTD) among African Americans are the leading cause of excess infant mortality among African Americans. Failure to fully explain racial disparity in PTD has led to speculation that genetic factors might contribute to this disparity. Current evidence suggests that genetic factors contribute to PTD, but this does not imply that genetic factors contribute to racial disparity in PTD. Environmental factors clearly contribute to PTD. Many of these factors acting over a women's life prior to pregnancy disproportionately affect African Americans and contribute significantly to racial disparity in PTD. Thus, inferring genetic contribution to racial disparity in PTD by attempting to control for environmental factors measured at a single point in time is flawed. There is emerging evidence of gene-environment interactions for PTD, some of which disproportionately affect African Americans. There is also evidence of racial differences in the prevalence of polymorphisms potentially related to PTD. However, to date there is no direct evidence that these differences contribute significantly to racial disparity in PTD. Given the complexity of polygenic conditions such as PTD, the possibility of any single gene contributing substantially to racial disparity in PTD seems remote.

Black or African American↗
PubMed2004

Are racial differences in vaginal pH explained by vaginal flora?

OBJECTIVES: The study assessed racial differences in vaginal pH among women without bacterial vaginosis. STUDY DESIGN: Data from the Vaginal Infections and Prematurity (VIP) Study were analyzed. From 1984 to 1989, 13,917 largely low-income women were enrolled during routine prenatal visits from 23 to 26 weeks' gestation. Vaginal cultures, Gram stains, and pH levels were collected. Comparisons of pH by race were made among women with Gram stain scores <7 and without trichomoniasis before and after adjustment for actual Gram stain score. RESULTS: Among women with Gram stain scores <7, there was a modest but statistically significant racial difference in vaginal pH level. However, after controlling for difference in Gram stain score, age, and study site, there was no longer a significant difference in vaginal pH. CONCLUSION: There is no significant difference in vaginal pH level between black and white women after controlling for differences in confounding factors, particularly vaginal flora.

Adolescent↗
PubMed2004

Estimating racial/ethnic disparity in mammography rates: it all depends on how you ask the question.

BACKGROUND: Estimates of racial disparity in mammography appear to differ depending on the data source. This study examined the impact of different survey methodology on estimates of racial disparity in mammography. METHODS: Responses from 3,090 women > or =40 years to two different questions from the 1996 Medical Expenditure Panel Survey (MEPS) were compared when a mammogram was last obtained versus what medical services, including mammography, were obtained over a 4-month interval, aggregated across 1 year. RESULTS: There was no significant racial disparity in 1-year mammography prevalence based on the first question (white-black difference, 3.3%; 95% confidence interval [CI], -2.5, 9.2). In contrast, a significant disparity in 1-year mammography prevalence was found based on the medical services question (difference, 13.1%; 95% CI 8.6, 17.6). Disparity estimates by Hispanic ethnicity were similar for the two questions: white-Hispanic difference, 1.6%; 95% CI -4.3, 7.5, and white-Hispanic difference 5% (-0.2, 10.1). Adjustment for age, income, and insurance did not alter these findings. CONCLUSIONS: Estimates of racial, but not ethnic, disparities in mammography seem to depend on how the question is asked. These results caution against exclusive reliance on annual self-reports for monitoring disparities in preventive care.

Adult↗
PubMed2004

Racial disparity in infant and maternal mortality: confluence of infection, and microvascular dysfunction.

OBJECTIVES: Racial disparities in infant and maternal mortality have been attributed to the unique stresses faced by Black women in the United States, but the underlying pathophysiological pathways are poorly understood. This paper reviews the literature related to potential causes of racial disparities in infant and maternal mortality. METHODS: A review of the literature from 1966 to 2003 was conducted using a series of searches of Medline, obstetrical journals, and bibliographies. The review focused on potential contributing pathophysiological factors to infant and maternal mortality. RESULTS: Racial disparities in neonatal mortality largely result from excess rates of preterm birth, fetal growth restriction, and neonatal sepsis while racial disparities in maternal mortality reflect greater prevalence and/or severity of cardiovascular/preeclamptic complications, hemorrhage, and infection among African American women. A large body of epidemiological, placental, and pathophysiological evidence suggests that racial disparities in these disparate outcomes result from two distinct, but potentially converging, pathways: infection and vascular. Racial disparities in intrauterine infection and microvascular dysfunction during pregnancy may result from a constellation of environmental and intergenerational risk factors including psychosocial stress, douching, bottle-feeding, lead exposure, diet, intrauterine growth, and genes. CONCLUSIONS: Disparities in infant and maternal mortality appear to reflect a confluence of infections and microvascular dysfunction during pregnancy among African American women. Interventions that target these conditions offer promise for reducing racial disparities in these critical outcomes.

Black or African American↗
PubMed2004

Jail management of arrestees/inmates enrolled in community methadone maintenance programs.

Anecdotal evidence suggests that many jails fail to adequately detoxify arrestees/inmates who are enrolled in methadone programs, but there are few empirical data. The objective of this study was to assess how jails manage arrestees/inmates enrolled in methadone programs. A national survey of 500 jails in the United States was conducted. Surveys were mailed to the 200 largest jails in the country in addition to a random sample of 300 of the remaining jails (10% sample). Jails were specifically asked about management of opiate dependency among arrestees/inmates enrolled in methadone programs. Weighted logistic regression analyses were conducted to assess predictors of continuing methadone during incarceration and use of recommended detoxification protocols. Among the 245 (49%) jails that responded, only 1 in 4 (27%) reported they contacted the methadone programs regarding dose, and only 1 in 8 (12%) continued methadone during the incarceration. Very few (2%) jails used methadone or other opiates for detoxification. Most used clonidine. However, half (48%) of jails failed to use clonidine, methadone, or other opiates to detoxify inmates from methadone. Weighted logistic regression models showed that moderately large jails and those located in the South and Midwest were significantly more likely to continue methadone. Very large jails, those with an estimated prevalence of opiate dependence of 6%-10% among arrestees/inmates, and those located in the Northeast were significantly more likely to use recommended detoxification protocols. Very few jails provided continuous treatment to arrested persons on methadone, and half failed to detoxify arrestees/inmates using recommended protocols. These practices jeopardize the health and well-being of persons enrolled in methadone programs and underscore the need for uniform national policies within jails.

Heroin Dependence↗
PubMed2004

Health disparities based on socioeconomic inequities: implications for urban health care.

Health is unevenly distributed across socioeconomic status. Persons of lower income, education, or occupational status experience worse health and die earlier than do their better-off counterparts. This article discusses these disparities in the context of urban medical practice. The article begins with a discussion of the complex relationship among socioeconomic status, race, and health in the United States. It highlights the effects of institutional, individual, and internalized racism on the health of African Americans, including the insidious consequences of residential segregation and concentrated poverty. Next, the article reviews health disparities based on socioeconomic status across the life cycle, beginning in fetal health and ending with disparities among the elderly. Potential explanations for these socioeconomic-based disparities are addressed, including reverse causality (e.g., being poor causes lower socioeconomic status) and confounding by genetic factors. The article underscores social causation as the primary explanation for health disparities and highlights the cumulative effects of social disadvantage across stages of the life cycle and across environments (e.g., fetal, family, educational, occupational, and neighborhood). The article concludes with a discussion of the implications of health disparities for the practice of urban medicine, including the role that concentration of disadvantage plays among patients and practice sites and the need for quality improvement to mitigate these disparities.

Cities↗