Biomedical subjects

L M Baldwin

Publications and source records attributed to L M Baldwin.

At least 37 records · Page 2Linked to original sources

PubMed1994

Do providers adhere to ACOG standards? The case of prenatal care.

OBJECTIVE: To examine the extent to which obstetric providers abide by prenatal practice guidelines published by ACOG. METHODS: The prenatal records were abstracted for low-risk patients initiating care with randomly selected urban obstetrician-gynecologists, rural obstetrician-gynecologists, urban family physicians, rural family physicians, and urban certified nurse-midwives in Washington state between September 1, 1988 and August 30, 1989. The prenatal care recorded in their medical charts was compared with the ACOG-recommended guidelines. RESULTS: Overall, providers of all five types adhered closely to the published standards. Certified nurse-midwives recorded a standard of practice that most closely matched that recommended by ACOG. Overall, there was less complete adherence in the recording of maternal height, fetal activity after 30 weeks' gestation, and fetal presentation at or after 36 weeks' gestation. Those laboratory tests that ACOG has recommended most recently (serum alpha-fetoprotein and diabetes screening) and those not recommended for routine use were ordered less often on average by providers. CONCLUSIONS: The cross-sectional nature of this study cannot demonstrate definitively that ACOG's guidelines have changed provider prenatal practices. However, these findings demonstrate that providers in varying specialties and geographic locations can adhere to a detailed set of clinical guidelines if they are appropriately disseminated and implemented.

Adult↗

PubMed1993

The effect of coordinated, multidisciplinary ambulatory care on service use, charges, quality of care and patient satisfaction in the elderly.

This study evaluated a multidisciplinary care center, the Pike Market Clinic (PMC), whose physicians provide and coordinate inpatient and outpatient care for downtown low-income elderly in Seattle. We interviewed users of PMC and their near-neighbors with a 206 item questionnaire to compare their medical and social service use, quality of care, and satisfaction. We then estimated mean annual charges/person for inpatient, outpatient and emergency room services in the two groups. Demographic and health status characteristics were similar in the two groups. PMC patients made significantly more annual visits than neighbors to their primary physicians. Visits to non-primary physicians occurred at the same rate in both groups, but PMC patients were referred more often by their primary physicians. Both emergency room and inpatient use were higher in the neighbor group. Social services were used at the same rate by PMC patients and neighbors. Various indices suggested that quality of care and satisfaction were comparable or superior among PMC patients. Using utilization data, we estimated that neighbors generated charges over $1000/person/year greater than PMC patients. Coordination by PMC providers rather than the availability of multidisciplinary services may be largely responsible for utilization differences between PMC patients and their neighbors.

Aged↗

PubMed1993

Access to obstetric care.

Initially, this article examines the relationship between access to components of obstetric care and birth outcomes. It goes on to describe the significant decline in physician participation in obstetrics and its possible relationship to increasing rates of late or no prenatal care in the United States. The limitations of obstetric capacity and future access to providers of obstetric care in the United States versus Canada are explored. The article concludes with a discussion of strategies for improving access to obstetric care.

Female↗

PubMed1993

A comparison of student clerkship experiences in community practices and residency-based clinics.

BACKGROUND: In our required family medicine clerkship, we used data from student logbook records of clinical experience to compare the learning experiences of students in community practices and residency-based clinics. METHODS: Sixty-eight University of Washington students collected data on patients seen during the final two weeks of their family medicine clerkships. We compared patient demographics, location of patient encounters, and clinical problems seen at nine residency and eight community locations in a four-state area. National Ambulatory Medical Care Survey data were used to compare student experiences to national practices. RESULTS: Log data documented that both community practices and residency sites met the course curriculum goals. Some variations occurred between the two types of clerkship sites, however. Students at community practices saw a higher mean number of patients and did more procedures than students at residency sites. Students at residencies were more likely to see patients for health maintenance and pregnancy care and less likely to see lacerations, sprains or strains, and some chronic diseases. CONCLUSION: Episodic log data were successfully used to monitor the objective educational strategies for residency- and community-based student clerkship sites. Although all students met clerkship objectives, there were significant differences in certain aspects of students' clinical experiences at the two types of clerkship sites.

Ambulatory Care Facilities↗

PubMed1992

Professional relationships between midwives and physicians: collaboration or conflict?

This study examines the professional relationships between midwives and physicians providing obstetrical care in Washington State. Four hundred ninety-six randomly sampled family physicians and obstetrician-gynecologists and 211 certified nurse, licensed, and lay midwives were surveyed to learn more about midwife/physician consulting relationships. Only certified nurse midwives have forged mutually satisfactory relationships with the physician community. Increased hospital-based training and practice opportunities are needed before licensed midwives can improve their professional relationships with physicians.

Certification↗

PubMed1991

Tort reform and the obstetric access crisis. The case of the WAMI states.

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.

Alaska↗

PubMed1991

Characteristics of physicians with obstetric malpractice claims experience.

This study compared the demographic and practice characteristics of physicians with and without obstetric malpractice experience. The sample consisted of 387 family physicians and 204 obstetricians in Washington state who were insured for obstetrics by a major malpractice carrier between January 1982 and June 1988. Fifty-three physicians (9%) had an obstetric malpractice claim during the study period. The approximate overall rate of obstetric malpractice claims was low: 0.32 per 1000 deliveries. The higher the total delivery volume (exposure), the greater the chance of having malpractice experience. Although physicians with practices of over 200 deliveries per year were more likely to have had malpractice experience, their risk of malpractice experience per delivery was lower than that of providers doing fewer than 200 deliveries per year. Our work suggests that insurers might consider basing obstetric malpractice premiums on numbers of deliveries rather than specialty.

Female↗

PubMed1991

Differences in the obstetric practices of obstetricians and family physicians in Washington State.

In response to the obstetric malpractice crisis, both obstetrician-gynecologists and family physicians have raised their fees and preferentially selected lower risk patients. In addition, large numbers of general and family physicians have left obstetric practice altogether. The impact of these responses was explored by examining the differences in the demographic and clinical profile of patients served by these two disciplines in the State of Washington. Eighty-five percent (45,540) of all complete records from 1983 births attended by physicians in the State of Washington were matched to physician specialty information. These births represent 67% of the total deliveries in Washington State in 1983. Although twice as many general and family physicians as obstetricians were practicing obstetrics, obstetricians delivered 2.5 times as many infants as did general and family physicians. Obstetricians served an older patient population with more low-birthweight infants, multiple births, and complications of pregnancy than family physicians. General and family physicians were more likely to care for minorities, teenagers, and unmarried and rural mothers. Obstetricians cared for patients with higher medical risks, whereas general and family physicians provided care to more socially vulnerable and geographically isolated populations. To the extent that general and family physicians are differentially abandoning obstetric practice because of the current malpractice crisis, access to care for rural and socially vulnerable groups may deteriorate rapidly.

Adolescent↗

PubMed1990

The relation of obstetrical volume and nursery level to perinatal mortality.

We investigated the relation of hospital delivery volume and nursery technology level to perinatal outcome in 226,164 White singleton births in Washington State, 1980-83. Level III facilities (neonatal intensive care unit) were defined by the state licensing commission. We defined the Level II (intermediate) and Level I (normal newborn) facilities using published criteria. Infants under 2000 gm born in Level III facilities had half the risk of perinatal death compared to those born in a Level I or II facility. No significant improvement was noted among level or volume groupings for normal birthweight infants. A loglinear regression model of hospital perinatal death rates showed that when birthweight and maternal risk were controlled, obstetrical volume added minimal explanatory power to level of nursery care.

Birth Weight↗

PubMed1988

Growth patterns of first-generation Southeast Asian infants.

The growth patterns of Southeast Asian infants appear to differ from those of the National Center for Health Statistics standards for US children. This study examines the length, weight, and head circumference curves of 175 healthy, full-term, US-born Laotian and Cambodian infants seen periodically at a pediatric clinic from birth to 18 months of age. The median length, weight, and head circumference values of these infants were significantly lower than those of the National Center for Health Statistics standards for infants older than 6 months. These differences were more striking in girls than boys. A decision to observe rather than to pursue a diagnostic work-up in an otherwise healthy Southeast Asian infant who exhibits a slow growth pattern may be the most appropriate management style.

Body Height↗

PubMed1988

Outcomes of regionalized perinatal care in Washington State.

We evaluated the extent to which the regionalization of perinatal care in Washington State has succeeded in concentrating high-risk pregnancies in technologically appropriate referral centers and in reducing differences in neonatal outcome among hospitals. Of all infants weighing less than 1,500 grams born between 1980 and 1983, nearly 68% were delivered in level III hospitals, although only 24% of all babies are born in these hospitals, indicating that the state is highly regionalized. Neonatal outcomes-as measured by standardized mortality ratios-are similar in level I, II and III hospitals and are not greatly influenced by the rural or urban location of the hospital. The most promising strategy for further reducing neonatal mortality is to decrease the number and proportion of very-low-birth-weight births.

Female↗

PubMed1986

Copatient relationships on a short-term psychiatric unit.

Emotional and physical relationships among copatients on a short-term psychiatric unit were assessed in a two-year prospective study. Sixty-four relationships involving 102 patients were reported; the incidence rate was estimated at 10.7 percent. Thirty-three percent of the relationships were characterized as emotional, 9 percent as physical, and 58 percent as both. Patients involved in the relationships tended to be young and unmarried and to have a diagnosis of eating disorder, personality disorder, or bipolar disorder. Although most of the relationships were reciprocal, half were judged to be destructive and to create management problems. Staff discussed the relationship with the patients when it was considered destructive or exploitative but ignored relationships felt to be positive and healthy. The authors urge further studies of such relationships to help clarify patient management issues.

Adolescent↗

PubMed1984

Gender and psychiatric clerkship performance.

This study compared the performance of male and female medical students on a psychiatric clerkship rotation. The women performed at a higher level than the men, although the difference was not significant. In general, the men scored significantly higher on national standardized medical examinations. Correlations between psychiatric clerkship evaluations and national examinations were low, suggesting that the two measures are independent. These findings for psychiatric clerkship are consistent with those for clerkships in medicine, surgery and obstetrics, implying that female clinical clerks are just as capable as male clinical clerks in providing high quality medical care.

Achievement↗

PubMed1982

Effect of vocal disguise on estimations of speakers' ages.

To determine the effect of speakers' attempts to disguise their voices on listeners' accuracy in age judgments, 26 speakers, 13 females and 13 males, recorded six sentences under three conditions: (a) in a normal manner, actually were, and (c) in a manner in which they attempted to sound much older than they actually were. Three master tapes were constructed, one for each of the three conditions. A total of 20 judges, 10 females and 10 males, participated in three sessions, one for each of the three master tapes. In each session they were asked to judge the age of the speaker of each sentence and, using a seven-point confidence rating scale, to indicate the over-all confidence in their judgments at the end of each session. Although a majority of speakers yielded age estimates consistent with the conditions of intended disguise, the differences in listeners' estimates among all three conditions were relatively small. Moreover, differences between speakers' actual ages and listeners' age estimates in the control condition were also small. Implications of the findings and suggestions for research are discussed.

Adolescent↗

PubMedDate not supplied

Influence of provider characteristics and insurance status on maternal serum alpha-fetoprotein screening.

BACKGROUND: The maternal serum alpha-fetoprotein test (MSAFP) was developed to screen for neural tube defects. Little is known about the adoption of the MSAFP test. This study examines the effect of provider specialty and geographic location and patient insurance status on MSAFP test use in Washington State. METHODS: We conducted a retrospective cohort study of MSAFP use in low-risk obstetric patients of five provider groups. MSAFP use was examined for Medicaid and privately insured patients, as well as for the patients of the five provider types. RESULTS: Patients of urban and rural obstetrician-gynecologists were most likely to have MSAFP testing (80.4 percent and 77.0 percent, respectively); patients of urban certified nurse midwives and rural family physicians were least likely to have MSAFP testing (64.2 percent and 62.2 percent, respectively). Patients of certified nurse midwives were more likely to decline MSAFP testing when offered (26.1 percent). Medicaid-insured women were significantly less likely to have MSAFP testing than privately insured women (60.5 percent versus 79.1 percent, P < or = 0.05). CONCLUSIONS: Providers and patients did not uniformly use MSAFP screening. Efforts should be made to ensure that all patients are adequately informed of screening tests for neural tube defects.

Female↗

PubMedDate not supplied

Is hospitalism new? An analysis of medicare data from Washington State in 1994.

CONTEXT: Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology. DATA SOURCE: 1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State. RESULTS: For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists." CONCLUSION: Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists."

Aged↗

PubMedDate not supplied

Differences in the obstetric malpractice claims filed by Medicaid and non-Medicaid patients.

BACKGROUND: Many physicians believe Medicaid patients are more likely than non-Medicaid patients to file malpractice claims. This study examines the accuracy of this belief in regard to obstetric malpractice claims. METHODS: Claims filed between January 1982 and June 1988 from the major malpractice insurer in Washington State were used to compare obstetric malpractice claims filed on behalf of Medicaid and non-Medicaid patients. RESULTS: Eleven percent (7/62) of all closed obstetric claims were filed by Medicaid patients, whereas 19 percent of all births in Washington State were to Medicaid patients between 1982 and 1988. Failure to diagnose or treat a fetal condition was the most commonly alleged negligence in both Medicaid and non-Medicaid groups. Most claims in both groups were settled before the cases went to court; a substantial minority of claims were dropped. The mean cost of Medicaid claims ($406,984) was three times that of non-Medicaid claims ($133,743), suggesting that paid Medicaid claims were more severe than paid non-Medicaid claims. CONCLUSIONS: Medicaid patients appear no more likely to file obstetric malpractice claims than non-Medicaid patients. The low likelihood of filing claims, coupled with large settlements, suggests that Medicaid patients may have less access to legal services than non-Medicaid patients.

Female↗

PubMedDate not supplied

Can physicians be induced to resume obstetric practice?

BACKGROUND: Decreased numbers of obstetric providers during the last decade have limited access to obstetrics care, especially for some groups of women. Increasing or stabilizing the number of providers could increase access. METHODS: A questionnaire was mailed in 1989 to 1965 Washington State family physicians and obstetricians to determine their attitudes toward the practice of obstetrics. Sixty-six percent of physicians responded to the survey. RESULTS: Of those who had quit obstetrics in the previous 3 years, 42 percent of responding family physicians and 19 percent of responding obstetricians would consider resuming. Those family physicians willing to consider resuming their obstetric practices were more likely to have been in practice fewer years, employed by a health maintenance organization (HMO), or located in a rural area. A majority of all respondents cited excessive malpractice premiums and fear of malpractice suit as reasons for stopping obstetric practice. Family physicians willing to consider resuming obstetrics were more concerned about the overall number of obstetric providers in their area. Rural family physicians willing to consider resuming obstetrics listed poor backup or shared call more often as a reason they had quit. CONCLUSIONS: Attention targeted to the concerns of family physicians who have been in practice for a short time, who work for HMOs, or who are in rural practice might help induce some physicians to resume obstetrics.

Attitude of Health Personnel↗