Biomedical subjects
S E Radecki
Publications and source records attributed to S E Radecki.
RBRVS: objections to Maloney, II.
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Determinants of child-bearing intentions of low-income women: attitudes versus life circumstances.
Surveys of low-income women in Los Angeles County in 1985 and 1986 were used to examine the relative impact of child-bearing motivations versus life circumstances on the intention to have a(nother) child. Future child-bearing intentions are strongly related to current parity level regardless of marital status, race/ethnicity or economic status. Psychological motivating factors predict child-bearing intentions of nulliparous women, but not those of parous women. Multivariate analyses showed that motivation for parenthood and life circumstances combined predicted women's child-bearing intentions 88.6% of the time for nulliparous women, but 73.7% for parous women. These findings suggest that, in a low-income population, the onset of parenthood reduces the relationship between specific motivations for child-bearing and actual child-bearing intentions, and diminishes the ability to predict child-bearing intentions based on both attitudinal and social/structural factors.
Improving the educational process of cancer case conferences.
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Clinical training in human immunodeficiency virus disease for community physicians. The Los Angeles experience.
In the past decade, the increased number of persons being treated for infection with the human immunodeficiency virus (HIV) has placed an enormous burden on specialty clinics. This is especially true in Los Angeles, where care of patients with the acquired immunodeficiency syndrome (AIDS) has been termed a "crisis" situation. Especially in its early stages, HIV disease can be appropriately managed by primary care physicians who provide patients with medical and psychological counseling and refer them to specialists when major AIDS-related complications develop. Physicians completing their training as recently as 5 years ago, however, received little systematic preparation in the care of HIV-infected patients and thus may lack important skills such as the ability to recognize opportunistic infections early in their course. By means of a 1-week intensive preceptorship in a high-volume AIDS clinic, we are preparing community physicians to assume a more active role in providing care for this growing patient population. In the preceptorship, participants receive one-on-one training from specialists in infectious diseases, pulmonary diseases, and hematology and oncology, as well as from internists and family physicians. Evaluation of the clinical experience demonstrated a greater level of confidence on the part of program participants in treating HIV-infected patients and showed that participants screen and test high-risk patients in their practices and devote a substantial proportion of their practices to caring for HIV-infected patients.
Risk of needlesticks and occupational exposures among residents and medical students.
PROBLEM: Occupational exposure to human immunodeficiency virus (HIV) disease is a problem of concern to all health care workers, especially those in large urban teaching hospitals with large numbers of HIV-positive patients. METHOD: The self-reported incidence of needlesticks and other exposures to patients' blood and body fluids in 550 medical students and residents at the Los Angeles County-University of Southern California Medical Center during the 1989 through 1990 training year was studied by means of an anonymous survey. RESULTS: Seventy-one percent of respondents reported one or more needlesticks or other exposures during the training year. Surgical residents had a sixfold greater rate of occupational exposure compared with medicine residents and were significantly more likely to experience suture needlesticks, cuts, open wound contamination, and mucous membrane exposure. Medical students generally were at somewhat lower risk compared with residents, but had greater rates of hollow-needle puncture accidents. No trend was found for accidental exposure by level of residency training. The known HIV-positive exposure rate for students and residents was 9.5% per person per year. Only 9% of exposures were actually reported to the health center. CONCLUSIONS: Based on the rate of exposures reported, numbers of known and estimated HIV-positive patients, and previously published HIV seroconversion rates, we would expect an annual rate of HIV seroconversion rates, we would expect an annual rate of HIV seroconversion as a result of occupational exposures of between 27 and 46 per 100,000. This rate is similar to the leading cause of death in this age group--motor vehicle accidents--and is equivalent to one student or resident in this medical center seroconverting every 2 to 3 years. Although only a portion of accidental exposures are regarded as preventable, these data emphasize the importance of increased efforts toward improved education, prevention, and accessibility of protective equipment.
Investigation into the educational process of cancer case conferences.
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Effect of on-site facilities on use of diagnostic radiology by non-radiologists.
This study uses self-reports from a nationwide sample of 5447 physicians in ten medical and surgical specialties to assess the impact of on-site facilities on the use of radiologic examinations by non-radiologists. Data from 169,559 patient visits show that when on-site radiologic facilities are available to non-radiologists, radiographs increase by a factor of 1.2 (internal medicine) to 1.7 (pediatrics). Use of radiologic examinations is up to four times greater for hospitalized compared with nonhospitalized patients and is slightly higher for hospital-based physicians and for younger physicians.
Family medical care: who provides it, who receives it?
A national survey of physicians was used to examine the extent to which they provide family care. Care of other family members was noted for 64.9% of patients of family physicians, 33.9% of patients of general internists, and lesser percentages for patients of medical subspecialists and surgeons. Family physicians in office-based practice and those in rural areas show the highest percentages of family care. Family care is more likely to be noted for patients receiving obstetrical and preventive care and least likely for patients receiving care for psychosocial problems. Family care is most common for children 10 years and under and for older adults, and least common for males 21-30 years of age.
End-stage renal disease and the practice of nephrology.
Data from a national survey of 336 nephrologists who provide dialysis care on capitation reimbursement show differences in practice activity associated with the proportion of patients with end-stage renal disease (ESRD). On the average, ESRD patients account for 53% of patients seen by these physicians. Nephrologists who have the majority of their visits with ESRD patients average more than 120 patient encounters per week, approximating the practice workloads of primary care physicians. Nephrologists spend comparable amounts of time providing treatment for ESRD and non-ESRD patients in the same settings, schedule additional office visits for facility dialysis patients, and provide treatment and advice for problems not related to dialysis. Whereas care for acute renal failure patients is primarily based on consultations and involves a narrow focus, treatment for ESRD involves the provision of comprehensive primary medical care by nephrologists to their patients being treated with dialysis.
Telephone patient management by primary care physicians.
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Dialysis for chronic renal failure: comorbidity and treatment differences by disease etiology.
A national sample of dialysis physicians was used to obtain data for a comparison of patient characteristics, comorbid conditions and treatment patterns associated with the five leading causes of end-stage renal disease (ESRD). The data are used to assess trends in physician care for ESRD patients and likely changes in program costs. The analysis shows that patients with glomerulonephritis are the youngest. Those with hypertensive nephropathy are the oldest, and include the highest proportion of blacks, while those with polycystic kidney disease include the lowest proportion of blacks. Patients with diabetic nephropathy have the most problems noted at the time of physician contact, the most emergent and severe problems, the highest number of diagnostic tests utilized, the most complex treatments required and the longest physician time spent per encounter. Patients with 'other interstitial nephritis' are significantly more likely to have infections, musculoskeletal disorders, chronic obstructive pulmonary disease and neoplasms noted as comorbid conditions. They also have the highest number of therapeutic procedures and the greatest percentage of referrals for consultations. Survey data highlight the evolving nature of Medicare's ESRD program. With increasing numbers of elderly and diabetic patients, more physician time will be required for the overall care of the dialysis patient, and increasing costs associated with necessary diagnostic tests and referrals can be expected.
Use of clinic versus private family planning care by low-income women: access, cost, and patient satisfaction.
Use of private physicians versus public family planning facilities by poverty level and near poverty level women was examined by means of a sample survey conducted in low-income areas of Los Angeles County. Utilization differed by race/ethnicity, with Hispanics more likely to go to federally subsidized family planning clinics (primarily county-run), Whites and Blacks to private physicians. Private family planning offers easier access, greater convenience, and higher satisfaction, albeit at almost double the cost. Clinic usage is influenced by lack of a regular source of medical care and lack of insurance coverage more than poverty level per se. Clinic patients report greater patient education regarding contraceptive methods, but less general medical care during clinic visits. They are more likely than private patients to express a desire for a different source of family planning care.
Case-mix and treatment in end-stage renal disease: hemodialysis v peritoneal dialysis.
The University of Southern California School of Medicine conducted a nationwide survey of 336 nephrologists to obtain demographic and clinical data on 6,411 patients with end-stage renal disease (ESRD). Patient demographic data, along with ESRD etiology and comorbid conditions noted by the physician, were compared across various modalities of dialysis. Characteristics of the treatment provided were differentiated by the mode of dialysis and the location of the patient encounter. Results of the analysis show that patients on peritoneal dialysis are more likely to be female and have higher rates of diabetes compared with hemodialysis (HD) patients. Statistically, patients on intermittent peritoneal dialysis are older, more likely to be black, and have a higher incidence of cardiovascular conditions. Continuous ambulatory peritoneal dialysis patients have greatest problem severity and require more physician time and more complex services, whereas home HD patients require the greatest number of diagnostic tests and therapeutic procedures. Hospital inpatient care shows greater case-mix severity and more intensive treatment, but this does not differ by the mode of dialysis. Finally, patients of freestanding dialysis facilities are more likely to have hypertensive renal disease, whereas patients at hospital-based facilities are older, more likely to be seen in the hospital, have more urgent and severe problems during dialysis rounds, and require more physician time, more complex services, and more diagnostic tests and therapeutic procedures.
Do physicians spend less time with older patients?
In view of the additional time that older persons require for giving and receiving information, as well as for the examination process, it is important for manpower and reimbursement planning to better understand the nature of the physician-patient encounter with the elderly. We examined a series of national surveys of physicians' professional activities and found that physicians tend to spend less time with their older patients and also that encounter time by physicians in different specialties varies widely. Internists and cardiologists spend substantially more time with patients compared with general and family practitioners. For 65-74-year-old ambulatory patients, the average visit lengths are 18.3 minutes for internists, 18.0 for cardiologists, 11.2 for general practitioners, and 12.1 for family practitioners. Compared with ambulatory visit lengths for patients aged 45 to 64 years, average encounter times for 75-year-olds with family physicians were 0.8 minutes shorter, with general practitioners 1.2 minutes shorter, with internists 2.3 minutes shorter, and with cardiologists 3.0 minutes shorter. However, when all characteristics of the visit were considered, the effect of patient age remained significant only for general practitioners. A multivariate analysis of factors related to physician time for ambulatory care showed that more time is associated with multiple problems, problem severity, and the use of diagnostic testing. For general and family practice, the greater the number of previous visits for a problem, the shorter the encounter time is. Additional characteristics associated with shorter physician-patient encounter times include the volume of patients per week and the use of physician assistants within the practice. These findings have implications for medical education and manpower projections.
Are physicians sensitive to the special problems of older patients?
The sensitivity of primary care physicians to the health care needs of older patients was explored by means of an analysis of the use of diagnostic tests and therapeutic procedures during ambulatory visits. Survey data on a total of 28,265 visits to internists, family and general practitioners were examined to determine possible age-related differences in care. The study found that diagnostic testing falls off significantly for patients 75 years of age or older and that internists use substantially more tests for each age group than do family and general practitioners. The pattern of use of diagnostic tests in this secondary analysis does not address the issue of "appropriateness" but does suggest a pattern that makes little sense based on the known distribution of disease and functional disability in aging populations.
Diagnostic radiology usage in ambulatory and hospital care.
Data from a nationwide survey of physicians show that there were a total of 214 million medical radiologic examinations performed in the United States in 1977, or just under one for each member of the resident population. Approximately 58% of these procedures were performed in ambulatory patients (including those in hospital outpatient departments) and 42% were in hospitalized patients. Data for the number of visits with (single or multiple) radiologic examinations produced an estimate of 184 million annual visits with one or more diagnostic radiographs. These estimates provide a comprehensive measure of national use of diagnostic radiology at the time the data were collected, as well as a basis of comparison for analyses of contemporary patterns of utilization of radiologic procedures.
A national study of internal medicine and its specialties: I. An overview of the practice of internal medicine.
A nationwide study of 24 medical and surgical specialties has been conducted by the University of Southern California School of Medicine, Division of Research in Medical Education. This article is the first in a series reporting findings for general internal medicine and 10 subspecialties of internal medicine. Populations for these 11 specialties are defined and enumerated, and the specialties are compared in terms of demographic and geographic distribution. Practice comparisons are presented based on characteristics such as workload, allocation of professional time, location of encounters with patients, distribution of primary problem diagnoses, and projections of annual patient encounters. Forthcoming specialty-specific articles will present highly detailed information for general internal medicine and for the subspecialties of cardiology, gastroenterology, pulmonary disease, allergy, hematology, endocrinology, nephrology, medical oncology, rheumatology, and infectious diseases.