Affiliated Clinics Research Articles

Bridging the gap between service need and service utilization: a school-based mental health program.

In an effort to bridge the gap between service need and service utilization, an urban based, university affiliated children's psychiatric outpatient clinic has implemented a program which provides mental health services in inner city schools. When compared with the central clinic populations (N = 304), the school sample (N = 44) was markedly socioeconomically disadvantaged, minority, and as psychiatrically impaired as the central clinic population. School based mental health services have the potential for bridging the gap between need and utilization by reaching disadvantaged children who would otherwise not have access to these services. Implications for such services are discussed.

Use, don't lose, the wind Presidential address

Use, don't lose, the wind Presidential address

Epidemiologic research in an integrated regional medical care system: The Marshfield Epidemiologic Study Area

To capitalize on Marshfield Clinic's advantages for population-based health research, we developed the Marshfield Epidemiologic Study Area (MESA). Marshfield Clinic is an integrated system consisting of a large multispecialty clinic and 23 affiliated clinics. Clinic physicians provide virtually all of the medical care, both inpatient and outpatient, for residents of the area. MESA consists of 14 ZIP codes in which over 95% of the 50,000 residents and most significant health events are captured in Marshfield Clinic databases, including all deaths, 94% of hospital discharges, and 92% of medical outpatient visits. MESA exemplifies the research potential of integrated medical care systems and the efforts required to realize that potential. Because it is representative of a defined population and provides an unselected sample of patients, MESA is well suited for epidemiologic research and research elucidating the clinical spectrum and natural history of diseases and the effectiveness of treatment.

Cost Savings Using a Stepped-Care Prescribing Protocol for Nonsteroidal Anti-inflammatory Drugs

To lower nonsteroidal anti-inflammatory drug (NSAID) costs while maintaining quality patient care and clinician satisfaction. Before and after 21-month trial with one study site and two control sites and a questionnaire that was sent to 203 clinicians. Two military medical centers and two affiliated primary care clinics. All beneficiaries filling outpatient NSAID prescriptions. An NSAID prescribing protocol was implemented requiring a trial of either ibuprofen or indomethacin before new prescription of more expensive NSAIDs. One control center used an NSAID computer cost-prompt and the other had no intervention. The proportion of expensive NSAIDs prescribed at each institution and total NSAID costs adjusted for prescription volume. Clinician acceptance and patient impact were assessed by the questionnaire. Study site clinicians (n=158) reported very few protocol-related patient care problems. A minority (9%) of study site clinicians considered the protocol very bothersome, and only 2% felt it should be discontinued. Quarterly use of expensive NSAIDs at the study site fell from 34% to 21%, decreasing costs by 30% (P<.001). In contrast, the site with a computer cost-prompt had only a 5% decrease in NSAID costs, while costs at the site with no intervention increased 2%. For drugs with similar benefits and adverse effects, a "stepped formulary" approach requiring an initial trial of one of the less expensive agents can maintain physician prescribing choices and satisfaction while lowering costs.

A comparison of recruitment methods for an osteoarthritis exercise study

Patient recruitment often involves a great deal of effort and cost. We sought to determine successful recruitment methods for an osteoarthritis (OA) exercise study, and to subsequently focus on using those approaches. Eleven methods were developed to recruit subjects for this large research project. Financial constraints ensured that we focused on low-cost measures. Over a 20-month period, the numbers of both total respondents and eventual participants were recorded. Responses were recorded for 263 individuals, and 108 subjects entered the study. The most successful recruitment method was via physician referrals from affiliated clinics. In general, methods that were free of direct cost seemed no less successful than those requiring expenditures. Successful subject recruitment, even for a large study, may not require costly advertising. Direct contact and frequent reminders rendered to our own clinics proved most effective, but other free and low-cost approaches were also of benefit.

Evaluation of oncology registry follow-up methods.

The accuracy and completeness of oncology (tumor) registry patient follow-up information directly affects the validity of the oncology registry system for determining outcomes, as a quality assurance measure, and for research activities. At this institution, if a hospital-based patient encounter has not been identified during the previous year, a follow-up letter is sent to the attending physician to obtain current information about the patient. Difficulties using this method include (1) correct identification of the appropriate physician (2) constraints on physician and staff time to provide information, and (3) accuracy, currentness, and completeness of information provided. A study was conducted to compare the accuracy and completeness of the oncology registry patient follow-up information obtained from three sources: responses from the patient, responses from the physician, and affiliated clinic chart reviews. Seven hundred ninety-one patient and physician letters were sent during a 2-month period, and 122 clinic charts were reviewed. Physicians responded more frequently than patients (82% vs. 58%) (P < 0.003). From the responses received, requested information regarding recurrence, treatment, quality of survival, and survival was obtained most frequently from patients. However, it was difficult to ascertain information about cancer status from patient responses. Patients supplied more current follow-up information than physicians or the clinic chart reviews. A follow-up system that delivers accurate and complete information while maintaining efficiency is a critical aspect of an oncology registry. Requesting follow-up information from the patient before physician contact or chart review allows for more current information while maintaining accuracy regarding cancer recurrence, treatment, quality of survival, and survival. Consequently, staff time required for obtaining follow-up information from physicians and/or chart reviews is lessened and costs decreased.

A teleradiology case conference system.

To investigate the use of teleradiology in the quality assurance programme of a multicentre radiotherapy practice, we installed image acquisition and display workstations at each of two affiliated radiation oncology clinics. A commercial diagnostic teleradiology system was successfully modified to suit the requirements of the radiotherapy subspecialty. The system allowed intersite transmission of images, access to high-resolution images from each site and, by use of laser film scanners, made accessible all types of radiation therapy image. Transmission speed and storage capacity were better than expected. Using the system, radiation oncology residents and staff reviewed 83 complex cases over eight months. Case presentation and discussion were enhanced. In the same period, 276 cases were reviewed by conference in person. Case conferences for quality assurance conducted with the teleradiology system influenced changes in treatment planning as effectively as those conducted in person. Equivalent treatment outcomes were produced. The teleradiology system facilitated quality assurance through review of patients' radiation treatments by allowing natural interactive consultation.

A comparative study of patient satisfaction with health care in Japan and the United States

Patient satisfaction with medical care received at selected medical facilities in the United States (895 patients) and in Japan (856 patients) was compared using self-administered questionnaires. In each country, patients at a large government hospital and a smaller affiliated clinic were surveyed. Patients responded to questions concerning specific aspects of medical care, general satisfaction with the care received, waiting time to see the physician and time spent with the physician. Results suggest that patients at study sites in both countries were generally satisfied with the medical care they received. However, American patients were more likely to report satisfaction than their Japanese counterparts on each dimension of health care measured. The largest discrepancies were found in satisfaction with waiting time to see the doctor and time spent with the doctor. Stepwise discriminant analyses indicated that provider skill may be the most important predictor of overall satisfaction with medical care in both countries. These results are discussed in the framework of the underlying health care system.

Use of Zinc Protoporphyrin Measured by the Protofluor-Z Hematofluorometer in Screening Children for Elevated Blood Lead Levels

To determine the usefulness of zinc protoporphyrin, as measured by the Helena Protofluor-Z hematofluorometer, for detecting elevated lead levels. Observational, descriptive review of laboratory records from a university toxicology laboratory. Inner-city university pediatric clinic and two affiliated community clinics in Chicago, Ill. Seven hundred seventy-five children younger than 7 years with paired lead-zinc protoporphyrin results. Fifty-six percent had lead levels of at least 0.48 mumol/L and 8% had lead levels of at least 1.21 mumol/L. The sensitivity, positive predictive value, and negative predictive value of a zinc protoporphyrin level of 70 mumol/mol of hemoglobin for detecting a lead level of 0.48 mumol/L were 42%, 66%, and 50%, respectively, and for a lead level of 1.21 mumol/L were 74%, 18%, and 97%, respectively. Receiver operating characteristic curves demonstrated that for detecting lead levels of 0.48 mumol/L with zinc protoporphyrin, the probability of a true-positive result is close to that of a false-positive one. Zinc protoporphyrin is not a reliable screening test for detecting low blood lead levels.

Relationship of follicle number, serum estradiol, and other factors to birth rate and multiparity in human menopausal gonadotropin-induced intrauterine insemination cycles

ObjectiveTo determine the characteristics associated with pregnancy and multiple gestation after human menopausal gonadotropin intrauterine insemination (hMG-IUI). DesignProspective study of all patients undergoing hMG-IUI between January 1, 1984 and December 31, 1989. SettingUniversity affiliated private clinic. PatientsFour hundred twenty-four infertility patients undergoing 779 cycles of hMG-IUI. Main Outcome MeasuresThe relationship between estradiol (E2), number and size of follicles, age, and initial semen quality on pregnancy and multiple gestations in hMG-IUI cycles. ResultsThe number of follicles ≥ 12 mm was correlated with births and predicted all multiple births (r = 0.140, P < 0.001). The corrected birth rate was 25.8% for age < 35 and 14.0% for age ≥ 35 when four or more follicles were ≥12mm. The uncorrected clinical pregnancy rate (PR) and birth rate were 12.8% and 10.5%, respectively. Decreased births were associated with tubal adhesions alone (P < 0.03) or with endometriosis (P < 0.002), more than four cycles of treatment (P = 0.01), initial sperm count < 5 × 106 per mL (P < 0.01), initial sperm motility < 30% (P < 0.002), and age ≥35 (P < 0.01). Estradiol was correlated with birth rate (r = 0.160, P < 0.001), which increased from 3.6% when E2 was <500pg/mL to 19.6% when E2 was ≥2,500pg/mL. ConclusionsThe outcome of hMG-IUI is related to the number of follicles ≥ 12 mm, to E2, and to age. Optimal PRs from hMG-IUI require mild ovarian hyperstimulation.

Preventive care in a Veterans Administration continuity clinic

Low levels of compliance with established guidelines for preventive care have been documented in a variety of settings. Although the Veterans Administration (VA) is the largest health care provider in the United States, data concerning preventive care to veterans is lacking. A study was conducted to examine preventive care in a university affiliated VA continuity care clinic staffed by resident physicians. Recognized guidelines were used to generate criteria specifying appropriate periodic health examinations and preventive procedures. A random sample of patients followed in the Baltimore VA Primary Care Clinic was reviewed. Compliance was highest for the traditional elements of the periodic health examination. Over 85% of patients had received histories and physical examinations, complete blood counts, electrolytes, chest radiographs, urinalyses, weight measurements, blood pressure determinations and electrocardiograms. Compliance was lower for cholesterol determination (51%) and for cancer screening procedures. Of appropriately selected patients, 19% had sigmoidoscopies, 44% rectal examinations, 50% PAP smears, and 17% mammograms. Lowest compliance was seen for influenza immunization. Only 12.5% of high risk males and 0% of high risk females had received the vaccine. Compliance did not consistently vary by duration of clinic enrollment, age, race, or sex. Efforts must be made to improve compliance with established guidelines for preventive care.

Analysis of the Use of HIV Antibody Testing in a Minnesota Hospital

We retrospectively studied the clinical use of human immunodeficiency virus (HIV) antibody serology at one 450-bed medical center and affiliated clinics from April 1985 through August 1986. No restrictions were placed on the use of HIV antibody serology during that time, although it was recommended that consent be obtained and risk-reduction information be provided. Testing was performed for 275 patients; results for 25 (9%) of these were positive. Nearly half (44%) of the patients had no recognized risk factor for HIV infection recorded in their charts. For an additional 44% of the patients, the test was medically indicated but consent and counseling were not documented. For only 10% of HIV antibody tests was there notation that consent was obtained and that risk-reduction information was provided. These results indicate that HIV antibody testing is often done without consent and that opportunities to provide risk-reduction counseling are being missed.

Analysis of the use of HIV antibody testing in a Minnesota hospital

We retrospectively studied the clinical use of human immunodeficiency virus (HIV) antibody serology at one 450-bed medical center and affiliated clinics from April 1985 through August 1986. No restrictions were placed on the use of HIV antibody serology during that time, although it was recommended that consent be obtained and risk-reduction information be provided. Testing was performed for 275 patients; results for 25 (9%) of these were positive. Nearly half (44%) of the patients had no recognized risk factor for HIV infection recorded in their charts. For an additional 44% of the patients, the test was medically indicated but consent and counseling were not documented. For only 10% of HIV antibody tests was there notation that consent was obtained and that risk-reduction information was provided. These results indicate that HIV antibody testing is often done without consent and that opportunities to provide risk-reduction counseling are being missed. ( JAMA 1988;259:229-232)

686 CHILDREN AND YOUTH WITH RECURRENT INJURIES

In a study initiated to identify causative factors for recurrent trauma in rural children and youth the charts of 51 patients treated at 3 university affiliated rural health clinics were reviewed. The patients selected had had 3 or more injuries occurring within the previous 5 years.Of these injured children 7.8% were 1-4 years old, 11.8% 6-10, 41.2% 11-15, and 39.2% 16-21. Of the patients, 80.4% were male while 19.6% female; 86.3% were white and 13.7% black. There was a total of 244 incidents of injuries sustained by these patients during the study. Twenty-two injuries were fractures, 6 dislocations, 5 sprains, 11 head injuries, 56 lacerations, 56 contusions, 17 abrasions and 26 were other types including puncture wounds, eye injuries, burns, toxic substance ingestions, exposures to toxic chemicals, gunshot wounds, joint effusions, and ear drum injuries. The injuries occured during these activities: 11 at work, 72 at school, 48 during competitive athletics, 24 in physical education classes, 18 in unsupervised athletic competition, 73 at play, 9 in automobile accidents, 7 in motorcycle accidents, 4 in bicycle accidents, and 23 in activities such as walking, stepping on glass, falling out of non-moving vehicles and windows, fingers caught in doors and windows, dropping objects on extremities, horseback riding and tending a fireplace.A program to prevent recurrent injuries in these children which will include psychosocial as well as general education counseling is being developed.

Hypertension control among patients referred by a community blood pressure screening program

Since 1974 the Milwaukee Blood Pressure Program (MBP) has screened more than 175,000 people for hypertension, 4672 newly identified hypertensives have been referred for treatment to practicing physicians and to a medical school affiliated hypertension clinic on the basis of two elevated blood pressure readings. The mean duration of follow-up has been 20 months for private patients and 14 months for clinic patients. Ninety-two per cent of the referred patients, were subsequently confirmed to have an elevated blood pressure. Approximately 90% of the confirmed hypertensive patients received antihypertensive drugs. Seventy-three per cent of the private patients and 97% of the clinic patients received a diuretic. The antihypertensive drugs were stopped on few occasions by the physician. Lifestyle changes in terms of weight loss and reduction in smoking and drinking were attempted in the clinic. Whereas heavy smoking and alcohol intake could be reduced in some patients, little change in weight was generally observed. Hypertension was controlled in 65% of the private patients and 84% of the clinic patients. The better clinic results may reflect more frequent use of combination antihypertensive therapy and use of the nurse clinicians for reinforcement of the physician's advice in the clinic setting.

A new regional center for child care

The new Children's Hospital of Philadelphia, in conjunction with affiliated Philadelphia Child Guidance Clinic, opened in June of this year, after 15 years in planning and construction. Ground-breaking took place in September 1968, construction began February 1969, and the physical relocation began June 1974. The new children's medical center merits attention as a major example of a new tertiary care facility, serving a tristate region and a university complex, while also rendering primary care through expanded ambulatory and emergency facilities, new transient one-day surgical service, and growing affiliations with health maintenance organizations in the general neighborhood. Regionally, the Hospital serves as a major consultative resource and pediatric referral center for hundreds of Delaware Valley hospitals and physicians.