Family Practice Clinic Research Articles

Depression, Physical Impairment, and Treatment of Depression in Chronic Heart Failure

This study examines the contribution of attitudes about impairment to the relation between depression and physical impairment in patients with heart failure. It also describes the current status of antidepressant treatment in a sample of outpatients with heart failure. A total of 32 depressed and 51 nondepressed patients with heart failure were recruited while seeking heart failure treatment in an outpatient heart failure or family practice clinic. Medical, functional, cognitive, and psychological measures were administered at baseline. Depression measures were readministered to the 32 depressed patients at 8, 16, and 24 weeks after the baseline interview. Attitudes about impairment and perceived social support were the strongest cross-sectional correlates of depression. The strong association between physical impairment and depression was no longer significant after controlling for attitudes about impairment. In addition, attitudes about impairment predicted chronicity of depressive symptoms longitudinally after controlling for baseline depressive symptom severity. The relation between physical impairment and depression in heart failure is strongly related to how patients cope with impairment. These results call for the development of additional interventions to treat depression that focus on the emotional adjustment to physical impairment.

Why Do Patients With Chronic Illnesses Fail To Keep Their Appointments? A Telephone Interview

Missed appointments affect patients' health in addition to reducing practice efficiency. This study explored the rate and reasons of non-attendance among patients with chronic illnesses. It was a cross-sectional descriptive study carried out in a family practice clinic over a one-month period in 2004. Those who failed turn up for scheduled appointments were interviewed by telephone based on a structured questionnaire. Out of 671 patients, the non-attendance rate was 16.7%. Sixty-seven percent of non-attenders were successfully interviewed. Males (p = 0.01), Indians (p = 0.015), patients with coronary artery disease (p = 0.017), multiple diseases (> 4) (p = 0.036) and shorter appointment intervals (p = 0.001) were more likely to default. The main reasons for non-attendance were: forgot the appointment dates (32.9%), not feeling well (12.3%), administrative errors (19.1%) and work or family commitments (8.2%). The majority would prefer a reminder through telephone (71.4%), followed by letters (41.3%). In conclusion, appropriate intervention could be taken based on the reasons identified in this study.

A comprehensive patient assessment and physician reminder tool for adult immunization: Effect on vaccine administration

We determined if a patient-self assessment/provider reminder tool (A/R) would increase administration of the eight vaccines that may be indicated for adults. In three family practice clinics, the A/R was completed by intervention patients and given to their provider. Control patients received an exercise reminder. On the day of the intervention, influenza, pneumococcal polysaccharide, and tetanus–diphtheria (Td) vaccines vaccine were administered significantly ( P < 0.01) more commonly to intervention patients in one clinic, Td in the second, and none in the third. There were no additional significant differences during one year of follow-up. A number of barriers to comprehensive vaccination were encountered.

Osteopathic manipulative treatment of somatic dysfunction among patients in the family practice clinic setting: a retrospective analysis.

Relatively little has been published about contemporary use of osteopathic manipulative treatment (OMT) in family practice. To provide an "epidemiology" of somatic dysfunction, assessing prevalence and severity of somatic dysfunction encountered in the family practice setting, also characterizing physician use of OMT. Retrospective analysis of Outpatient Osteopathic SOAP Note Form data collected in 1998 and 1999 by 20 osteopathic medical trainee-investigators under the supervision of seven site-based osteopathic physicians. Three university-based, osteopathic family practice clinics. The authors analyzed records for 1331 patient encounters and 424 adult patients. The mean (SD) age of patients was 56.9 years (16.2 years), and 71% were women. The median number of days between repeat encounters was 29 days. Somatic dysfunction was diagnosed in 418 (31%) patient encounters, affecting a total of 1199 anatomic regions (2.9+/-1.2 anatomic regions per patient). Investigators used OMT in 335 (25%) patient encounters to treat a total of 952 anatomic regions (2.8+/-1.2 anatomic regions per patient). For women, the odds ratio for receiving OMT was 1.4 (95% confidence interval [CI], 1.0-2.2); for patients using analgesics, anti-inflammatory agents, or muscle relaxants, the odds ratio was 2.2 (95% CI, 1.2-4.1). Immediately after OMT, investigators reported that patients' somatic dysfunction resolved or improved in a total of 747 (96%) anatomic regions and remained unchanged in 32 (4%) anatomic regions (P<.001). The authors used cluster analysis to classify anatomic regions by prevalence and severity of somatic dysfunction. Somatic dysfunction was diagnosed in almost one-third of patient encounters. In one-quarter of patient encounters, investigators used OMT.

Intimate Partner Violence and Disabilities among Women Attending Family Practice Clinics

To estimate the frequency and type of disabilities preventing work among those experiencing intimate partner violence (IPV) compared with those never experiencing IPV. We used a large cross-sectional survey of women, ages 18-65, attending family practice clinics from 1997 through 1998. Participation included a 5-10-minute in-clinic survey assessing IPV experience and a longer telephone survey assessing health status and chronic disabilities that prevented work outside the home or housework. Of 1,152 eligible women surveyed, 54% experienced some type of IPV, and 24% were currently in a violent relationship. Women who had ever experienced IPV were more than twice as likely to report a disability (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [CI] 1.6, 3.0). The most commonly reported disabilities were those associated with heart or circulatory disease (4.9%), followed by back problems (3.5%), chronic pain (3.4%), arthritis (3.0%), nerve system damage (2.4%), asthma or another respiratory problem including emphysema (1.7%), and either depression (1.6%) or another mental illness (1.0%). Women ever experiencing IPV were more likely to report a disability due to generalized chronic pain (aOR = 2.5, 95% CI 1.5, 4.3) and mental illness (aOR = 4.5, 95% CI 1.5, 13.1). IPV-related injuries were associated in a dose-dependent manner with having any disability and with disability from chronic pain, asthma and other respiratory diseases, mental illness, and chronic diseases. Primary care-based efforts to screen for IPV and effectively intervene to reduce the impact of IPV on women's lives must be a public health priority to reduce the shortterm and long-term health effects, including disabilities.

The Montana Model: Integrated Primary Care and Behavioral Health in a Family Practice Residency Program

To address the local health care needs of both patients and primary care providers in Montana, an integrated primary care and behavioral health family practice clinic was developed. In this paper we describe our experience with integrating mental health and substance abuse services into a primary care setting (a community health center) while simultaneously teaching family practice physicians to take the lead in providing these services. The Deering Community Health Center in Billings, Montana, is a Federally Qualified Health Center serving a largely low-income patient population. The medical care at the clinic is provided primarily by the faculty and residents of the Montana Family Medicine Residency. The teaching model was founded on the belief that improved care will result when physicians have increased comfort with, and are able to enjoy the challenges of, patients with mental illnesses. The enhanced longitudinal curriculum incorporates mental health across the 3 years of the family practice residency. Unique characteristics of this model include staffing and the concurrent delivery of a high volume mental health service while teaching family practice resident physicians and the faculty to integrate this competency into their primary care practices.

Protein C Deficiency

We describe the management of a patient who presented to a family-practice clinic with gangrenous digits. After a thorough evaluation, she was found to have protein C deficiency, which produced a hypercoagulable state. Differential diagnosis in the evaluation of the coagulopathic patient with appropriate hematologic tests is briefly discussed.

KNOWLEDGE ABOUT TUBERCULOSIS AMONG PATIENTS ATTENDING FAMILY PRACTICE CLINICS IN KARACHI

OBJECTIVE: Tuberculosis is on the rise throughout the world and better understanding and knowledge about tuberculosis remains an important tool in its control. The objective of this study was to determine the level of knowledge about tuberculosis among patients attending Family Practice clinics in Karachi. SETTING: Family practice clinics affiliated to a tertiary care hospital in Karachi, Pakistan during July to September 2003. METHODS: Total 204 subjects aged 18 years and above were interviewed on convenient basis in a cross-sectional survey. Data was collected through a pre-tested structured questionnaire which comprised of socio-demographic variables and questions about cause, transmission, common clinical features and cure of tuberculosis. RESULTS: Respondents were predominantly female (58%) with an extended family structure (78%). More than one-third (35%) of the respondents were illiterate and almost a similar proportion (31%) had received primary education. Only 39% of study subjects knew that tuberculosis is an infectious disease, 19% reported that there is an asymptomatic stage of infection, 33% said that it is curable with proper treatment while 51% considered tuberculosis as a preventable disease. Forty-five percent of respondents did not know about possible consequences of uncured cases and 61% did not know tuberculosis as one of the major health problems of Pakistan. CONCLUSION: In this study, majority of study subjects had poor knowledge about tuberculosis, its prevention and magnitude. Proper knowledge and education about tuberculosis is vital to cope the challenge of this devastating disease. Family Practitioner, being first care providers to the community can play a critical role to raise knowledge about tuberculosis prevention.

TALE OF A WOMAN WITH STOMATITIS AND RESPONSE OF HEALTH CARE SYSTEM

6 . A properly trained primary care practitioner with assistance from sub-specialists can effectively diagnose and treat patients with multiple complaints due to diseases involving several organ systems. A health care system is required to meet the healthcare needs of our people. In this report, a case of failure in our healthcare system is presented. ABSTRACT A 55 year-old housewife presented to the Family Medicine Clinic due to recurrent oral ulcers for a year. She also had generalized itching, weakness, anorexia and abdominal distension after meals. She had visited several practitioners including family physicians and sub-specialists but a diagnosis was not reached. She was diagnosed to have Lichen Planus and Hepatitis C at family practice clinic. Since a health care system does not properly exist, patients seek treatment from sub-specialists without first consulting a primary care practitioner. This report identifies a failure in health care system and it is also recommended that all patients should be first seen by a primary care practitioner.

The effect of illustrations on patient comprehension of medication instruction labels

BackgroundLabels with special instructions regarding how a prescription medication should be taken or its possible side effects are often applied to pill bottles. The goal of this study was to determine whether the addition of illustrations to these labels affects patient comprehension.MethodsStudy participants (N = 130) were enrolled by approaching patients at three family practice clinics in Toronto, Canada. Participants were asked to interpret two sets of medication instruction labels, the first with text only and the second with the same text accompanied by illustrations. Two investigators coded participants' responses as incorrect, partially correct, or completely correct. Health literacy levels of participants were measured using a validated instrument, the REALM test.ResultsAll participants gave a completely correct interpretation for three out of five instruction labels, regardless of whether illustrations were present or not. For the two most complex labels, only 34–55% of interpretations of the text-only version were completely correct. The addition of illustrations was associated with improved performance in 5–7% of subjects and worsened performance in 7–9% of subjects.ConclusionThe commonly-used illustrations on the medication labels used in this study were of little or no use in improving patients' comprehension of the accompanying written instructions.

Oral health practices among adolescents. A study from family practice clinics in Israel

Dental caries and periodontal disease are highly prevalent among adolescents. Preventive dental visits and proper oral health practices effectively reduce the occurrence of these entities. The objective of this study was to determine the rates of tooth brushing, flossing, and visits to dentists and hygienists among Israeli adolescents in a family practice setting. One hundred and eighty-four 7th and 10th graders who attended preventive health visits completed questionnaires that included questions regarding dental visits and personal oral health habits. Structured counseling by the family nurse was provided following completion of the questionnaire. Ninety-seven percent of the teenagers brushed their teeth at least once a day, but only 7% used dental floss daily, 44.5% never flossed, and another 10% didn't know what dental floss was. Eighty-three percent had visited a dentist, but only 33% had been to a dental hygienist in the past two years. Twenty-nine percent did not know what a hygienist was. We conclude that primary care providers can promote oral health by screening and providing counseling to their adolescent patients.

ASHP survey of ambulatory care pharmacy practice in health systems—2004

The characteristics of and trends in pharmacy practice in ambulatory care settings across the United States were studied. A 2004 national survey of the ambulatory care responsibilities of pharmacists across a spectrum of organizational types (community hospitals, county facilities, Indian Health Services facilities, Veterans Affairs (VA) facilities, teaching institutions, integrated health networks, military facilities, and health maintenance organizations) was conducted and related to organizational features that could promote pharmacist participation. From 1672 deliverable Web-based surveys, 233 organizations reported at least some pharmacist involvement in ambulatory activities, while 475 reported none. Over half of the 228 organizations with some pharmacist involvement reported pharmacists tracking adverse drug reactions (67%), providing written (53%) or oral (52%) information with new prescriptions, and conducting medication management programs (51%). Some 85% reported having at least one clinic with pharmacist involvement. Clinics for anticoagulation services (36%) and oncology services (28%) were most prevalent, followed by primary care or family practice clinics (23%) and diabetes clinics (21%). New survey items found a high prevalence of pharmacist involvement in emergency preparedness programs (90%), medication management services in complex medication situations (63%), and using evidence-based practice guidelines (60%). Of nine enabling factors (factors potentially promoting pharmacist involvement) investigated, participation on multidisciplinary teams and having collaborative practice agreements were significantly associated with pharmacist participation in at least one ambulatory care activity. Having at last one ambulatory care staff pharmacist with advanced training, having at least one residency program, and having collaborative practice agreements were significantly associated with pharmacist participation in at least one clinic or program. Pharmacist participation in ambulatory care activities was not equally distributed across different types of organizations, and VA facilities were notable for the amount and extent of participation. Pharmacists' roles and responsibilities in ambulatory care appear to continue to evolve, with VA facilities leading the way.

UISESS scale for staging and classifying clinical–epidemiological risk in type 2 diabetes mellitus and for establishing multidiscipinary preventive actions

Purpose The goal of this study is the creation and use of a five-stage scale for the description of the health status of a type 2 diabetes mellitus patient population, as individuals and as a set. The scale, named UISESS, ranges from the pre-pathological to the sequelae stage, and can help orient multidisciplinary prevention actions. Setting and sampling A sample of nondiabetics ( n = 404), together with a census of all type 2 diabetic patients ( n = 2,702) over 30 years of age, were obtained from a family medicine clinic of the Mexican Federal Social Security System (IMSS) in Guadalajara, Mexico. Design and method A descriptive study in which the Natural History of the Disease and an epidemiological focus on risk were used to create the UISESS scale. Case histories of a total of 3,106 persons from a family practice clinic were used. The data was classified in five stages and three risk control levels were used for analysis. Results In the type 2 diabetic group, the average age was 57.6 years; 58% were women. In the nondiabetic group, the average age was 55.38 years; 63% were women. The UISESS scale was applied. A large majority (86%) of the studied type 2 diabetic patients were classified within unfavorable stages for controlling their illness, and 65% of the 3,106 people were at high or very high risk of increasing deterioration of their health status. Conclusions The UISESS scale appears to be a useful tool to detect the distribution, evolution and control of type 2 diabetes in a population attended at the outpatient clinic of a family medicine unit, according to the Natural History of the Disease.

Assessment of dizziness among older patients at a family practice clinic: a chart audit study

BackgroundDizziness is a common complaint among the elderly with a prevalence of over 30% in people over the age of 65. Although it is a common problem the assessment and management of dizziness in the elderly is challenging for family physicians. There is little published research which assesses the quality of dizziness assessment and management by family physicians.MethodsWe conducted a retrospective, chart audit study of patients with dizziness attending the Sunnybrook Family Practice Center of Sunnybrook and Women's College Health Sciences Center (SWCHSC) in Toronto. We audited a random sample of 50 charts of patients from 310 eligible charts. Quality indicators across all dizziness subtypes were assessed. These quality indicators included: onset and course of symptoms; symptoms in patients' own words; number of medications used; postural blood pressure changes; symptoms of depression or anxiety; falls; syncope; diagnosis; outcome; specialty referrals. Quality indicators specific to each dizziness subtype were also audited.Results310 charts satisfied inclusion criteria with 20 charts excluded and 50 charts were randomly generated. Documentation of key quality indicators in the management of dizziness was sub-optimal. Charts documenting patients' dizziness symptoms in their own words were more likely to have a clinical diagnosis compared to charts without (P = 0.002).ConclusionsDocumentation of selected key quality indicators could be improved, especially that of patients' symptoms in their own words.

Promoting Health in Type 2 Diabetes: Nurse-Physician Collaboration in Primary Care

The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study. Forty patients from a family practice clinic with type 2 diabetes were randomly assigned to control or experimental groups. The control group received standard care, whereas the experimental group received standard care plus home visits from a nurse, as well as consultation with an exercise specialist and/or nutritionist. Follow-up continued for 3 months. Clinical end points included standard measures of diabetes activity as well as quality-of-life indicators. Focus group interviews were used to explore patients' responses to the program. Although findings were not statistically significant, a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure. Quality of life measures also showed a trend toward small to moderate, but nonsignificant, improvements in physical functioning, bodily pain, vitality, social and global functioning, energy, impact of diabetes, and health distress. Focus group interviews indicated a very positive response from patients, who expressed feelings of empowerment. In this study, patients treated with nurse-physician collaboration demonstrated small, but nonsignificant, improvements in blood chemistry after only 3 months. Physical and social functioning, energy, and bodily pain also showed a small improvement. Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term.

Postvasectomy Semen Analysis: Are Men Following Up?

Many family physicians perform outpatient vasectomies in their office. Postvasectomy semen analysis (PVSA) is critical to establish the success of this sterilization procedure. We investigated the compliance rate of our patients with the PVSA over a 10-year period. To determine compliance rates of men who have undergone vasectomy for recommended PVSA, a retrospective chart review in a private family practice clinic was performed. The records of all patients who underwent vasectomy from 1991 to 2001 were reviewed. Patients are instructed to return at 6 weeks, 3 months, and 1 year for semen specimen evaluation to determine vasectomy success. Records of 551 patients were reviewed. The age of the patient at the time of the vasectomy and number of PVSAs were evaluated. PVSA compliance rates were also correlated with age. In total, 233 (42%) men did not return for 6-week, 3-month, or 1-year PVSA. Of 551 men, 318 (58%) returned for 6-week PVSA, and 138 (25%) returned for 3-month PVSA. Only 44 (8%) of the 551 eligible for a 1-year analysis returned for PVSA. Compliance with instructions to men undergoing vasectomy to return for PVSA is low both from the perspective of this study, as well as other studies evaluated. Older men are more likely to return for PVSA.

Terror Distress in a New York City Primary Care Sample

As a result of the terrorist activities of September 11, 2001, the entire country has experienced increased stress. Coping with the events of 9/11 poses a unique challenge, as there have been frequent terror alerts issued by the government to the residents of New York City. It has also been shown that people with a previous history of childhood abuse are more likely to have difficulty coping with new traumatic events. The aim of this study was to describe a Brooklyn primary-care community's response to the ongoing terrorist threat around the two year anniversary of 9/11. This study further intended to explore the relationship between childhood abuse and current distress from the terror threat. Fifty patients waiting for medical appointments at an urban family practice clinic anonymously completed measures of their terror-related distress and childhood trauma. Analyses indicated substantial distress due to the ongoing terror threat and concomitant restriction of activity. People who reported a history of childhood abuse appear to be coping as well as people who do not report a history of abuse. Implications of the results are discussed.

Continuity of care and patient satisfaction in a family practice clinic.

Continuity is a tenant central to family practice. Continuity is associated with improved satisfaction in populations that can easily change providers. However, little is known about the importance of continuity where patients are assigned providers. A pretested survey was distributed to patients of a family practice residency clinic in a military medical center for a week's period. Results were analyzed using chi2, unpaired t test, correlation matrices, and linear regression for patient satisfaction. The response rate was 68.3%. Responders were not more likely to be seeing their primary care provider (PCP). Regression analysis revealed that 12% of patient satisfaction was associated with long-term continuity rates, 23% by PCP satisfaction, and 17% by how easy it was to make the appointment. For high clinic users (>10 visits/year), 78% of patient satisfaction is determined by PCP satisfaction and long-term continuity rates. A subset of patients (13%) values choice of appointment time or other providers over PCP continuity. Satisfaction is not diminished in this group despite low long-term continuity (P <.05 for all results). Patient satisfaction is associated with continuity, especially for high clinic users. Although continuity is important, a subset of patients values the ability to see other providers and to change providers.

Parents' health and demographic characteristics predict noncompliance with well-child visits.

The purpose of this study was to investigate factors related to well-child visit noncompliance in an ethnically diverse family practice clinic population. Participants included 146 parents (131 mothers and 15 fathers) of children aged 0 to 24 months who received care at a St. Paul residency clinic. Participants completed telephone surveys that asked about their demographic characteristics, attitudes toward well-child visits, whether the most recent planned well-child visit had been kept, and their own and their child's health characteristics. All participants thought that well-child visits were important, with immunizations being the highest rated reason for importance. Fourteen percent of parents said they had missed a recent well-child visit, mostly because they forgot. More than three fourths of parents believed visit reminders were helpful, and the preferred type of reminder was a telephone call. Noncompliance with well-child visits was associated with the parent's depressive symptoms, transportation difficulties, working at a job, having private (vs public) health insurance, and being older (vs younger). These results suggest that well-child visit compliance might be enhanced by visit reminders and improved access to transportation. The relationship of well-child visit noncompliance to parental depressive symptoms, if verified in other populations, points to a need for greater surveillance of children/families who do not schedule or keep well-child visits.

Patients' perspectives on taking warfarin: qualitative study in family practice.

BackgroundDespite the well-documented benefits of using warfarin to prevent stroke, physicians remain reluctant to initiate therapy, and especially so with the elderly owing to the higher risk of hemorrhage. Prior research suggests that patients are more accepting of the risk of bleeding than are physicians, although there have been few qualitative studies. The aim of this study was to employ qualitative methods to investigate the experience and perspective of individuals taking warfarin.MethodsWe conducted face-to-face interviews with 21 older patients (12 male, 9 female) who had been taking warfarin for a minimum of six months. Participants were patients at a family practice clinic situated in a large, tertiary care teaching hospital. We used a semistructured interview guide with four main thematic areas: decision-making, knowledge/education, impact, and satisfaction. Data were analysed according to the principles of content analysis.Results and DiscussionParticipants tended to have minimal input into the decision to initiate warfarin therapy, instead relying in great part on physicians' expertise. There appeared to be low retention of information received regarding the therapy; half the patients in our sample possessed only a superficial level of understanding of the risks and benefits. This notwithstanding, participants reported a high level of satisfaction with the care provided and a low level of impact on their day-to-day lives.ConclusionsMinimal patient involvement in the initial decision and modest knowledge did not appear to diminish satisfaction with warfarin management. At the same time, care providers exert a tremendous influence on the initiation of warfarin therapy and should strive to incorporate patient preferences and expectations into the decision-making process.