Preventive Medical Services Research Articles

Addressing Health Disparities Through Dental‐Medical Collaborations, Part III: Leadership for the Public Good

This is the third in a series of articles featuring dental-medical collaborations to reduce oral health disparities. Previous articles have targeted disparities among children, the elderly, and those with mental retardation and developmental disabilities and the importance of cultural factors in health disparities. Articles in this third group describe projects that originated in the public health sector or utilize public health approaches. They include training of non-dental providers and Head Start/Early Head Start workers in children's oral health promotion; case management to ensure early preventive medical, dental, and developmental services for children; and a dental school-led outreach, training, and research effort to address oral cancer disparities. In this introductory article, we review lessons learned from the entire series of projects reported in these articles. The primary take-home message is that educational changes are needed in dental and medical training to better address oral health disparities. Other important lessons include the value of local or state-specific data, the need for partnerships with key stakeholders, and the role of financial incentives in leveraging change. We recommend more attention to outcome assessments in educational initiatives, greater partnering with families and patients, and utilization of change-management methodologies with systems, providers, and patients. We also advocate increased collaboration with the public health sector and bold leadership in dental education.

Task Force Report 5. Report of the Task Force on Family Medicine's Role in Shaping the Future Health Care Delivery System

<b>BACKGROUND</b> Recognizing that the implementation of needed changes within family medicine will be enhanced through a concurrent effort to transform the broader health care system, this Future of Family Medicine task force was charged with determining family medicine’s leadership role in shaping the future health care delivery system. <b>METHODS</b> After reviewing the changes taking place within family medicine and the broader health care system, this task force identified 6 priorities for fostering necessary modifications in the health care system. In addressing the leadership challenge facing the discipline, the task force presents a 3-dimensional matrix that provides a useful framework for describing the audiences that should be targeted, the strategic priorities that should be pursued, and the specific recommendations that should be addressed. Noting that leadership is part of the heritage of family medicine, the task force reviewed past successes by the discipline as important lessons that can be instructive as family physicians begin advocating for needed changes. <b>MAJOR FINDINGS</b> Effective leadership is an essential ingredient that will determine, to a large extent, the success of family medicine in advocating for needed change in the health care system overall and in the specialty. It is vitally important to groom leaders within family medicine and to create venues where policy makers and influence leaders can look beyond their usual constituencies and horizons to a comprehensive view of health care. A central concept being proposed is that of a relationship-centered personal medical home. This medical home serves as the focal point through which all individuals—regardless of age, gender, race, ethnicity, or socioeconomic status—receive a basket of acute, chronic, and preventive medical care services that are accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians. <b>CONCLUSION</b> Family medicine has and will continue to have an important leadership role in health system change. It has been most successful when it has been able to identify a high-priority goal through consensus within the discipline, to focus and coordinate local and national resources, and to use a multipronged approach in addressing the priority. Although the Future of Family Medicine project has provided an important impetus for the identification of key priorities across the discipline, for the FFM project ultimately to be a success, implementation steps will need to be identified and prioritized. The leadership matrix presented in this report can provide a useful structuring tool to identify, understand, and coordinate change efforts more effectively. Strategic alliances with primary care groups and others also will be critical to the success of change initiatives.

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback.

BackgroundInterventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia.MethodsThe intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management.ResultsLevels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period.ConclusionsImprovements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.

Receipt of clinical preventive medical services among psychiatric patients.

A total of 267 patients who were receiving care for psychiatric and substance use disorders at a university medical center completed a self-report instrument assessing their previous receipt of clinical preventive services. High rates of mammography and Pap tests within the past year were observed (76 and 77 percent). Rates of immunization (hepatitis B and tetanus vaccines) varied from 11 percent to 78 percent. Rates of preventive counseling for sexual practices, diet, and avoidance of alcohol were lower than 25 percent in all groups. Only 6 percent of all patients reported having been screened for gun ownership, despite the high risk of suicide among gun owners.

Receipt of preventive medical services at psychiatric visits by patients with severe mental illness.

The authors used data from the National Ambulatory Medical Care Survey from 1992 to 1999 on 3,198 office visits to explore the extent to which psychiatrists provide clinical preventive medical services to patients with severe mental illness. Preventive services were provided during 11 percent of the visits. A multivariate analysis showed that preventive services were more likely to have been provided for patients with a chronic medical condition, for patients who were also seen by a nurse or other health provider during the visit, in rural areas, and during longer visits. Preventive services were less likely to have been provided during visits to health maintenance organizations and visits that took place later in the study period.

The quality of health care for adults with developmental disabilities.

The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive. Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations. Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon. Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.

A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users

Substance abuse is associated with high risk for tuberculosis (TB) and poor adherence to medication regimens. This study compared completion rates for isoniazid (INH) preventive therapy for injection drug users (IDUs) randomly assigned to methadone treatment combined with directly observed preventive treatment (DOPT) versus those assigned to routine TB clinic referral without methadone treatment. One hundred and eleven opioid-dependent patients with latent TB were assigned to one of three 6-month treatment conditions: standard methadone treatment including substance abuse counseling combined with daily INH DOPT ( n=37); minimal methadone treatment without counseling, also combined with daily INH DOPT ( n=35); or routine care referral to TB clinic for monthly INH supplies without DOPT and without methadone treatment ( n=39). INH completion rates were 77.1% for minimal methadone and 59.5% for standard methadone, as compared with only 13.5% for routine care ( P<0.0001). Mean duration of INH treatment retention was 5.7, 5.0 and 1.6 months, respectively ( P<0.0001). TB incidence at 4-year follow-up was 0 of 54 subjects who completed preventive therapy versus 2 of 57 who failed to complete. One of these two had been assigned to routine care, and the other to minimal methadone. In conclusion, INH retention time and completion rates were significantly improved by methadone treatment combined with observed INH, whether or not substance abuse counseling was provided. The results of this study indicate that methadone treatment offers clear public health benefits when it is used to deliver preventive medical services.

Factors associated with use of preventive dental and health services among U.S. adolescents1 1The opinions expressed in this paper are the authors’ and do not necessarily reflect the views or policies of the institutions with which the authors are affiliated.

To examine adolescents' use of preventive medical and dental services and its relationship to demographic characteristics and other variables reflecting access to and need for care. Self- and parent-reported data from a sample of 5644 adolescents aged 11 to 21 years from the National Longitudinal Study of Adolescent Health (Add Health). Variables studied include the influence of both the adolescents' demographic and socioeconomic characteristics (age, race/ethnicity, place of birth, acculturation, insurance status, and perception of health), as well as those of their parents (race/ethnicity, income, level of education, place of birth) on their lifetime use and use within the past year of medical and dental services. Bivariate and logistic regression analyses were conducted using SAS and SUDAAN. Approximately 32% of respondents had not had a physical examination in the year before the survey, and the same percentage had not had a dental examination. Approximately 2% reported never having had either a physical or a dental examination. Logistic regression reveals that lack of insurance, low family income, and low parental education level are significantly associated with the lack of preventive medical care. Lack of an annual dental visit was associated with male gender; black, Hispanic, or mixed race/ethnicity; and lack of insurance. Never having had a dental visit was the only dependent variable found to be associated with place of birth. Health insurance and family income are most consistently related to adolescents' use of preventive medical and dental care. However, the relationship between lack of dental care and place of birth emphasizes the need to improve access to dental services for immigrant teens. These findings are particularly relevant as states design systems of care for adolescents under the State Children's Health Insurance Program.

Child poverty, health and health care use in Canada

Child poverty, health and health care use in Canada

Injury prevention and emergency medical services for children in a managed care environment

Each year, 1 in 5 US children receives medical care as a result of injury. Injuries are the leading cause of medical spending for children ages 5 to 21 years, accounting for more than 20% of hospital admissions and days spent in the hospital. Pediatric injuries become an important issue for managed care organizations because of concern for member safety and increasing medical costs related to treatment. Because effective prevention decreases health care consumption, injury prevention often costs less than treating injuries. Simple devices, such as bicycle helmets, smoke detectors, and child safety seats, help keep children safe and save money. Appropriate emergency care at the scene of an injury, poison control centers that dispense expert advice over the telephone, and triaged regional trauma systems improve the outcome and save money at the same time. This article continues the white paper series by the Emergency Medical Services for Children Managed Care Task Force. [Moody-Williams JD, Athey J, Barlow B, Blanton D, Garrison H, Mickalide A, Miller T, Olson L, Skripak D. Injury prevention and emergency medical services for children in a managed care environment. Ann Emerg Med . March 2000;35:245-251.]

Historical Evolution of Preventive Medical Informatics in the USA

A major reorganization of healthcare services is occurring in the United States. It has evolved from the solo- and group-practice models of the 1940s with fee-for-service and insurer-indemnification financing that used paper-based information systems to support preventive medical services. In the 1990s there emerged nation-wide, managed-care plans employing enhanced computer-based information systems with online preventive medical practice guidelines and Internet-supported home-care telemedicine. It is helpful to review how this major reengineering of medicine has come about.

Medical Problems in Adults with Cerebral Palsy: Case Examples

The United Cerebral Palsy Association estimates that there are approximately one-half million adults with cerebral palsy in the United States. The number may be growing due to advances in medical care and the increased life expectancy of adults in general. Little has been published regarding their medical issues and rehabilitation needs. What little has been published has indicated almost a total neglect of specialty care and preventive medical services. Five case examples are presented to help illustrate particular medical and surgical problems not identified by either pediatric or adult healthcare providers alone. Each individual shows improvement with comprehensive team-oriented specialty care. Further study is encouraged.

Health problems and service utilization in the homeless.

This study examined the health problems and utilization patterns of homeless individuals (n = 292) seeking medical services in a small, southern community. Results showed that the medical problems for which the homeless sought treatment were often (72.6 percent) a reoccurring problem for which treatment had been previously received. The most prevalent medical problem was upper respiratory infection (47 percent), likely exacerbated by the high rate (73 percent) of cigarette smoking found among the sample. More than half (51.4 percent) of the participants had used other medical services in the past month. Despite these high rates of utilization, the homeless may, in fact, be underutilizing appropriate preventive medical services, waiting until the medical problem becomes serious before seeking treatment, and overutilizing emergency rooms for nonemergency care. Community-based services sensitive to the needs of the homeless are likely to cost communities less money while providing better services to the homeless.

The use of acute and preventative medical services by a general population: relationship to alcohol consumption.

To investigate the hypothesis that increasing alcohol consumption is accompanied by increasing use of acute, but decreasing use of preventative, medical services among the general population. Health and life-style survey of 41,000 randomly-sampled adults in SE England who self-completed a validated questionnaire covering socio-demographics, alcohol and tobacco usage and use of acute (A&E department and general practitioner) and preventative (dental, optician, mammography and cervical cytology) services: the response rate was 60%. Comparative use of acute and preventative health care services by patients with varying consumption of alcoholic beverages. This was estimated by the odds ratio for service use, after correcting for the following confounding variables; age, social class, ethnic group, employment status, whether lives with children or with other adults, whether is a career, limiting long-term illness, depression status, smoking habit and use of private health insurance. There was increased use of accident and emergency services by the harmful and intermediate drinking groups compared with the safe drinking group. Male abstainers attended their A&E departments more frequently than 'safe limit' drinkers. With respect to preventative services, both male and female abstainers and harmful drinkers used dental services less than safe limit drinkers. For females, mammography and cervical cytology services were less frequently used by abstainers and by harmful drinkers. This study supports the generally held view that heavy alcohol consumers are disproportionate users of acute medical services but they are relative under-users of preventative medical care services. Alcohol abstainers are also over-users of acute services, but under-users of preventative services. These latter observations are relevant to the claims that moderate alcohol consumers have lower apparent morbidity and mortality rates compared to abstainers.

Association between use of unconventional therapies and conventional medical services.

The terms alternative and complementary medicine suggest 2 contradictory possibilities. Whether individuals use unconventional therapies as a substitute for or as an "add on" to conventional medical treatments is uncertain. To determine the association between use of unconventional therapies and conventional medical care in a national sample. The 1996 Medical Expenditure Panel Survey was distributed to a probability sample of the noninstitutionalized civilian US population. Of 24676 individuals responding (77.7% response rate), 16068 adults 18 years or older were included in the analysis. Visits to practitioners for unconventional therapies and conventional medical services, including number of inpatient, outpatient, and emergency department visits and use of 8 types of preventive medical services (blood pressure, cholesterol level, physical examination, influenza vaccination, prostate examination, breast examination, mammography, and Papanicolaou test). During 1996, an estimated 6.5% of the US population had visits for both unconventional therapies and conventional medical care; 1.8% used only unconventional services; 59.5% used only conventional care; and 32.2% used neither. Compared with those with only conventional visits, those who used both types of care had significantly more outpatient physician visits (7.9 vs 5.4; P<.001), and used more of all types of preventive services except mammography. These groups did not differ significantly in inpatient care, prescription drug use, or number of emergency department visits. Individuals in the top quartile of number of physician visits were more than twice as likely as those in the bottom quartile to have used unconventional therapies in the past year (14.5% vs 6.4%; P<.001). The association between unconventional treatments and physician visits remained after adjusting for potential confounders and across different types of unconventional treatment. In this sample, use of unconventional therapies was substantially lower than has been reported in previous national surveys, but was associated with increased use of physician services. From a health services perspective, practitioner-based unconventional therapies appear to serve more as a complement than an alternative to conventional medicine.

Aging versus disease: the opinions of older black, Hispanic, and non-Hispanic white Americans about the causes and treatment of common medical conditions.

Little is known about how older people interpret disease and how those interpretations might relate to use of medical services. To assess opinions of older subjects about the cause and treatment of common diseases and how they are related to health behaviors. In-home interview of a population-based sample (n = 601) of noninstitutionalized black, Hispanic, and non-Hispanic white American men and women aged 75 and older in Galveston County, Texas. Substantial proportions of the subjects considered heart disease, arthritis, or difficulty sleeping to be a normal part of aging. In multivariate analyses including age, gender, education, marital status, living arrangement, global self-rating of health, and comorbidity, older black subjects were less likely to view heart disease (OR = 0.41; 95% CI, 0.26-0.64), arthritis (OR = 0.48; 95% CI, 0.31-0.73), or sleep problems (OR = 0.50; 95% CI, 0.32-0.77) as a normal part of aging than were non-Hispanic whites. Blacks were more than three times as likely to attribute heart disease to overwork or stress than were non-Hispanic whites. In multivariate analyses, subjects who considered all three of the medical conditions to be a normal part of aging ("fatalistic") were less likely to have received preventive medical services in the previous year (OR = 0.13; 95% CI, 0.02-0.96), and subjects who felt that nothing could be done to treat any of the conditions ("nihilistic") were less likely to have a regular physician (OR = 0.24; 95% CI, 0.08-0.74). Substantial numbers of older subjects are fatalistic about the cause of disease and/or nihilistic about its treatment. These attitudes are associated with decreased utilization of health services. Attempts to improve the health of underserved groups should employ interventions that are sensitive to the health beliefs of the targeted group.

Costs and Benefits of Prevention and Disease Management

Prevention and long term disease management have been added relatively recently as ‘new’ components of a modern day total healthcare services system. The goal of primary prevention, which includes medical preventive services, lifestyle interventions and screening services, is to maintain a symptom- and disease-free population. Disease management is a systematic post-disease attempt to manage the consequences of a disease. This article focuses on the costs and savings of prevention and treatment for 7 major diseases which accounted for nearly 80% of the deaths in the US in 1990: heart disease, cancer, diabetes, arthritis, chronic bronchitis, influenza and asthma. The potential impact of prevention and disease management on costs, including productivity, represents a significant return-on-investment to society. Differences in the allocation of direct resources, however, make it nearly impossible to find a single suitable cost measure for the relative cost-effectiveness comparisons of prevention, acute treatment of disease and long term disease management. The relevant question may not be so much the relative cost effectiveness or benefits of the components of healthcare, but the benefits that an integrated approach brings to a total healthcare delivery system.

Psychiatrists' and Internists' Knowledge and Attitudes About Delivery of Clinical Preventive Medical Services

Changes in the health care environment have placed a greater responsibility on psychiatrists to deliver basic primary care services. The study assessed baseline knowledge and attitudes about clinical preventive medical services among psychiatric faculty and psychiatric residents at a tertiary care medical center. Residents and faculty in psychiatry and general internal medicine completed a structured questionnaire, including 20 case scenarios, that assessed their baseline knowledge of clinical preventive medical services, their attitudes concerning delivery of those services, and their beliefs about the effectiveness of those services in changing patients' behavior. The case scenarios and knowledge questions were based on the clinical preventive medical services recommendations outlined by the U. S. Preventive Services Task Force. Psychiatrists reported more frequent assessment of and counseling about the use of illicit drugs and weapons, and internists were more likely to query about measures related to physical health such as cancer screening and immunizations. The two groups reported similar attitudes toward the need for and the efficacy of preventive medical services. Commonly cited barriers to the delivery of preventive care included lack of time and education. Psychiatrists scored reasonably well on baseline knowledge about guidelines for preventive medical services, particularly given their recent lack of specific education in these matters. Psychiatrists believe clinical preventive services are important and express interest in their delivery. Additional educational interventions are needed to train psychiatrists in clinical preventive services to avoid missed clinical opportunities for intervention in psychiatric populations that may have poor access to other medical care.

Primary Health Care initiatives in colonial Kenya

Most contemporary development practitioners have only passing familiarity with development strategies employed by their predecessors, especially for programs that occurred during colonial periods. An examination of the colonial medical system of Kenya reveals that many of the strategies now employed in Primary Health Care programs were preceded by comparable programs administered by the colonial medical authorities. The colonial system did not include universal or egalitarian access to health care, nor were the programs ever adequate to remedy many of the major threats to health, but the lessons derived from a careful review of this period validate the appropriateness of many Primary Health Care approaches now promoted. In particular, the emphasis on decentralized, preventive medical services, the use of comprehensive immunization programs, concerted efforts at improvements in sanitation, and promotion of health education were important components of the colonial medical services, that effected positive changes in the health of indigenous populations. Examination of specific colonial programs should inform contemporary Primary Health Care policies.

Socioeconomic status and changes in body mass from 3 to 5 years

The influence of social status on the development of body mass was analysed in a retrospective cohort study of 675 Belgian children monitored between the ages of 3 and 5...