Decreasing Antibiotic Use in
Ambulatory Practice: Impact of a Multidimensional Intervention
on the Treatment of Uncomplicated Acute Bronchitis in Adults
Gonzales R; Steiner JF; Lum A; Barrett
PH Jr; JAMA 1999 Apr 28;281(16):1512-9.
Context: The emergence and spread of antibiotic-resistant
Streptococcus pneumoniae in US communities is due, in part,
to the excessive use of antibiotics for acute respiratory tract
infections.
Objective: To decrease total antibiotic
use for uncomplicated acute bronchitis in adults.
Design: Prospective, nonrandomized controlled
trial, including baseline (November 1996--February 1997) and
study (November 1997--February 1998) periods.
Setting: Four selected primary care practices
belonging to a group-model health maintenance organization in
the Denver, Colorado, metropolitan area.
Participants: Consecutive adults diagnosed
as having uncomplicated acute bronchitis. A total of 2462 adults
were included at baseline and 2027 adults were included in the
study. Clinicians included 56 physicians, 28 physician assistants
or nurse practitioners, and 9 registered nurses.
Intervention: The full intervention site
received household and office-based patient educational materials,
as well as a clinician intervention consisting of education,
practice-profiling, and academic detailing. A limited intervention
site received only office-based educational materials, and control
sites provided usual care.
Main Outcome Measure: Antibiotic prescriptions
for uncomplicated acute bronchitis during baseline and study
periods.
Results: Antibiotic prescription rates
for uncomplicated acute bronchitis were similar at all four
sites during the baseline period. During the study period, there
was a substantial decline in antibiotic prescription rates
at the full intervention site (from 74% to 48% [P = .003]),
but not at the control and limited intervention sites (78% to
76% [P = .81] and 82% to 77% [P = .68], respectively). Compared
with control sites, changes in nonantibiotic prescriptions (inhaled
bronchodilators, cough suppressants, and analgesics) were not
significantly different for intervention sites. Return office
visits (within 30 days of the incident visit) for bronchitis
or pneumonia did not change significantly for any of the sites.
Conclusions: Antibiotic treatment of adults
diagnosed as having uncomplicated acute bronchitis can be safely
reduced using a combination of patient and clinician interventions.
Copyright 1999, American Medical
Association
Choice of a Personal Physician
and Patient Satisfaction in a Health Maintenance Organization
Schmittdiel J; Selby JV; Grumbach K; Quesenberry
CP Jr; JAMA 1997 Nov 19;278(19):1596-9. [Published erratum appears
in JAMA 1998 Mar 4;279(9):656.]
Context: Being able to choose one's health
care plan has been shown to increase subsequent patient satisfaction
with the plan, but it is not known whether choosing one's own
primary care physician affects patient satisfaction with the
physician.
Objective: To compare satisfaction with
care between members of a group-model health maintenance organization
(HMO) who chose their primary care physician and members who
were assigned a physician.
Design: Cross-sectional mailed survey with
response rate of 71.4%.
Setting: A large group-model HMO in northern
California.
Main Outcome Measure: Nine questions on
satisfaction with the primary care physician.
Subjects: Random sample of HMO members
35 to 85 years of age who were impaneled with a primary care
physician.
Results: Among the 10,205 survey respondents,
patients who chose their personal physician (n=4748) were 16
to 20 percentage points more likely to rate their satisfaction
as "excellent" or "very good" than patients
who were assigned a physician (n=5457) for nine satisfaction
measures (P<.001 for each comparison). The association of
choice with satisfaction was not due to physicians with higher
patient satisfaction being chosen more often, or to differences
in patient demographic or socioeconomic characteristics, health
values, or health beliefs, or to differences in physician demographics
or specialty. In a logistic regression model that adjusted for
all of these characteristics, having chosen one's physician
was the single predictor most strongly related to having high
overall satisfaction (odds ratio, 2.18, 95% confidence interval,
1.95-2.42).
Conclusion: These results suggest that
even in a setting of limited physician choice, the opportunity
to select one's personal physician may influence subsequent
satisfaction.
Copyright 1997, American Medical
Association
Public Health in Managed Care:
A Randomized Controlled Trial of the Effectiveness of Postcard
Reminders
Clayton AE; McNutt LA; Homestead HL; Hartman
TW; Senecal S; Am J Public Health 1999 Aug;89(8):1235-7.
Objectives: This study evaluated the effectiveness
of an annual public health intervention in a managed care setting.
Methods: Managed care organization members
65 years and older who received influenza immunization in 1996
were randomized to an intervention group (mailed a postcard
reminder to receive an influenza vaccination in 1997) or a control
group (no postcard). Vaccination rates for both groups were
assessed monthly.
Results: Members receiving the intervention
were no more likely to be immunized (78.6%) than members of
the control group (77.2%, P=.222). Members were vaccinated at
the same pace regardless of vaccination history and postcard
intervention status.
Conclusions: Postcard reminders were not
an effective intervention among seniors who had been vaccinated
the previous year.
Copyright 1999, by the American
Public Health Association.
Gender, Psychosocial Factors
and the Use of Medical Services: A Longitudinal Analysis
Green CA; Pope CR; Soc Sci Med 1999 May;48(10):1363-72.
Many researchers have reported gender differences
in levels of reported symptoms, morbidity, mortality and medical
care utilization, but the debate continues about the underlying
causes of these differences. Some have argued that women use
more medical services because they are more sensitive to symptoms
and interested in health, while others believe that women's
greater service utilization arises from the fact that women
experience more morbidities than do men. To date, these questions
have not been studied prospectively. Using data from a household
interview survey carried out in 1970-1971 and linked to 22 years
of health services utilization records, we explored the effects
of gender, self-reported health status, mental and physical
symptom levels, health knowledge, illness behaviors and health
concerns and interest on the long-term use of health services.
After controlling for the aforementioned factors, female gender
remained an independent predictor of higher utilization over
the 22-year period studied, and psychosocial and health factors
measured at the initial interview predicted service use even
19-22 years later. Controlling for factors identified as likely
causes of gender-related differences in healthcare utilization,
gender remains an important predictor of medical care use before
and after removing sex-specific utilization. In addition, the
consistent predictive ability of attitudinal and behavioral
factors, combined with the finding that health knowledge did
not predict utilization, indicates that efforts to help patients
assess their service needs should target the attitudinal and
behavioral factors that vary with gender, rather than health-related
knowledge alone.
Reprinted from Social Science and
Medicine, Vol 45(10), Green CA; Pope CR; Gender, psychosocial
factors and the use of medical services: a longitudinal analysis,
1363-72, copyright 1999, with permission from Elsevier Science.
Fast Relief: Buying Time with
Medications
Vuckovic N; Med Anthropol Q 1999 Mar;13(1):51-68.
The experience of time famine in contemporary
US culture affects household decisions about self-care and the
use of pharmaceuticals for self-medication. This article examines
the manner in which time demands shape lay interpretations of
medicine efficacy and drive increases in medication use for
adults as well as children. Medicines, like other time-saving
commodities, appear to shift the time-power differential in
favor of individuals, placing them in control of how time is
spent. When there is "no time to be sick," allopathic
medicines become time-saving devices that enable women to fulfill
responsibilities at work or home while they attend to sick children
or to being ill themselves. Medicines are used to beat the clock
by increasing one's own capacity to be productive.
Reprinted by permission of the
American Anthropological Association from Medical Anthropology
Quarterly 13:1, March 1999. Not for further reproduction.
Differences in Resource Use
and Costs of Primary Care in a Large HMO According to Physician
Specialty
Selby JV; Grumbach K; Quesenberry CP Jr; Schmittdiel
JA; Truman AF; Health Serv Res 1999 Jun;34(2):503-18.
Objective: To determine if primary care
physician specialty is associated with differences in use of
health services.
Data Sources: Automated outpatient diagnostic,
utilization, and cost data on 15,223 members (35-85 years of
age) of a large group model HMO.
Study Design: One-year prospective comparison
of primary care provided by 245 general internists (GIMs), 60
family physicians (FPs), and 55 subspecialty internists (SIMs)
with case-mix assessed during a nine-month baseline period using
Ambulatory Diagnostic Groups.
Principal Findings: Adjusting for demographics
and case mix, patients of GIMs and FPs had similar hospitalization
and ambulatory visit rates, and similar laboratory and radiology
costs. Patients of FPs made fewer visits to dermatology, psychiatry,
and gynecology (combined visit rate ratio: 0.86, 95% CI: 0.74-0.96).
However, they made more urgent care visits (rate ratio 1.19,
95% CI: 1.07-1.23). Patients of SIMs had higher hospitalization
rates than those of GIMs (rate ratio 1.33, 95% CI: 1.06-1.68),
greater use of urgent care (rate ratio: 1.14, 95% CI:1.04-1.25),
and higher costs for pharmacy (cost ratio: 1.17, 95% CI: 0.93-1.18)
and radiologic services (cost ratio: 1.14, 95% CI: 1.01-1.30).
The hospitalization difference was due partly to the inclusion
of patients with specialty-related diagnoses in panels of SIMs.
Radiology and pharmacy differences persisted after excluding
these patients.
Conclusions: In this uniform practice environment,
specialty differences in primary care practice were small. Subspecialists
used slightly more resources than generalists. The broader practice
style of FPs may have created access problems for their patients.
Reprinted with permission of the
Health Research and Educational Trust, copyright 1999.
Effect of Cigar Smoking on the
Risk of Cardiovascular Disease, Chronic Obstructive Pulmonary
Disease, and Cancer in Men
Iribarren C; Tekawa IS; Sidney S; Friedman GD;
N Engl J Med 1999 Jun 10;340(23):1773-80
Background: The sale of cigars in the United
States has been increasing for the past six years. Cigar smoking
is a known risk factor for certain cancers and for chronic obstructive
pulmonary disease (COPD). However, unlike the relation between
cigarette smoking and cardiovascular disease, the association
between cigar smoking and cardiovascular disease has not been
clearly established.
Methods: We performed a cohort study among
17,774 men 30 to 85 years of age at baseline (from 1964 through
1973) who were enrolled in the Kaiser Permanente health plan
and who reported that they had never smoked cigarettes and did
not currently smoke a pipe. Those who smoked cigars (1546 men)
and those who did not (16,228) were followed from 1971 through
the end of 1995 for a first hospitalization for or death from
a major cardiovascular disease or COPD, and through the end
of 1996 for a diagnosis of cancer.
Results: In multivariate analysis, cigar
smokers, as compared with nonsmokers, were at higher risk for
coronary heart disease (relative risk, 1.27; 95 percent confidence
interval, 1.12 to 1.45), COPD (relative risk, 1.45; 95 percent
confidence interval, 1.10 to 1.91), and cancers of the upper
aerodigestive tract (relative risk, 2.02; 95 percent confidence
interval, 1.01 to 4.06) and lung (relative risk, 2.14; 95 percent
confidence interval, 1.12 to 4.11), with evidence of dose-response
effects. There appeared to be a synergistic relation between
cigar smoking and alcohol consumption with respect to the risk
of oropharyngeal cancers and cancers of the upper aerodigestive
tract.
Conclusions: Independently of other risk
factors, regular cigar smoking can increase the risk of coronary
heart disease, COPD, and cancers of the upper aerodigestive
tract and lung.
Copyright ©1999 Massachusetts
Medical Society. All rights reserved.
Predicting Advanced Proximal
Colonic Neoplasia with Screening Sigmoidoscopy
Levin TR; Palitz A; Grossman S; Conell C; Finkler
L; Ackerson L; Rumore G; Selby JV; JAMA 1999 May 5;281(17):1611-7.
Context: Indications are not well defined
for follow-up colonoscopy for all patients with distal colonic
tubular adenomas (TAs) found at screening sigmoidoscopy.
Objective: To determine whether distal
adenoma size, number, and villous histology, along with family
history and age, are predictors of advanced proximal colonic
neoplasia.
Design: Cross-sectional analysis conducted
between January 1, 1994, and December 31, 1995.
Setting: Large group-model health maintenance
organization in northern California.
Patients: A total of 2972 asymptomatic
subjects aged 50 years or older undergoing colonoscopy as follow-up
to a screening sigmoidoscopy.
Main Outcome Measure: Based on sigmoidoscopy,
colonoscopy, and pathology reports, occurrence of advanced proximal
neoplasia, defined as adenocarcinoma or TAs 1 cm or larger or
with villous features or severe dysplasia located beyond sigmoidoscopic
view.
Results: The prevalence of advanced proximal
neoplasia was similar among patients with no TAs at sigmoidoscopy,
those with TAs less than 1 cm in diameter, and those with TAs
1 cm in diameter or larger (prevalence, 5.3%, 5.5%, and 5.6%,
respectively). Of patients with a distal tubulovillous or villous
adenoma, 12.1% had advanced proximal neoplasia. In multivariate
analyses, having a distal tubulovillous adenoma or villous adenoma
was the strongest predictor of advanced proximal neoplasia (odds
ratio, 2.30; 95% confidence interval, 1.69-3.14). Age of 65
years or older, having more than 1 adenoma, and a positive family
history of colorectal cancer were also significant predictors.
Distal adenoma size was not a significant predictor in any multivariate
analyses.
Conclusions: Advanced proximal neoplasia
is not uncommon in subjects with or without distal TAs, but
subjects with advanced distal histology and those older than
65 years are at increased risk. Age-specific screening using
sigmoidoscopy starting at ages 50 to 55 years and colonoscopy
after age 65 years may be justified.
Copyright 1999, American Medical
Association
Identifying Women with Cervical
Neoplasia: Using Human Papillomavirus DNA Testing for Equivocal
Papanicolaou Results
Manos MM; Kinney WK; Hurley LB; Sherman ME; Shieh-Ngai
J; Kurman RJ; Ransley JE; Fetterman BJ; Hartinger JS; McIntosh
KM; Pawlick GF; Hiatt RA; JAMA 1999 May 5;281(17):1605-10.
Context: A Papanicolaou (Pap) test result
of atypical squamous cells of undetermined significance (ASCUS)
presents a clinical challenge. Only 5% to 10% of women with
ASCUS harbor serious cervical disease, but more than one third
of the high-grade squamous intraepithelial lesions (HSILs) in
screening populations are identified from ASCUS Pap test results.
Objective: To determine whether human papillomavirus
(HPV) DNA testing of residual material from liquid-based Pap
tests and referral of cases found to be HPV-positive directly
to colposcopy could provide sensitive detection of underlying
HSILs in women with ASCUS Pap results, compared with repeat
Pap testing.
Design and Setting: Natural history of
women with ASCUS Pap smear results, all of whom had liquid-based
cytology, HPV testing, and subsequent repeat Pap tests and colposcopy
with histologic evaluation, conducted at 12 gynecology clinics
in a large managed care organization between October 1995, and
June 1996.
Participants: From a cohort of 46,009 women
who had routine cervical examinations, 995 women with Pap test
results of ASCUS who consented to participate were identified.
Main Outcome Measures: Cervical histology,
HPV test results, and repeat Pap smear results, and sensitivity
of HPV testing to identify patients found to have HSIL+ histology.
Results: Of 995 participants with ASCUS
Pap test results, 973 had both a definitive histologic diagnosis
and HPV result. Sixty-five (6.7%) had histologic HSIL or cancer.
For women with histologic HSIL+, the HPV test was positive in
89.2% (95% confidence interval [CI], 78.4%-95.2%), and the specificity
was 64.1% (95% CI, 60.9%-67.2%). The repeat Pap smear result
was abnormal in 76.2% (95% CI, 63.5%-85.7%). Triage based on
HPV testing only or on repeat Pap testing only would refer similar
proportions (approximately 39%) to colposcopy. The sensitivity
of HPV DNA testing for HSIL was equivalent to, if not greater
than, that of the repeat Pap test. We further estimated that
an HPV-based algorithm including the immediate colposcopy of
HPV-positive women, and then repeat Pap testing of all others,
would provide an overall sensitivity of 96.9% (95% CI, 88.3%-99.5%).
Conclusions: For women with ASCUS Pap tests,
HPV DNA testing of residual specimens collected for routine
cervical cytology can help identify those who have underlying
HSIL. By testing the specimen collected at initial screening,
the majority of high-risk cases can be identified and referred
for colposcopy based on a single screening.
Copyright 1999, American Medical
Association
Advance Directives are More
Likely among Seniors Asked about End-of-Life Care Preferences
Gordon NP; Shade SB; Arch Intern Med 1999 Apr
12;159(7):701-4.
Objectives: To estimate the proportion
of seniors in a large health maintenance organization (HMO)
who had been asked about their end-of-life care preferences
(EOLCPs) by a clinician and who had completed an advance directive
(AD). To examine the association of having had an EOLCP discussion
and AD completion.
Subjects and Methods: A random sample of
HMO members aged 65 years or older were asked to complete a
mailed survey about health and health-related issues in 1996.
Data provided by 5117 seniors (80% response rate) were used
to estimate the prevalence of EOLCP and AD among seniors overall
and in specific risk groups. Bivariate and multiple logistic
regression models were used to identify predictors of AD completion,
especially having been asked about EOLCP.
Results: One third of seniors reported
having an AD on file with the HMO, but only 15% had talked with
a clinician about EOLCP. Both having been asked about EOLCP
and having an AD were positively associated with age, but not
significantly associated with sex, race/ethnicity, marital status,
or self-rated health status. Having been asked by a clinician
about EOLCP was significantly associated with completion of
an AD.
Conclusion: Clinicians can play an important
role in increasing AD completion rates among seniors by bringing
up the subject of EOLCPs.
Copyright 1999, American Medical
Association
Cognitive-Behavioral Treatment
of Adolescent Depression: Efficacy of Acute Group Treatment
and Booster Sessions
Clarke GN; Rohde P; Lewinsohn PM; Hops H; Seeley
JR; J Am Acad Child Adolesc Psych 1999 Mar;38(3):272-9.
Objective: This trial examined the effects
of both acute and maintenance cognitive-behavioral therapy (CBT)
for depressed adolescents.
Method: Adolescents with major depression
or dysthymia (N=123) were randomly assigned to one of three
eight-week acute conditions: adolescent group CBT (16 two-hour
sessions); adolescent group CBT with a separate parent group;
or waitlist control. Subsequently, participants completing the
acute CBT groups were randomly reassigned to one of three conditions
for the 24-month follow-up period: assessments every four months
with booster sessions; assessments only every four months; or
assessments only every 12 months.
Results: Acute CBT groups yielded higher
depression recovery rates (66.7%) than the waitlist (48.1%),
and greater reduction in self-reported depression. Outcomes
for the adolescent-only and adolescent + parent conditions were
not significantly different. Rates of recurrence during the
two-year follow-up were lower than found with treated adult
depression. The booster sessions did not reduce the rate of
recurrence in the follow-up period but appeared to accelerate
recovery among participants who were still depressed at the
end of the acute phase.
Conclusions: The findings, which replicate
and expand upon a previous study, support the growing evidence
that CBT is an effective intervention for adolescent depression.
Maternal Placental Abnormality
and the Risk of Sudden Infant Death Syndrome
Li DK; Wi S; Am J Epidemiol 1999 Apr 1;149(7):608-11.
To determine whether placental abnormality (placental
abruption or placenta previa) during pregnancy predisposes an
infant to a high risk of sudden infant death syndrome (SIDS),
the authors conducted a population-based case-control study
using 1989-1991 California linked birth and death certificate
data. They identified 2,107 SIDS cases, 96% of whom were diagnosed
through autopsy. Ten controls were randomly selected for each
case from the same linked birth-death certificate data, matched
to the case on year of birth. About 1.4% of mothers of cases
and 0.7% of mothers of controls had either placental abruption
or placenta previa during the index pregnancy. After adjustment
for potential confounders, placental abnormality during pregnancy
was associated with a twofold increase in the risk of SIDS in
offspring (odds ratio = 2.1, 95% confidence interval 1.3-3.1).
The individual effects of placental abruption and placenta previa
on the risk of SIDS did not differ significantly. An impaired
fetal development due to placental abnormality may predispose
an infant to a high risk of SIDS.
Alcohol Consumption and Breast
Cancer Oestrogen and Progesterone Receptor Status
Enger SM; Ross RK; Paganini-Hill A; Longnecker
MP; Bernstein L; Brit J of Cancer 1999 Mar;79(7-8):1308-14.
We examined the role of alcohol on the risk of
breast cancer by the joint oestrogen receptor (ER) and progesterone
receptor (PR) status of the tumour using data from two case-control
studies conducted in Los Angeles County, USA. Eligible premenopausal
patients were 733 women aged < or = 40 years and first diagnosed
from 1 July 1983, to 1 January 1989. Eligible postmenopausal
patients were 1169 women aged 55-64 years and first diagnosed
from 1 March 1987 to 31 December 1989. Patients were identified
by the University of Southern California Cancer Surveillance
Program. Neighbourhood controls were individually matched to
patients by parity (premenopausal patients) and birth date (+/-3
years). ER and PR status were obtained from medical records
for 424 premenopausal and 760 postmenopausal patients. The analyses
included 714 premenopausal and 1091 postmenopausal control subjects.
Alcohol use was generally not associated with premenopausal
risk of breast cancer, regardless of hormone-receptor status.
Among the postmenopausal women, those who consumed, on average,
> or = 27 g of alcohol/d experienced an odds ratio (OR) of
1.76 [95% confidence interval (CI) 1.14-2.71] for ER-positive/PR-positive
breast cancer relative to women who reported no alcohol consumption.
Alcohol use was less clearly associated with risk of other receptor
types among postmenopausal women. These data suggest that alcohol
may preferentially increase risk of ER-positive/PR-positive
breast cancer in postmenopausal women.
Reprinted from the British Journal of Cancer;
Vol. 79 (7-8). Enger SM, Ross RK, Paganini-Hill A, Longnecker
MP, Bernstein L; Alcohol consumption and breast cancer oestrogen
and progesterone receptor status; 1308-14; 1999; by permission
of the publisher Churchill Livingstone.
Relationships Between Duration
of Asthma and Asthma Severity among Children in the Childhood
Asthma Management Program
Zeiger RS; Dawson C; Weiss S; J Allergy Clin
Immunol 1999 Mar;103(3 Pt1):376-87.
Background: Many factors, including heredity,
atopic status, and environment, have been implicated in the
determination of asthma severity. Relatively
little is known about the degree to which asthma duration influences
asthma severity.
Objective: The Childhood Asthma Management
Program (CAMP), consisting of 1041 children (age 8.9 +/- 2.1
years at enrollment) with mild-to-moderate asthma, offers an
opportunity to examine the relationship between asthma duration
and asthma severity.
Methods: By using the extensive CAMP baseline
cross-sectional data on asthma duration, spirometry, bronchial
responsiveness, symptomatology, and markers of atopy, univariate
and multivariate regression models were used to evaluate whether
asthma duration is associated with asthma severity.
Results: Duration of asthma in the study
cohort from time of diagnosis until randomization into CAMP
ranged from 0.3 to 12.1 years (mean, 5.0; SD, 2.7; median, 4.8).
Asthma duration is associated in univariate analyses both with
lower levels of several lung functions (P<.001), including
methacholine bronchial reactivity (natural log [ln] FEV1 PC20,
mg/mL; r = -0.112), prebronchodilator and postbronchodilator
percent predicted FEV1 (r = -0.176 and r = -0.130, respectively),
and prebronchodilator and postbronchodilator FEV1/forced vital
capacity (FVC) (%) (r = -0.237 and r = -0.211, respectively),
as well as higher levels of symptoms (symptom score: r = 0.147,
P < .001) and borderline greater use of albuterol for symptoms
(r = 0.058, P=.064) during a 28-day screening period before
randomization. Simple linear regression detected the following
differences in lung functions per year of asthma duration: ln
FEV1 PC20,
-0.050 mg/mL/y; prebronchodilator FEV1, -0.907 percent predicted/y;
and prebronchodilator FEV1/FVC,
-0.729 percent predicted/y. After controlling for potential
explanatory variables (atopy, inflammatory markers, household
Der p 1 levels, anti-inflammatory medication use, and clinical
center), regression models revealed that the duration of asthma
remained significantly and independently associated with ln
FEV1 PC20 (P=.004), prebronchodilator percent predicted FEV1
(P=.043), and prebronchodilator and post-
bronchodilator FEV1/FVC (%) (P<.001), as well as being positively
associated with mean daily symptom score (P<.001) and albuterol
use for symptoms (P=.003) during a 28-day screening period.
Duration was also found to be significantly associated with
physician/nurse assessment of asthma severity and other historical
measures of medication use.
Conclusions: These data demonstrate that
asthma duration is associated with lower lung function, greater
methacholine responsiveness, more asthma symptomatology, and
greater use of as-needed albuterol, which are all measures of
asthma severity. As such, early diagnosis and intervention may
be necessary to ameliorate these adverse effects of persistent
asthma.
Reproduced from J of Allergy Clin
Immunol, with permission from Mosby-Year Book, Inc.
Computer-Assisted Health Counselor
Visits: A Low-Cost Model for Comprehensive Adolescent Preventive
Services
Paperny DM; Hedberg VA; Arch Pediatr Adolesc
Med 1999 Jan;153(1):63-7.
Objective: To evaluate a low-cost strategy
for providing preventive health services to adolescents using
computerized health assessments with individualized educational
videos, trained health counselors, and nurses.
Design: Feasibility study, cost analysis,
and comparative evaluation of health problems identified, guidance
delivered, and patient satisfaction.
Setting: Eleven sessions at nontraditional
sites including schools, universities, shopping malls, and after-hours
clinics on Oahu, Hawaii.
Participants and Intervention: Adolescents
(N=258, mean age 17 years) completed confidential computerized
health assessments, received individualized feedback, and viewed
automatically selected educational videos on a laptop computer.
The computer additionally printed a prioritized problems list
for the graduate student-level health counselor to
review with the adolescent. The counselor subsequently reviewed
each encounter with a nurse-educator who performed further counseling
and physical examinations when indicated.
Results: Visit length averaged 44 minutes.
Subjects spent an average of 21 minutes completing the automated
health assessment and viewing interactive multimedia and 15
minutes with the health counselor. One third of subjects required
further evaluation and counseling by the nurse (average, 8 minutes).
A team of two counselors and one nurse provided comprehensive
screening, health counseling, and physical examinations to one
patient every ten minutes at a salary cost of $7.46 per visit.
This model identified risk behaviors at levels consistent with
local behavioral data, and addressed and documented them significantly
more often than do physicians in traditional settings. Subjects
(71%) preferred the computer-assisted visits to standard office
visits, and 92% felt the amount of time spent was acceptable.
Conclusions: Computer-assisted delivery
of adolescent preventive services using nonphysician health
counselors is a feasible, economical, and acceptable alternative
to traditional clinical practice for screening young people
for health-compromising behaviors and providing individualized
health education and routine physical examinations. This model
would likely increase adolescents' access to needed preventive
services at a very modest cost.
Copyright 1999, American Medical
Association
