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Purpose: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices.Methods: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports.Results: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting.Conclusions: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted. [ABSTRACT FROM AUTHOR]

Although diabetes management remains an important problem, little is known about the effectiveness of employing emerging information technologies to enhance self-management strategies in order to improve diabetes care and patient outcomes. This report reviews the use of a community-based participatory research (CBPR) approach with user feedback to understand the feasibility of introducing the personal digital assistant (PDA) as a self-management tool for diabetes management. We focused on problem identification, intervention selection, and methodological issues. Both physician and patient perspectives are addressed. A search of electronic medical records helped to identify diabetes as a major clinical issue for primary care physicians in an integrated group practice. Physicians subsequently identified technological innovations as a promising tool to enhance patient outcomes. User feedback data confirmed the usefulness of using PDAs to assist patients to keep track of their appointments, physical activity, dietary intake, medication use, and daily blood glucose readings. While those with more computer experience caught on quicker, even some of those with limited computer experience were able to draw some benefit. Needed adaptations for greater success with this technological innovation in a wider range of patients were identified. Implementation of new technological approaches in disease management can benefit from a CBPR framework that addresses factors affecting both physician and patient acceptance and uptake. [ABSTRACT FROM AUTHOR]

A 72-year-old woman with a prior history of stage IIIa lung adenocarcinoma was seen with complaints of knee pain, swelling, and difficulty sleeping at night for 1 month. Although mimicking osteoarthritis, patellofemoral syndrome, and iliotibial band syndrome, radiographs showed a lytic lesion suspicious for metastatic disease. The right tibial lesion was excised, saphenous neurolysis was performed, and radiation treatment and four cycles of chemotherapy were administered. This case shows the importance of early imaging in patients with knee pain of prolonged duration seen in the primary care setting. [ABSTRACT FROM AUTHOR]

Rationale and objectives: The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs’ ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined.Materials and methods: A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics.Results: Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient’s gender, site of care, and insurance status under the health care system’s Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39–1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered.Conclusion: These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint. [Copyright &y& Elsevier]

The authors determined the incidence of concussion as well as correlates of grade II and grade III concussion among high school varsity football athletes. School team physicians completed an Internet-based incident card on their athletes who sustained a concussion on the field of play over three football seasons. Reported information included demographic data, school size, play position, game quarter of injury, and grade of concussion. A total of 70 concussions were reported on 981 eligible athletes for a cumulative incidence of 2.4 per 100 eligible players. The majority was grade II (52.9%). Most concussions occurred during the second (41.4%) and fourth (28.6%) quarters. The risk of concussion increased with increasing school size. After controlling for grade, weight, play position, and school size, playing during the fourth quarter was the only significant correlate of grade II and grade III concussion. Compared to playing during the first quarter, the risk of grade II and grade III concussion occurring during the fourth quarter was 8.7 (95% confidence interval, 1.2-64.2). Although the authors found a lower incidence of concussion than reported by others, they recommend that football coaches and team physicians be extra vigilant during the fourth quarter. [ABSTRACT FROM AUTHOR]

Injuries have now become a recognizable public health problem in developing Countries. However, no definite policies regarding their surveillance and control are yet available in most of these countries. This paper, using Ghana as a prototype, examines the need for policy and action which has been accentuated in recent times by public outcry. The paper also provides some recommendations to solve this problem: the urgent need to initiate programs such as needs assessment, the establishment of a surveillance system for injuries at various levels of health services, creation of public awareness and provision of health education, and the institution of simple first-aid measures. Specific policies regarding injuries from motor vehicle accidents and fires are also given. [ABSTRACT FROM AUTHOR]

Objectives-This study examined determinants of modern health care use by families after their child aged 0-5 years sustained a burn injury in the Ashanti Region of Ghana. Methods-A community based survey of children aged 0-5 years was conducted in 50 enumeration areas in the region. Mothers of all children with scars as evidence of a burn were selected for a follow up interview using a standard questionnaire two to three months later. Determinants of health care use were investigated through a multivariate logistic regression using interview responses from mothers of 617 children for whom report on some treatment was given. Results-Overall, 48% of the burned children were taken to a modern health facility for treatment. Of those taken to a modern health facility, 68% were sent within 24 hours of the burn event. Factors with large adjusted odds ratios for modern health care use included wound infection, burns covering 6% or more of the body surface, and third degree burns. Compared with scalds, children with contact and flame burns were less likely to be taken to a health facility, as were burns to rural children, and those given first aid treatment at home. Conclusions-It is concluded that families, particularly rural residents, should be educated about appropriate health care seeking practices after a burn. [ABSTRACT FROM AUTHOR]

Presents a team approach to reducing the financial deficit of a multispecialty medical group in the United States. Request to physicians to help find solutions; Plans to cut their salaries; Need to raise productivity; Development of an action plan.

Primary care physicians' perceptions of diabetes treatment protocols (DTPs) in the management of type 2 diabetes mellitus (T2DM) were examined at the individual and organizational levels. A 27-item electronic survey was administered to primary care physicians from an integrated multispecialty health care system in Texas. Information was collected on various aspects of DTPs, including attitudes toward these protocols, perceived barriers, and knowledge, as well as utilization of diabetes self-management programs. Besides quality of care, the primary care physicians surveyed generally had mixed feelings regarding DTPs' ability to contribute positively to other aspects of health care; in addition, only a small percentage were familiar with some currently available self-management programs. Given that implementation of DTPs depends on primary care physicians, we should address physicians' attitudes and perceptions toward DTPs so as to increase utilization of these helpful protocols.

Background and Objectives: Primary care practitioners can play a significant role in helping patients adopt healthy behaviors such as physical activity (PA). The aim of this qualitative study was to assess family physicians' understanding and perception of the personal and environmental factors influencing PA, especially walking, and factors affecting their counseling of obese patients about environmental motivators and barriers to PA., Methods: We conducted five focus groups with 35 family physicians and 14 family medicine residents in four clinics and a residency program affiliated with CenTexNet, a primary care practice-based research network in central Texas. Data were transcribed and analyzed using thematic content analysis., Results: Physicians were aware of the PA guidelines, but not many actually brought up PA during their counseling of patients. Physicians agreed that neighborhood environments are important for walking and reported that their patients often brought up environmental barriers. Physicians recommended walking as an ideal type of PA for obese patients and sidewalks, parks, and trails/tracks with smooth and soft surfaces as ideal places to engage in walking. However, they rarely talked about these factors with their patients due to a perceived ineffectiveness in counseling, an inability to address environmental factors, and time constraints in the medical encounter., Conclusions: While physicians believe neighborhood environments often present many barriers to PA, they still believe that environmental factors are secondary to personal motivation in promoting PA among obese patients. Physicians, if better informed of the growing evidence on the environment-PA links, may be able to facilitate patients' behavior change more effectively.

Background: Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice., Methods: The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer., Results: Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44))., Conclusions: While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

We determined the nature and magnitude of extant health disparities in patients with type 2 diabetes (T2DM) by race and ethnicity. Data were abstracted from the electronic medical records and charts of all patients 18 years or older who had been diagnosed with T2DM and seen over a 1-year period in one primary care clinic. Data abstracted included patient demographics; provision of counseling on smoking cessation, diet, exercise, and home blood glucose monitoring (HBGM); health care utilization; laboratory measures; and clinical outcomes. No significant racial or ethnic differences were found in the rate of provision of counseling on smoking cessation, diet, exercise, and HBGM, which were all suboptimal according to American Diabetes Association recommendations. In addition, no significant differences were found in the mean number of hospital admissions, emergency room visits, and referrals for specialty care. However, the mean HbA1c levels for African Americans (9.9%) and Hispanics (9.0%) were significantly higher than that of whites (8.7%; P<.0001), even after controlling for body mass index and age. Explanation of the significant racial and ethnic differences found in HbA1c levels, despite similar diabetes self-management treatment protocols or health care utilization, calls for further research.

Use of information technology in diabetes management has been shown to improve self-care. We determined whether enhancing type 2 diabetes (T2DM) self-care with a personal digital assistant (PDA) by patients in the ambulatory setting would improve glycemic control. A pretest/posttest intervention study was conducted in four family practice clinics in a large multispecialty group practice associated with an 186,000-member Health Maintenance Organization. Adults with T2DM and last measured glycosylated hemoglobin (HbA1c) of > or = 8.00% received one-on-one training on the use of a loaned PDA pre-installed with "Diabetes Pilot." Changes in HbA1c and other outcomes were assessed at 6 months from baseline for all participants and by participant-reported PDA use patterns, dichotomized into high PDA users (> or =3 days in past 7) and low PDA users (< 3 days). Of 43 subjects enrolled, 18 (41.90%) completed the 6-month intervention. Their mean HbA1c decreased 17.50% from 9.70% at baseline to 8.00%, a significant mean HbA1c change of -1.7% (95% CI = -2.60 to -0.90). The mean HbA1c change was higher among reported high PDA users (n = 9, mean difference = -1.90, 95% CI = -3.20 to -0.50) than among reported low PDA users (n = 9, mean difference = -1.50, 95% CI = -2.80 to -0.30). Significant increases were reported for the foot care and general diet subscales of the Summary of Diabetes Self-Care Activities from 3 to 6 months. Enhancing T2DM self-care by adults with a PDA was associated with significant reductions in HbA1c; the reductions were greater among reported high PDA users.

Context: Although physician influence can be especially powerful with older adults, relatively little is known about how primary care physicians (PCPs) interact with their patients regarding lifestyle issues., Objective: To document the length of time that PCPs discuss lifestyle issues with their older patients and to examine patient, physician, and contextual correlates., Design: Descriptive and multivariate analysis of videotapes of physician-patient encounters., Setting: Medical encounters from 3 primary care ambulatory settings., Patients: There were 116 ongoing medical encounters with patients aged 65 years or older., Main Outcome Measures: Total time spent in physical activity (PA) discussions and total time spent discussing PA, nutrition, and smoking during the medical encounter., Results: Very little time was spent in lifestyle discussions. On average, PA was discussed for less than a minute (58.28 seconds) and nutrition for slightly less than 90 seconds (83.11 seconds). Only about 10% of the average 17-minute, 22-second encounter was spent on physical activity, nutrition, or smoking topics. Physician supportiveness score (beta = 8.92, P

Background: The objective of this study was to examine variations in MRI/CT utilization between family physicians (FPs) and general internists (IMs) within a multi-specialty group practice., Material/methods: Using administrative data, we computed ordering rates of MRI/CT per 1,000 outpatient clinic visits and per 1,000 unique patients and rate ratios (RR) to compare rates between 34 FPs and 24 IMs practicing in 7 clinics located within 50 miles of the radiology facility. We also assessed intra-specialty variation. Sources and degree of variation were determined separately for FPs and IMs through multivariate linear regression modeling., Results: The IMs ordered MRI/CTs at twice the rate of FPs (29.6 vs. 14.8 per 1,000). Although the absolute ranges by specialty were statistically similar, the variance was significantly higher for IMs (86.1 vs. 52.3; p<0.0001). FPs' ordering rates ranged from 2.8 to 35.2 (SD=7.23), while IMs' ranged from 16.0 to 47.9 (SD=9.27). Female physicians ordered the tests at a higher rate (RR=1.38; 95% CI=1.17-1.53). After controlling for physician gender, years of practice, and patient panel size, distances from their clinics to the radiology facility site and patient severity index were the only variables that were significantly associated with MRI/CT ordering among FPs, explaining 39% of the total variance., Conclusions: Although IMs ordered MRI/CTs at a higher rate, as were females from both specialties, there was a higher ratio between high and low FP utilizers. The variation in FPs can be partly explained by their clinic distance to the radiology facility site and their patient severity index.

Background: Although current recommendations advocate screening persons 50 years of age or older for colorectal cancer (CRC), actual screening practice is highly variable among primary care physicians (PCPs). Knowledge of the factors that influence whether or not screening is offered during a clinic visit is essential to develop effective screening strategies., Methods: A cross-sectional telephone survey of one in four randomly selected patients aged 50 years or older (n = 400) attending a primary care clinic within an integrated health care system in central Texas was conducted. A survey of all PCPs (n = 32) at the practice sites was also administered., Results: The visit type was an important determinant of whether CRC screening was discussed, with most discussion occurring during visits for physicals (P < 0.0001). This finding was corroborated by the physician survey. Patient age and education were also associated with a higher likelihood of having been offered CRC screening (P = 0.009 and 0.014, respectively). Patient race, gender, primary language, PCP, or clinics attended were not significantly associated with the discussion of CRC screening., Conclusions: Discussions regarding CRC screening are most likely to occur during preventive care visits. Thus, facilitating preventive visits especially for the elderly represents an opportunity to improve CRC screening rates in primary care practice.

Rationale and Objectives: The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs' ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined., Materials and Methods: A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics., Results: Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient's gender, site of care, and insurance status under the health care system's Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39-1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered., Conclusion: These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint.

Background: We determined the agreement between parents and their school-age children on reported barriers to bicycle helmet use., Material/methods: We conducted a cross-sectional survey in a 2-county Central Texas region with no helmet use legislation. Parent-child pairs, selected through a randomized, multi-stage sampling procedure and pre-matched by unique identifiers, were surveyed independently with self-administered questionnaires. Parent-child concordance was assessed using Kappa statistic., Results: Of 1,987 surveys distributed, children returned 1,203 (61%) while parents returned 636 (53% of child respondents). Parents included 31% college graduates and 33% reported annual income of >55,000 dollars. Children included 60% whites, 16% blacks, and 16% Hispanics. The most popular reasons cited by children as barriers to helmet use were not having one (34%), being a safe rider (31%), and helmets messing up hair (18%). Good concordance was found on reported child bicycle riding (parent=88.0% vs. child=88.0%; K=0.64) and child helmet use the last time child rode a bicycle (parent=25.1% vs. child=28.0%; K=0.54). While good concordance was also found for reported helmet ownership (parent=31.9% vs. child=29.9%; K= 0.50), poor concordance was found for other barriers to helmet use including helmets looking ugly (parent=6.5% vs. child=13.4%; K=0.38) and messing up hair (parent=5.6% vs. child=15.2%; K=0.36)., Conclusions: Although parents may be generally aware of their children's bicycle riding and helmet use habits, they may not be fully aware of the reasons why their children may not use a helmet. Public education and interventions on helmet promotion need to focus on parents.