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PURPOSE: Rural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians. METHODS: This qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts. FINDINGS: Patient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians. CONCLUSIONS: The rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.

Introduction: Medical education topics might be locally prioritized using public health data on health outcomes and risk factors unrelated to quality of care. Methods: The Missouri Information for Community Assessment (MICA) supplied preventable hospitalization rates (PHRs) for asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart failure, and hypertension in 114 counties from 1998 to 2002. For each disease, a linear regression model predicted PHR from behavior, access, and disease prevalence data from MICA and other public data sources. For each disease in each county, the residual, unexplained PHR should include effects of local medical practices. Variation in relative priority of diseases between counties was estimated from raw PHR and unexplained PHR. Results: The raw values of the five PHRs varied geographically in different patterns. Regression models explained between 46% and 83% of the variability. The medical education priorities implied by unexplained PHR values differ from priorities inferred from unadjusted PHR or disease prevalence. Discussion: Patient behavior and poor health care access contribute to PHR but do not fully explain variation in PHR. If county-level unexplained PHR values identify high priority medical education topics, then other measures of importance, notably disease prevalence and PHR, are poor identifiers of high value topics. Although available predictor and outcome variables constrain the current analysis, unexplained variation in health outcome measures might identify educational opportunities. These observations suggest strategies for balancing and evaluating controlled trials of knowledge dissemination efforts and eventually for deploying educational activities. (Contains 2 tables and 1 figure.)

Patients with the same degree of chronic chest pain may differ in the amount of distress they experience. Researchers surveyed 211 patients with chronic stable chest pain to assess the amount of distress experienced by the patients. In each progressively severe disease class, the patients experienced increasing distress from their symptoms. Patients with less severe chest pain categorized in treatment classes I or II were bothered significantly less by their symptoms than patients with more severe chest pain in treatment classes III or IV. Within each treatment class, patients were bothered to varying degrees by their symptoms. There was approximately a 33% chance that patients in treatment class II would be bothered by their symptoms more than patients in treatment class III or IV. Clinical practice guidelines for chronic stable chest pain should be based on patient preferences instead of the severity of symptoms alone., Objective. - Although practice guidelines sometimes make recommendations based on symptom severity, they rarely account for how patents feel about their symptoms. To investigate the possible importance of patent preferences in treatment of ischemic heart disease, we assessed attitudes toward symptoms in patients with angina pectoris. Design. - case series. Selling.- Ambulatory cardiology clinics at two tertiary care medical centers. Patients. - A total of 220 subjects were selected from 589 patients with chronic stable angina referred from cardiologists to achieve patent samples balanced for sex, race, and angina severity. Main Outcome Measures. - We measured patients' attitudes toward their angina using the rating scale, time trade-off, and standard gamble utility metrics. Reliability of measurements was evaluated by repeating the assessments 2 weeks later on 50 willing patients. Results. - While the mean responses followed the expected patterns (those with more severe Canadian Cardiovascular Society scores chose lower utilities), attitudes toward symptoms varied substantially among patients with similarly severe angina. For example, there was a 33% chance that a patient with class II angina had a time trade-off utility that was lower (ie, more bothered by symptoms) than a patient with more severe angina (class III/IV). This variation in utilities was not due to random error in the assessments. Conclusions. - Angina patients with similar functional limitation vary considerably in their tolerance for their symptoms, as measured by utilities. Our findings suggest that guidelines for the management of ischemic heart disease should be based on the preferences of the individual patient rather than on symptom severity alone.

Abstract Background Tort law has legitimate social purposes of deterrence, punishment and compensation, but medical tort law does none of these well. Tort law could be counterproductive in medicine, encouraging costly defensive practices that harm some patients, restricting access to care in some settings and discouraging innovation. Discussion Patients might be better served by purchasing combined health and life insurance policies and waiving their right to pursue malpractice claims. The combined policy should encourage the insurer to profit by inexpensively delaying policyholders' deaths. A health and life insurer would attempt to minimize mortal risks to policyholders from any cause, including medical mistakes and could therefore pursue systematic quality improvement efforts. If policyholders trust the insurer to seek, develop and reward genuinely effective care; identify, deter and remediate poor care; and compensate survivors through the no-fault process of paying life insurance benefits, then tort law is largely redundant and the right to sue may be waived. If expensive defensive medicine can be avoided, that savings alone could pay for fairly large life insurance policies. Summary Insurers are maligned largely because of their logical response to incentives that are misaligned with the interests of patients and physicians in the United States. Patient, provider and insurer incentives could be realigned by combining health and life insurance, allowing the insurer to use its considerable information access and analytic power to improve patient care. This arrangement would address the social goals of malpractice torts, so that policyholders could rationally waive their right to sue.

Abstract Background Cigarette smoking takes a staggering toll on human health and attracts considerable public health attention, yet real solutions seem distant. The 2004 Family Smoking Prevention and Tobacco Control Act (US Senate bill S2461) would have given the US Food and Drug Administration limited authority to regulate cigarettes to "protect the public health." However, such legislation is unlikely to substantially reduce smoking or related deaths. Discussion The past 500 years of tobacco control efforts demonstrate that nicotine prohibition is a practical impossibility for numerous reasons, state revenue being one of the most ominous. The FDA already has regulatory authority over pharmaceutical grade nicotine products, and requires pharmacists to dispense the most addictive of these only with prescriptions. Meanwhile, every corner store can sell far more addictive and dangerous cigarettes to any adult. The FDA could immediately increase competition between cigarettes and clean nicotine products by approving available nicotine products for over-the-counter sales to adults. Similarly permissive regulation of cigarettes and addictive nicotine products will reduce tobacco use and improve smokers' health, but increase nicotine use in the population. Fortunately, restricted youth access and accurate labeling of nicotine's absolute risks will dissuade many non-smokers from experimenting with it, while accurate depiction of its risks relative to cigarette smoking will encourage many smokers to switch. The FDA could take a series of small steps that might ultimately replace a large proportion of cigarette smoking with equally addictive nicotine products, without risking serious public health setbacks. Vaccine, methadone, and injury prevention policies establish relevant public health precedents. Summary Cigarettes, or an equally addictive alternative, will be a permanent and common product in most societies. Regulations restricting only the safest addictive nicotine products are hard to justify. Addictive nicotine compliments other tobacco control strategies. Modern tobacco control policies are applicable to addictive nicotine. Controlled trials and test market studies are urgently needed to evaluate addictive nicotine as an alternative to smoking. Meanwhile, legislators should preserve the Food and Drug Administration's option to permit non-prescription sales of addictive nicotine.