Background and Objectives: Economics has been suggested as a barrier to vaccination, but data that link clinician reports to actual immunization rates are limited. This study examined the relationship between clinicians’ self-report regarding likelihood of vaccinating and actual age at vaccination from a registry of children seen by the clinicians.

Methods: Standardized telephone survey results of 29 providers were compared to the immunization records of children seeing these providers, using analysis of contingency tables (on time versus late) and conditional hierarchical linear models with log age at diphtheria-tetanus-pertussis (DTP)#3, DTP#4, and measles-mumps-rubella (MMR)#1 as the dependent variables.

Results: Children seeing providers likely to refer an uninsured child for immunization were vaccinated at a later log age at DTP#4 but not for DTP#3 or MMR#1 than children seeing providers unlikely to refer. Vaccination rates were higher for MMR#1 (77% versus 48%), DTP#3 (84% versus 71%), and DTP#4 (82% versus 66%) among providers who received free vaccine, compared with children seen by providers who did not receive free vaccine. These results remained significant in the hierarchical analyses. Providers likely to vaccinate an 18-month-old with watery diarrhea had higher vaccination rates than those unlikely to vaccinate for MMR#1, DTP#3, and DTP#4; the results were also significant in the hierarchical analyses.

Conclusions: Children are vaccinated later in the practices of providers who are likely to refer uninsured children to a public vaccine clinic for vaccination, who do not receive free vaccine supplies, or who overinterpret contraindications.

Special Series: Award-winning Research Papers From the American Academy of Family Physicians 1998 Scientific Assembly
(Fam Med 1999;31(5):317-23.)

Does Telephone Contact With a Physician’s Office Staff Improve Mammogram Screening Rates?
Kim Marvel, PhD; Gregory Major, MD

Background and Objectives: Mammography is an important screening tool for the early detection of breast cancer. However, mammogram screening rates are low, despite interventions to improve them. We investigated two methods to improve mammogram screening and compared mammogram rates among women who received these interventions to mammogram screening rates in a control group. We also investigated the costs involved in these interventions.

Methods: We studied mammogram screening rates of three randomized groups of women ages 50 and older from the Deighton Family Practice Center in Southfield, Mich. All women had had a mammogram 1 year previously and were due for another mammogram. Our control group (n=110) received no intervention. The second group of women (n=102) received a reminder letter from the radiology department. The third group (n=86) received a reminder letter followed by a phone call from the physician’s office staff if no mammogram had been obtained within 8 weeks after the due date for the mammogram. All three groups were monitored for 14 weeks after the due date to determine mammogram screening rates in each group.

Results: A mammogram was obtained by 33% of women in group 1, 37% of women in group 2, and 57% of women in group 3. The mammogram screening rate of the third group was significantly greater than in the first two groups. In the third group, the additional cost added by the phone call intervention was $9 per mammogram obtained.

Conclusions: Mammogram screening rates are increased when patients are contacted by both a reminder letter and a phone call.

Special Series: Award-winning Research Papers From the American Academy of Family Physicians 1998 Scientific Assembly
(Fam Med 1999;31(5):324-6.)

Shorter Dosing Interval of Opiate Solution Shortens Hospital Stay for Methadone Babies
Heidi Chumley Jones, MD

Background and Objectives: Methadone maintenance is the standard of care for pregnant opiate addicts. However, withdrawal of an infant from methadone after birth often results in a lengthy hospital stay. This study identified potentially modifiable factors that are associated with the length of hospital stay of infants of mothers on methadone.

Methods: This study used a retrospective case series of patients from a university hospital in Texas. Eligible participants included 41 neonates born between January 1991 and December 1996 to mothers taking methadone at time of delivery. Charts were reviewed for factors relating to administration of opiates to the newborn, and the length of the hospital stay was recorded for each infant. Bivariate and multiple regression analyses were performed using length of hospital stay as the outcome measure.

Results: Higher peak dose of tincture of opiate solution (TOS) and longer dosing interval were found to be related to longer length of hospital stay. These variables explained 23% of the variation in length of stay.

Conclusions: Lower peak doses of TOS and shorter dosing intervals may be associated with shorter hospital stays for infants with neonatal abstinence syndrome secondary to maternal methadone treatment.Lower peak doses of TOS and shorter dosing intervals may be associated with shorter hospital stays for infants with neonatal abstinence syndrome secondary to maternal methadone treatment.

Special Series: Award-winning Research Papers From the American Academy of Family Physicians 1998 Scientific Assembly
(Fam Med 1999;31(5):327-30.)


Using a Flow Sheet to Improve Performance in Treatment of Elderly Patients With Type 2 Diabetes
Gary Ruoff, MD; Lynn S. Gray, MD, MPH

Background and Objectives: Numerous studies have shown that physicians do not provide all the preventive and therapeutic care recommended for patients with diabetes. This study determined if use of a medical record flow sheet could increase compliance with seven quality-of-care indicators developed by the American Diabetes Association.

Methods: Subjects included Medicare enrollees with type 2 diabetes. Following an analysis of baseline data, physicians in the practice used a flow sheet that contained recommended guidelines for diabetes care. Staff inserted the flow sheet into the records of patients included in the baseline sample. Physicians and staff also received education about use of the flow sheet. The post-intervention sample consisted of the same subjects, if they had been seen by the practice during a 3-month period.

Results: The records of 114 subjects were reviewed at baseline. Of these subjects, 109 received care during the study period. Improvement was shown in six of the seven quality indicators and was also observed in the performance of post-intervention rates for patients whose flow sheet was used, compared with those for whom it was not used.

Conclusions: The results indicate that education and performance in diabetes care can improve with the use of a flow sheet.

Special Series: Award-winning Research Papers From the American Academy of Family Physicians 1998 Scientific Assembly
(Fam Med 1999;31(4):257-62.)

The Efficacy and Safety of Budesonide Inhalation Suspension: A Nebulizable Corticosteroid for Persistent Asthma in Infants and Young Children
Martha V. White, MD; Mario Cruz-Rivera, PhD; Karen Walton-Bowen, MSc, CStat

Background and Objectives: This study evaluated the efficacy and safety of four dosing regimens of budesonide inhalation suspension in children ages 6 months to 8 years with moderate persistent asthma.

Methods: This 12-week, randomized, double-blind, placebo-controlled, parallel-group study involved 481 children at 38 centers throughout the United States. Active treatment groups were budesonide inhalation suspension .25 mg once daily (QD), .25-mg two times daily (BID), .5-mg BID, or 1-mg QD. Efficacy was assessed by recording nighttime and daytime asthma symptoms, use of rescue medication, and discontinuation from the study because of worsening asthma and/or a requirement for systemic steroids. Objective measures of pulmonary function were assessed in children who were capable of consistently performing pulmonary function tests; peak expiratory flow (PEF) measurements were recorded twice daily on diary cards, and spirometry was recorded at clinic visits.

Results: Baseline patient demographics, nighttime and daytime symptom scores, and pulmonary function data were similar across placebo and budesonide treatment groups. The majority of patients were male (64%) with a mean age of 55.0 ± 26.3 months. The mean duration of asthma was 34.2 ± 22.9 months, and mean baseline forced expiratory volume in 1 second (FEV1) was 79.8% of predicted, with 29.1% reversibility. Significant improvements in nighttime and daytime asthma symptoms scores were observed in budesonide treatment groups, compared with placebo. The mean change from baseline to week 0–12 for nighttime and daytime asthma symptom scores was significantly greater for the .25-mg BID, .5-mg BID, and 1-mg QD budesonide treatment groups, compared with placebo; significant clinical improvement was observed by the second week of treatment. The lowest budesonide dose used (.25 mg QD) resulted in numerical improvements in symptom scores that were not statistically significant when compared to placebo. Significant improvements in morning PEF were observed in all budesonide treatment groups, except for the .25-mg QD group, compared with placebo. All treatment groups showed numerical improvement in FEV1, but only the .5-mg BID dose was significantly different from placebo.

Conclusions: The results of this study demonstrate that budesonide inhalation suspension is effective and well tolerated for infants and young children with moderate persistent asthma. Budesonide inhalation suspension is an important therapeutic option for young children who are not able to use other available delivery devices.

Special Series: Award-winning Research Papers From the American Academy of Family Physicians 1998 Scientific Assembly
(Fam Med 1999;31(5):337-45.)

Precept-Assist®: A Computerized, Data-based Evaluation System
Robert A. DiTomasso, PhD; James D. Gamble, MD; Mary A. Willard, MD

Background and Objectives: Traditional methods of resident evaluation have several limitations, including recall bias and memory decay. We developed a real-time, computerized, data-based evaluation system and determined 1) the feasibility of using such a system in an ambulatory care teaching center and 2) the types of evaluation data such a computer-based evaluation system provides to residency directors, faculty, and residents.

Methods: We developed Precept-Assist®, a computerized, data-based evaluation system. Reports from the system provide quantitative data, summative reports, and qualitative comments regarding specific competencies of residents. Following each precepting encounter between a faculty member and a resident, the faculty member entered into the system an array of coded information on the resident’s level of performance, competencies achieved, and procedural skills.

Results: We have entered more than 15,000 pieces of evaluative data on 4,504 precepting encounters. The average time to enter data was about 40 seconds per encounter. Reports were generated to monitor each resident’s progress through the program. The information was used to generate learning plans tailored to each resident’s needs.

Conclusions: Precept-Assist was useful for evaluating the performance of residents in this study.

Residency Education
(Fam Med 1999;31(5):346-52.)

Review of University of British Columbia Family Practice Resident Research Projects 1990–1997
Stefan Grzybowski, MD, MClSc; Harvey V. Thommasen, MD, MSc; Jocelyn Mills; Carol P. Herbert, MD

Background: Resident research projects can be an important component of building a strong and diversified research presence in family medicine. One of the requirements for graduation from the University of British Columbia (UBC) Family Practice Residency Program is that family practice residents complete a scholarly piece of work.

Methods: UBC family practice resident projects from 1990–1997 were reviewed and classified by methodology. A survey was sent to 251 former residents to determine 1) if their project was published, 2) if not, was there any interest in publication, and 3) what were the main reasons for not pursuing publication. Fifteen projects were selected as suitable for publication and were, with permission of the resident, submitted to medical journals.

Results: Sixty-nine percent of the resident projects involved data collection and hypothesis testing, and 40% were cross-sectional, of which patient surveys were the most common method. A total of 190 former residents (71%) have responded to our survey. Seven percent of respondents stated that their project had been published, and 55% would have liked to have tried to publish their project. Of the 15 resident projects we submitted for publication, seven were accepted.

Conclusions: Family practice residents are capable of producing a wide variety of research projects. Only a minority of projects are being published despite the fact that the majority of residents are interested in pursuing publication. Greater assistance by faculty can increase publication of research projects.

Residency Education
(Fam Med 1999;31(5):337-45.)

Diabetes Education Program Use and Patient-perceived Barriers to Attendance
Corina Graziani, MD; Michael P. Rosenthal, MD; James J. Diamond, PhD

Background and Objectives: Although self-management education is an essential component of optimal diabetes care, diabetes education programs are greatly underused. This study examined the use of diabetes education programs by a university-based family practice patient population in Philadelphia. Predictors of program attendance, as well as patient-perceived barriers to attendance, were identified.

Methods: A survey designed to collect information on demographics, clinical factors associated with diabetes, experience with diabetes education, and reasons for nonattendance at education programs was administered to 150 patients with diabetes.

Results: wenty-two percent of the subjects had attended a diabetes education program. Female gender, insulin use, and higher degree of obesity were positively associated with education program attendance. Physician recommendation was an important predictor of attendance. Significant barriers to attendance included lack of awareness of programs, misperceptions about what programs involved, structural barriers, and health beliefs.

Conclusions: Diabetes education programs are underused. Physicians can improve program attendance and outcomes for people with diabetes by implementing interventions designed to address the identified barriers.

Clinical Research and Methods
(Fam Med 1999;31(5):358-63.)