BACKGROUND:The patient-centered medical home model may be a strategic approach to improve delivery of women's health care and consistently provide women with accessible and comprehensive care. We examined whether primary care physicians (family medicine, internal medicine, and hospital general medicine clinics) and obstetrician-gynecologists differ in scope and the number of medical issues addressed during preventive gynecologic visits.METHODS:We analyzed data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to characterize visits with a primary diagnosis of gynecological examination or routine cervical Papanicolaou test between 1999 and 2008. We compared the number and type of concurrent nongynecologic diagnoses addressed by primary care physicians and obstetrician-gynecologists during visits.RESULTS:A total of 7882 visits were included, representing 271 million primary visits for Papanicolaou tests. Primary care physicians were 2.41 times more likely to include one or more concurrent medical diagnoses during the preventive gynecologic visit compared with obstetrician-gynecologists (odds ratio, 2.41; 95% confidence interval, 1.63-3.57).CONCLUSIONS:Primary care physicians are significantly more likely to address concurrent medical problems during preventive gynecologic visits compared with obstetrician-gynecologists. These findings demonstrate the vital role of primary care physicians in providing comprehensive health care to women, consistent with principles of the patient-centered medical home model.

Objective: The authors analyzed prescribing for antidepressant medications during 27,328 prenatal visits in ambulatory settings in the United States between 2002 and 2010. Methods: Data from the 2002-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were used to compare prescribing for antidepressant medication during visits for outpatient prenatal care between 2002-2006 and 2007-2010. Results: Prenatal visits associated with a prescription for an antidepressant increased from .7% in 2002-2006 to 2.1% in 2007-2010 (p<.01). The proportion of prescriptions for selective serotonin reuptake inhibitors (SSRIs) declined (from 87% to 66%, p=.04), particularly for paroxetine (from 19% to <1%, p<.01). Conclusions: Despite controversy over possible negative effects, prescribing of antidepressants during pregnancy increased between 2002 and 2010. SSRIs represented a smaller proportion of all antidepressants prescribed, and prescribing of paroxetine, likely in response to warnings by the U. S. Food and Drug Administration, dropped dramatically.

Objective: The aim of this study was to examine changes in the utilization of computed tomography (CT) in the evaluation of common chest symptoms and the rate of clinically significant diagnoses in emergency departments after 2004. Methods: This study analyzed the National Hospital Ambulatory Medical Care Survey, comparing 1997 to 1999 and 2005 to 2007. Set in US emergency departments, individuals older than 14 years old were eligible. The main outcome was proportion of common chest symptom-related visits (n = 17,098) associated with a CT order before 2000 and after 2004. Secondary outcomes were the proportion of these visits associated with a clinically significant diagnosis (pulmonary embolism, acute myocardial infarction, acute coronary syndrome, heart failure, pneumonia, and pleural effusion); an incidental diagnosis such as lung mass; and a clinically nonsignificant diagnosis such as nonspecific chest pain. Results: The proportion of common chest symptom-related visits associated with a CT order increased from 2.1% in 1997 to 1999 to 11.5% in 2005 to 2007 (P < .001), whereas the overall proportion of these visits associated with a clinically significant diagnosis decreased from 23.6% in 1997 to 1999 to 19.1% in 2005 to 2007 (P < .001).The rate of acute myocardial infarction diagnosis decreased from 6.6% to 3.3% (P < .001), whereas the rate of pulmonary embolism diagnosis did not change (0.33% vs. 0.47%; P = .24) from 1997 to 1999 to 2005 to 2007. The rate of incidental diagnoses did not change (0.13% vs. 0.17%; P = .69), whereas the rate of clinically nonsignificant diagnoses increased from 35.6% to 45.8% (P < .001) from 1997 to 1999 to 2005 to 2007. Conclusions: CT ordering in emergency departments for the evaluation of common chest symptoms has increased dramatically without improving the rate of pulmonary embolism or other clinically significant diagnoses. Overuse of CT exposes patients to radiation and increases health care costs without any apparent diagnostic benefit.

BACKGROUND AND OBJECTIVES:Family medicine has experienced variations in scope and comprehensiveness of care in recent years. To investigate whether these changes in practice have impacted women's health services, we measured trends in the proportion of preventive women's health visits provided by family physicians nationally.METHODS:We analyzed the National Ambulatory Medical Care Survey to identify the trend in the proportion of preventive women's health visits to family physicians and obstetrician-gynecologists and others between 1995 to 2007.RESULTS:A total of 6,088 sample records were included in the study, representing 239 million preventive women's health visits. The percentage of preventive women's health visits provided by family physicians remained stable over the 12-year study period from 18.6% in 1995-1996 to 20.3% in 2007. Family physicians provided care for 28% of total preventive women's health visits occurring in non-metropolitan statistical areas.CONCLUSIONS:Family physicians provided a stable amount of preventive women's health services between 1995 and 2007. Family medicine should continue to foster comprehensive residency training in preventive women's health care and inclusion of such services in future scope of practice.

The current state of affairs is that as a specialty, we underperform in scholarly and research output compared with our peers in other specialties,[4][1] and although this has been acknowledged for a while,[5][2] improvements in research productivity have been slow. Many barriers remain to the

Healthcare spending continues to rise and it is important to determine the factors associated with individuals who are super-utilizers (SUs) of healthcare resources. We designed a pilot study to identify the primary predic

BACKGROUND:The recent implementation of electronic medical record systems allows for the development of systems to track common illness across a defined community. With the threats of bioterrorism and pandemic illness, syndromic surveillance methodologies have become an important area of study. There has been limited study of the application of syndromic surveillance techniques to communities for tracking common illnesses to improve health system resource allocation and inform communities.METHODS:We analyzed visits from 26 primary care sites and one emergency department in a health system during a 13-month period in 2007 to 2008. Visits were coded for common respiratory and gastrointestinal illnesses. Using geographic information systems techniques, we plotted home addresses and developed criteria for census tract inclusion. The spatial distribution of the illnesses patterns was analyzed using Bayesian smoothing, Kriging and SaTScan (SaTScan, Boston, MA) statistical methods.RESULTS:The study included 857,555 visits, 107,286 of which were in the emergency department and 750,269 in the primary care sites. Patient visits were plotted and then aggregated to census tracts. We determined that at least a median of 10 visits per week was required to provide sufficient volume in defining census tracts included in the study (109 census tracts). Weekly visit rates by census tract were plotted using nearest neighbor empirical Bayesian smoothing and Kriging to produce a continuous surface. To detect statistical clustering of weekly visit rates, we used SaTScan and identified 7 weeks with statistically significant clusters for respiratory illnesses and 8 weeks with statistically significant clusters for gastrointestinal illnesses (out of 56 weeks included in the study). After adjusting for population density, the visit rate remained consistent for respiratory illnesses (analysis of variance P = .937), but the visit rate for gastrointestinal illnesses increased in the fourth population density quartile (statistically different from quartiles 1, 2 and 3; analysis of variance P < .001 with Tukey multiple comparisons test), which included the highest population density areas in the study.CONCLUSIONS:We were able to use geographic information systems to assess visit rates for common illnesses in a defined community and identified spatial variability over time. Additional research is needed to help define parameters for implementation, but we believe this can have benefit for allocation of health resources and communicating with the community.

BACKGROUND AND OBJECTIVES Increased intravenous (IV) hydration is associated with decreased labor duration and oxytocin augmentation in nulliparous women when oral fluid is restricted. The objective of this study was to determine the effect of increased IV hydration on the duration of labor when access to oral fluid was unrestricted. METHODS Term, nulliparous women with uncomplicated singleton pregnancies were randomly assigned to receive lactated ringers at 250 ml per hour (IV fluid group) throughout active labor or usual care. All women were allowed unrestricted access to oral fluids. RESULTS Eighty women completed the study, 37 in the IV fluid group and 43 in the usual care group. There was no difference in the primary outcome of total duration of labor (9.5 versus 9.4 hours) or in the secondary outcomes of duration of the first stage (7.9 versus 8.0 hours), duration of second stage (1.6 versus 1.4 hours), or rate of oxytocin augmentation (51% versus 44%). CONCLUSIONS Increased IV hydration does not decrease labor duration in nulliparous women when access to oral fluid is unrestricted.

OBJECTIVES: Observation without initial antibiotic therapy was accepted as an option for acute otitis media (AOM) management in the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline. The guideline also recommended amoxicillin as the first-line treatment for most children, and analgesic treatment to reduce pain if it was present. Our objective was to compare the management of AOM after publication of the 2004 guideline. PATIENTS AND METHODS: We analyzed the National Ambulatory Medical Care Survey, 2002–2006 (N = 1114), which occurred in US physicians' offices. The patients were children aged 6 months to 12 years who were diagnosed with AOM. The time comparisons were the 30-month periods before and after the guideline. The main outcome was the encounter rate at which no antibiotic-prescribing was reported. Secondary outcomes were the identification of factors associated with encounters at which no antibiotic-prescribing was reported and antibiotic- and analgesic-prescribing rates. RESULTS: The rate of AOM encounters at which no antibiotic-prescribing was reported did not change after guideline publication (11%–16%; P = .103). Independent predictors of an encounter at which no antibiotic-prescribing was reported were the absence of ear pain, absence of reported fever, and receipt of an analgesic prescription. After guideline publication, the rate of amoxicillin-prescribing increased (40%–49%; P = .039), the rate of amoxicillin/clavulanate-prescribing decreased (23%–16%; P = .043), the rate of cefdinir-prescribing increased (7%–14%; P = .004), and the rate of analgesic-prescribing increased (14%–24%; P = .038). CONCLUSIONS: Although management of AOM without antibiotics has not increased after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline, children who did not receive antibiotics were more likely to have mild infections. In accordance with the guideline, the prescribing of amoxicillin and analgesics has increased. Contrary to the guideline, the prescribing of amoxicillin/clavulanate has decreased, whereas the prescribing of cefdinir has increased.

PURPOSE Provision of prenatal visits by family physicians decreased by 50% from 1995 to 2004. To determine the impact of this trend on the provision of well-child visits by these professionals, we measured trends in and factors associated with well-child visits by children younger than 2 years of age to family physicians and pediatricians. METHODS Using the National Ambulatory Medical Care Survey, we identified well-child visits made in the first 2 years of life to family physicians and pediatricians between 1995 and 2007. The primary outcome measure was the trend in the proportion of such visits that were specifically to family physicians. RESULTS We identified a total of 4,999 visits, representing 213 million well-child visits at the national level. Compared with visits to pediatricians, visits to family physicians were associated with higher rates of Medicaid insurance (P < .01) and were more likely to occur in non metropolitan statistical area locations (P < .01) and in the Midwest and West geographic regions (P < .01). The percentage of all well-child visits for children younger than 2 years of age that were made to family physicians remained stable at 15% (95% confidence interval, 13%-17%; P = .29 for trend) during the study period. CONCLUSIONS The diminishing role of family physicians in prenatal care has not been accompanied by a similar decrease in provision of well-child care to children younger than 2 years of age.

PURPOSE It is unknown to what extent physicians address multiple problems while providing prenatal care. The objective of this study was to determine the percentage of prenatal encounters with 1 or more secondary and tertiary nonobstetric diagnoses and compare rates between family physicians and obstetricians. METHODS Using the National Ambulatory Medical Care Survey, 1995–2004, I analyzed prenatal visits to family physicians’ and obstetricians’ offices. The outcome measure was the percentage of prenatal encounters with 1 or more secondary and tertiary nonobstetric diagnoses seen by family physicians and obstetricians. RESULTS There were 6,203 visit records that met study criteria, representing 223 million visits to obstetricians and 21 million visits to family physicians. Of the prenatal encounters with a family physician, 17.6% (95% confidence interval [CI], 12.9%–22.4%) included 1 or more secondary and tertiary nonobstetric diagnoses compared with 7.8% (95% CI, 6.1%–9.6%) of prenatal encounters with an obstetrician (P <.01). After controlling for other variables, being seen by a family physician, compared with being seen by an obstetrician, remained an independent predictor of a prenatal visit with an additional nonobstetric diagnosis (OR = 2.57; 95% CI, 1.82–3.64). CONCLUSIONS Family physicians diagnose nonobstetric problems frequently and considerably more often than obstetricians while providing prenatal care. This practice style enhances access to comprehensive primary care for women.

BACKGROUND:Overuse of broad-spectrum antibiotics is associated with antibiotic resistance. Acute otitis media (AOM) is responsible for a large proportion of antibiotics prescribed for US children. Rates of broad-spectrum antibiotic prescribing for AOM are unknown.METHODS:Analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1998 to 2004 (N = 6,878). Setting is office-based physicians, hospital outpatient departments, and emergency departments. Patients are children aged 12 years and younger prescribed antibiotics for acute otitis media. Main outcome measure is percentage of broad-spectrum antibiotics, defined as amoxicillin/clavulanate, macrolides, cephalosporins and quinolones.RESULTS:Broad-spectrum prescribing for acute otitis media increased from 34% of visits in 1998 to 45% of visits in 2004 (P < .001 for trend). The trend was primarily attributable to an increase in prescribing of amoxicillin/clavulanate (8% to 15%; P < .001 for trend) and macrolides (9% to 15%; P < .001 for trend). Prescribing remained stable for amoxicillin and cephalosporins while decreasing for narrow-spectrum agents (12% to 3%; P < .001 for trend) over the study period. Independent predictors of broad-spectrum antibiotic prescribing were ear pain, non-white race, public and other insurance (compared to private), hospital outpatient department setting, emergency department setting, and West region (compared to South and Midwest regions), each of which was associated with lower rates of broad-spectrum prescribing. Age and fever were not associated with prescribing choice.CONCLUSION:Prescribing of broad-spectrum antibiotics for acute otitis media has steadily increased from 1998 to 2004. Associations with non-clinical factors suggest potential for improvement in prescribing practice.

Background: Maternal medical care (prenatal and postpartum) involves a set of clinical interventions addressing risk factors associated with important maternal and infant outcomes. Programs to increase the rate of delivery of these interventions in clinical practice have not been widely implemented. Methods: A practice-based research network focused on developing continuous quality improvement (CQI) processes for maternal care among 10 family medicine residency training sites in the northeastern United States (the IMPLICIT Network) from January 2003 through September 2007. Documented delivery of 5 standard maternal care interventions was assessed before and after initiating a program to increase their frequency. Proportion chart analyses were conducted comparing the period before and after implementation of the CQI interventions. Results: Data were available for 3936 pregnancies during the course of the study period. Results varied across the clinical interventions. Significant improvement in care processes was seen for 3 screening activities: (1) prenatal depression symptomatology (by 15 weeks' gestation); (2) screening for smoking at 30 weeks' gestation; (3) and postpartum contraception planning. Screening for smoking by 15 weeks' gestation and testing for asymptomatic bacteriuria were already conducted >90% of the time during the baseline period and did not increase significantly after initiating the CQI program. Screening for postpartum depression symptomatology was recorded in 50% to 60% of women before the CQI program and did not increase significantly. Conclusions: A practice-based research network of family medicine residency practices focused on CQI outcomes was successful in increasing the delivery of some maternal care interventions.

PURPOSE We wanted to measure trends in the proportion of prenatal visits provided by family physicians nationally for a 10-year period and determine characteristics of prenatal visits made to family physicians compared with visits made to obstetricians.METHODS We analyzed the National Ambulatory Medical Care Survey to identify prenatal visits made to family physicians and obstetricians between 1995 and 2004. The primary outcome measure was the trend in proportion of prenatal visits seen by family physicians. Multivariate logistic regression analysis determined characteristics of a prenatal visit occurring with a family physician vs an obstetrician.RESULTS A total of 6,203 records were included in the study, representing 244 million prenatal visits. The percentage of prenatal visits provided by family physicians decreased from 11.6% in 1995-1996 to 6.1% in 2003-2004 (P = .02 for trend). In non-metropolitan statistical areas, family physicians decreased their provision of prenatal visits from 38.6% in 1995-1996 to 12.9% in 2003-2004 (P = .03 for trend). Prenatal visits made to family physicians were associated with location in a non-metropolitan statistical area (OR = 5.56; 95% Cl, 3.23-9.62), Medicaid insurance (OR = 1.76; 95% Cl, 1.10-2.82), and younger maternal age (aged 30 years and older vs aged less than 24 years: OR = 0.63; 95% Cl, 0.41-0.95).CONCLUSIONS Family physicians reduced their provision of prenatal visits by nearly 50% during a 10-year period and at an even greater rate in rural, non-metropolitan statistical areas. These findings should be considered as family medicine considers the role of maternity care and strives to provide accessible prenatal services for all.

BACKGROUND:Medical liability concerns centered around maternity care have widespread public health implications, as restrictions in physician scope of practice may threaten quality of and access to care in the current climate. The purpose of this study was to examine national trends in prenatal care settings based on medical liability climate.METHODS:Analysis of prenatal visits in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1997 to 2004 (N = 21,454). To assess changes in rates of prenatal visits over time, we used the linear trend test. Multivariate logistic regression modeling was developed to determine characteristics associated with visits made to hospital outpatient departments.RESULTS:In regions of the country with high medical liability (N = 11,673), the relative number, or proportion, of all prenatal visits occurring in hospital outpatient departments increased from 11.8% in 1997-1998 to 19.4% in 2003-2004 (p < .001 for trend); the trend for complicated obstetrical visits (N = 3,275) was more pronounced, where the proportion of prenatal visits occurring in hospital outpatient departments almost doubled from 22.7% in 1997-1998 to 41.6% in 2003-2004 (p = .004 for trend). This increase did not occur in regions of the country with low medical liability (N = 9,781) where the proportion of visits occurring in hospital outpatient departments decreased from 13.3% in 1997-1998 to 9.0% in 2003-2004.CONCLUSION:There has been a shift in prenatal care from obstetrician's offices to safety net settings in regions of the country with high medical liability. These findings provide strong indirect evidence that the medical liability crisis is affecting patterns of obstetric practice and ultimately patient access to care.

Objective: Systems for efficient case finding of women with major depression during pregnancy and postpartum are needed. Here we assess the diagnostic accuracy of a modified 2-item patient health questionnaire (PHQ-2) as a pre-screen in assessing depression. Methods: Cross-sectional assessments at 15 weeks' gestation (n = 414), 30 weeks' gestation (n = 334), and 6 to 16 weeks postpartum (n = 193) among women from a diverse set of races/ethnicities, participating in the IMPLICIT maternal care quality improvement network. The Edinburgh Postnatal Depression Scale score (≥13) was used as the criterion measure for the PHQ-2. Results: A positive 2-item screen had sensitivity of 93%, 82%, and 80% and specificity of 75%, 80%, and 86% for Edinburgh Postnatal Depression Scale score of ≥13 for assessment at 15 and 30 weeks gestational age and postpartum, respectively. The positive/negative predictive values for the PHQ-2 were 44/98, 24/91, and 30/98 for each time point, respectively. Areas under the receiver operating characteristic curve analysis suggested that 2-item assessments at each time point had approximately equal diagnostic validity. Conclusions: Two questions were efficient to rule out depression and reduced the need for further screening of approximately 60% to 80% of women, depending on the point in pregnancy or postpartum. A diagnostic interview follow-up of women screening positive is still required.

PURPOSE This study evaluated the costs and utility of observation and routine antibiotic treatment options for children with acute otitis media. METHODS The cost-effectiveness analysis was performed among children aged 6 months to 12 years seen in primary care offices. The interventions studied were watchful waiting as practiced in the Netherlands, delayed prescription, 5 days of amoxicillin, and 7 to 10 days of amoxicillin. The main outcome measure was cost per quality-adjusted life-year (QALY). RESULTS In the base case analysis, delayed prescription was the least costly option and 7 to 10 days of amoxicillin was the most effective. The incremental cost utility ratio (ICUR) of 7 to 10 days of amoxicillin compared with delayed prescription was $56,000 per QALY gained. Watchful waiting and 5 days of amoxicillin were inferior options. The results were sensitive to the rate of nonattendance in the delayed prescription strategy: when the rate was less than 23%, watchful waiting was the least costly option and delayed prescription was an inferior option. Probabilistic sensitivity analysis, in which all model variables were simultaneously varied, showed with 95% certainty that compared with delayed prescription, 7 to 10 days of amoxicillin had a 61% probability of having an ICUR of greater than $50,000 per QALY gained, and watchful waiting had a 23% probability of having an ICUR of less than $50,000 per QALY gained. CONCLUSIONS Economically, an approach to the treatment of acute otitis media with either an initial period of observation or routine treatment with amoxicillin is reasonable.

PURPOSE Recognizing primary human immunodeficiency virus (HIV) infection is important for public health. The prevalence in outpatient settings is largely unknown but would be useful in developing testing guidelines. The objective of this study is to estimate the national prevalence of primary HIV infection in symptomatic ambulatory patients regardless of risk factors.METHODS Patients 13 to 54 years old with each of 17 primary HIV infection symptoms, as well as other reported reasons for their visit consistent with primary HIV infection, were identified from the 2000 National Ambulatory Medical Care and National Hospital Ambulatory Medical Surveys to provide the denominator for the prevalence estimate. These survey data can be extrapolated to represent 90% of all US ambulatory care visits, including those to physician's offices, emergency departments, and hospital clinics. Patients with symptoms and diagnoses inconsistent with a viral illness were excluded. The estimate for the numerator was derived from Centers for Disease Control and Prevention estimates and the medical literature.RESULTS Patients complaining of fever and other visit reasons consistent with primary HIV infection had a disease prevalence of 0.66% (0.57%-1.02%), those with rash had a prevalence of 0.50% (0.31%-0.82%), and those with pharyngitis had a prevalence of 0.16% (0.11%-0.22%). Patients with other symptoms represented numbers of visits insufficient for reliable estimates of their prevalence.CONCLUSIONS These estimates of the prevalence of. primary HIV infection in ambulatory patients with fever, rash, and pharyngitis can aid with development of clinical testing guidelines and clinical decisions around testing for acute HIV infection.

OBJECTIVE:To examine the relationship between the time a physician spends in an office encounter with the prescribing of antibiotics for pediatric patients with presumed viral respiratory infections.DESIGN AND SETTING:Cross-sectional analysis of the 2000 National Ambulatory Medical Care Survey in physician offices in the United States.PARTICIPANTS:Children and adolescents (aged < or = 18 years) with a diagnosis of upper respiratory infections or bronchitis.MAIN OUTCOME MEASURE:The time spent by a physician with a patient in an office encounter.RESULTS:Analysis of 269 office encounters representing 12,366,162 annual office visits for upper respiratory infections and bronchitis. The mean (SE) number of minutes a doctor spent with a patient in encounters for colds or bronchitis that resulted in an antibiotic prescription was 14.24 (0.85) minutes while 14.18 (1.03) minutes were spent in encounters without antibiotics prescribed. In multivariate analysis, the likelihood that the time spent by a physician was above or below the median visit time of 15 minutes was not associated with the use of antibiotics when controlled for patient age, race, sex, participation in a prepaid plan, or whether the encounter was with the patient's primary care physician.CONCLUSIONS:Prescribing antibiotics for children with upper respiratory infections or bronchitis is not associated with a reduction in the time that a physician spends with a patient in an office encounter. The impact on physician productivity of injudicious antibiotic prescribing for upper respiratory infections and bronchitis may not be as great as previously believed.