Bruce Goldberg

Smoking Cessation in Primary Care Clinics

AbstractOBJECTIVES: To document smoking cessation rates achieved by applying the 1996 Agency for Health Care Policy and Research (AHCPR) smoking cessation guidelines for primary care clinics, compare these quit rates with historical results, and determine if quit rates improve with an additional motivational intervention that includes education as well as spirometry and carbon monoxide measurements. DESIGN: Randomized clinical trial. SETTING: Two university-affiliated community primary care clinics. PATIENTS: Two hundred five smokers with routinely scheduled appointments. INTERVENTION: All smokers were given advice and support according to AHCPR guidelines. Half of the subjects received additional education with spirometry and carbon monoxide measurements. MEASUREMENTS AND MAIN RESULTS: Quit rate was evaluated at 9-month follow-up. Eleven percent of smokers were sustained quitters at follow-up. Sustained quit rate was no different for intervention and control groups (9% vs 14%; [OR] 0.6; 95% [CI] 0.2, 1.4). Nicotine replacement therapy was strongly associated with sustained cessation (OR 6.7; 95% CI 2.3, 19.6). Subjects without insurance were the least likely to use nicotine replacement therapy (p=.05). Historical data from previously published studies showed that 2% of smokers quit following physician advice, and additional support similar to AHCPR guidelines increased the quit rate to 5%. CONCLUSIONS: The sustained smoking cessation rate achieved by following AHCPR guidelines was 11% at 9 months, which compares favorably with historical results. Additional education with spirometry did not improve the quit rate. Nicotine replacement therapy was the strongest predictor of cessation, yet was used infrequently owing to cost. These findings support the use of AHCPR guidelines in primary care clinics, but do not support routine spirometry for motivating patients similar to those studied here.

The association of family continuity with infant health service use.

Purpose: Continuity of care is a fundamental component of family medicine that has been shown to improve health care quality. Family continuity, when different family members are seen by the same clinician or practice, has not been well studied. Methods: We performed a retrospective cohort study of Medicaid enrollees in Oregon using administrative data. Infants were determined to have family continuity if they received well-baby care at the same clinic as that in which their mothers received prenatal care. Results: Of the 1591 infants identified for participation in this study, 749 (47.1%) had family continuity. Infants had a mean of 4.55 well-child visits, 1.23 emergency department visits, and 0.17 hospitalizations in the first 13 months of life. Multivariate analyses found that infants with family continuity had increased numbers of well-child visits (relative risk, 1.05; P = .041), increased numbers of emergency department visits (relative risk, 1.36; P < .0001), and no difference in the number of hospitalizations (relative risk, 0.85; P = .282) when compared with infants without family continuity. Conclusions: Family continuity, when measured at the clinic level, is associated with a variable effect on infant health service use. This finding suggests that clinic-level continuity is not sufficient for achieving all the benefits of continuity.

State-Level Design: The Coordinated Care Model

Abstract Oregon’s means to achieving the “triple aim” was to fundamentally change how health care is delivered and Coordinated Care Organizations (CCOs) were created as the vehicle to make that happen. This chapter describes the theory behind CCOs and details the five critical elements upon which they were founded: local accountability, a global budget, flexibility in the use of services and health care dollars, coordinated care, and metrics. In addition, it outlines the progress to date and concludes with a discussion of lessons learned.

The Health of Migrant and Seasonal Farmworkers

The agricultural industry is among the most vital and strategic industries in the United States. Net farm income in 1998 was estimated at

A rural multidisciplinary clerkship in primary care

48 billion and agriculture remains at the economic and cultural foundation of most rural communities (U.S. Department of Agriculture, 1999). It is a critical component of the U.S. economy and helps support and sustain the American lifestyle. Our highly productive system for growing, processing, and distributing agricultural products allows Americans to enjoy a consistent supply of fruits and vegetables that are readily available in our grocery stores and markets. The foundation of the agricultural industry and of many rural communities is the farmworker.

Pain, disability, and satisfation outcomes and predictors of outcomes: A practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

No abstract available.