Christopher V. Chambers

The Effect Of Microcomputer-Generated Reminders On Influenza Vaccination Rates In A University-Based Family Practice Center

Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year. In most busy practice settings, it is difficult for primary care physicians to identify every patient in need of preventive health interventions. The purpose of this study was to assess the effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. The practice uses an interactive encounter form system from which updated clinical information is routinely entered into a cumulative database. During a 2-month period, 686 patients were identified in the database as eligible to receive influenza vaccine according to accepted criteria. Practice physicians (n = 32) were stratified by level of training and randomized to one of three groups, thereby receiving printed reminders on the encounter forms of all, none, or half of their eligible patients. Patients of physicians who always received reminders were more likely to receive influenza vaccine during the study period than patients of the never-reminded physicians (51 percent versus 30 percent, P < 0.001). Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed (38 percent) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed (20 percent, P < 0.001). This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter.

Attitudes toward sexual responsibility and parenting: an exploratory study of young urban males.

The self-reported sexual and parenting behaviors and attitudes of 42 urban males aged 16-22 who had fathered a child were compared with those of 49 demographically similar young men who were not fathers when they sought medical care at a public health center. Use of a questionnaire and structured interviews established that both groups had similar levels of self-esteem and similar ages at first intercourse. Fathers were less likely than the other respondents to feel that parenthood would interfere with their future (71% vs. 92%) or to have a concrete five-year plan (57% vs. 90%). They were more likely to believe that family (62% vs. 37%) and peers (68% vs. 40%) looked favorably upon early parenthood, to have a mother who was a teenage parent (74% vs. 47%) and to state that they lacked an adequate father figure while growing up (50% vs. 18%). Fathers also reported more frequent sexual activity and less consistent contraceptive use than did the others.

Screening and Prevention: Cervical Cancer

Cervical cancer is the leading cause of cancer death in women in developing countries and significant disparities in cervical cancer mortality rates persist in the United States. Improved recognition of the role of human papilloma virus (HPV) in cervical cancer pathogenesis has recently revolutionized screening and prevention strategies. Improved understanding and implementation of these advances will allow primary care physicians to significantly impact the cervical cancer mortality burden. This article reviews the basic physiology of the transformation zone, current understanding of cervical cancer pathogenesis, the history and evolution of cervical cancer screening in general and in specific populations of women, and an overview of the development and current use of the HPV vaccine.

THE IMPORTANCE OF ADVANCE DIRECTIVES IN PRIMARY CARE

The advance directive has been acknowledged widely by patients and physicians as a desirable tool to promote patient autonomy at the end of life. Rates of completion of advance directives, however, remain low among all segments of the population. Significant patient and physician barriers to completion of advance directives are considered. Legal and ethical principles of advance directives, as well as some practical means of overcoming barriers to these important discussions, are reviewed.

Compliance With Universal Precautions In A Medical Practice With A High Rate Of HIV Infection

Background: Universal precautions have been recommended to limit occupational exposure to the human immunodeficiency virus (HIV) and other infectious agents, but whether these recommendations have been incorporated into routine practice has not been demonstrated. Methods: Using a one-group, before-after design, we assessed the knowledge and attitudes concerning universal precautions and the level of compliance with these recommendations. The health care professionals had various levels of training and worked in an ambulatory practice with a high rate of HIV. A total of 195 procedures involving potential exposure to various body fluids were observed. Results: No improvement in compliance with recommended precautions was observed following a didactic educational program for either latex glove use (44 percent versus 49 percent, χ2 < 1, P > 0.2) or appropriate use of hand washing (34 percent versus 47 percent, χ2 = 3.38, P = 0.07). Faculty demonstrated the lowest levels of adherence to universal precautions. While knowledge of precautions was high, staff members at all levels overestimated their own compliance with these recommendations. Conclusions: Although the number of observations limits the conclusions, the results suggest that the basic protective measures included in universal precautions are not being routinely applied in ambulatory medical practice. Furthermore, didactic educational programs might not be sufficient to improve compliance. Finally, faculty in training programs should monitor their own compliance with universal precautions because of their responsibilities as role models for physicians in training.

The Reliability of Patient Self-Reported Blood Pressures

Self‐monitoring of blood pressure actively involves patients in hypertension management. However, the usefulness of self‐monitoring of blood pressure may be limited by inaccurate patient reporting. The study objective was to assess reliability of patient blood pressure reporting over 6 months. Forty‐nine subjects with Joint National Committee stage 1 or 2 hypertension were enrolled. Unaware that the monitors electronically store readings, the subjects were asked to check and record outpatient blood pressures twice weekly. Stored and written readings were compared. On average, patient‐recorded blood pressures were equivalent to stored monitor values 80% or more of the time. Reliability of patient self‐reporting was sustained over the 6‐month study period. Notably, patients did not selectively report lower blood pressure readings. The overall mean self‐reported and stored monitor blood pressures were nearly identical: blood pressure (±SD) 134±16.8/78±11.6 mm Hg and 135±19.6/80±13.3 mm Hg, respectively. The reliability of self‐reporting of blood pressures for many patients supports the potential usefulness of self‐monitoring of blood pressure in hypertension management.

Immunologic non-inferiority of a newly licensed inactivated trivalent influenza vaccine versus an established vaccine: A randomized study in US adults

A trivalent inactivated influenza vaccine (Fluarix™, GlaxoSmithKline Biologicals) was licensed under US accelerated approval regulations. We performed a randomized, observer-blind, post-approval study to demonstrate its immunological non-inferiority versus an established US-licensed vaccine (primary endpoint). Adult (including elderly) subjects received a single injection of newly-licensed vaccine (n=923) or established vaccine (n=922). Serum hemagglutination-inhibition titers were determined pre-vaccination and 21-28 days after vaccination. Non-inferiority was assessed by post-vaccination geometric mean titer (GMT) ratio (upper 95% confidence interval [CI] ≤1.5) and difference in seroconversion rate (upper 95% CI ≤0.1) for all three vaccine strains. Safety was monitored for 6 months. The newly-licensed vaccine was non-inferior to the established vaccine in all subjects (≥18 years) and in elderly subjects (≥65 years). Adjusted GMT ratios (established/newly-licensed) against the H1N1, H3N2 and B strains were 0.65 (95% CI: 0.58, 0.73), 0.93 (0.83, 1.04) and 1.13 (1.03, 1.25) for all subjects and 0.75 (0.67, 0.85), 0.95 (0.82, 1.09) and 1.13 (1.00, 1.27) for elderly subjects. Corresponding values for the differences in seroconversion rate (established minus newly-licensed) were -0.12 (-0.16, -0.07), -0.02 (-0.06, 0.03) and 0.01 (-0.04, 0.06) for all subjects and -0.11 (-0.16, -0.05), -0.02 (-0.07, 0.04) and 0.02 (-0.04, 0.08) for elderly subjects. The most common adverse events with both vaccines were injection site pain, fatigue and headache, and no serious adverse events or deaths were considered related; there were no clinically relevant differences between the vaccines. In conclusion, the newly-licensed vaccine was well tolerated and immunologically non-inferior to the established vaccine for all three vaccine strains in the whole population and the elderly.

Effective Strategies to Improve the Management of Heart Failure

The purpose of this article is to provide resources for primary care physicians to manage heart failure as a chronic disease. We review evidence-based interventions that can be adopted in primary care practices to improve adherence to available guidelines for medication use, promotion of self-care behaviors, transitions of care in acute decompensated heart failure, and end of life care. This information will be valuable to primary care providers who care for patients with heart failure in all care settings but is focused on the management of heart failure in the outpatient setting.