Margaret M. Love

The Pubertal Development Scale: A Rural and Suburban Comparison

The Pubertal Development Scale (PDS) is a noninvasive measure of pubertal development. The purpose of this study was to compare means and standard deviations on the PDS across samples of seventh graders from rural Iowa and suburban Chicago who were matched on gender, age, race, and grade in school. Matched samples of boys each comprised 50 subjects; those of girls each comprised 52 subjects. Results of MANOVAs showed that rural Iowa girls were more advanced on the five markers of pubertal development than were suburban Chicago girls. Rural Iowa boys were more advanced than their counterparts in the suburban Chicago sample on four of the five markers. Psychometric analysis of the five-item scale suggested adequate internal consistency for boys and girls (.66 to .81). The predictive validity of the PDS was satisfactory. Possible reasons for differences in rates of development are discussed.

Diabetes and Cancer Screening Rates among Appalachian and Non-Appalachian Residents of Kentucky

Background: Having diabetes may increase the odds of late-stage breast cancer. In Kentucky, the rates of late-stage disease are higher in rural than in urban areas, particularly in rural Appalachia. The objectives of the study were to examine the relationship between diabetes and cancer screening and to determine whether Appalachia residence modifies this association. Methods: One thousand thirty Kentucky adults responded to a 2008 telephone survey that measured whether they had diabetes; lived in Appalachia; had guideline-concordant screening for breast (mammogram, clinical breast examination), cervical (Papanicolaou), and colorectal (fecal occult blood test or sigmoidoscopy/colonoscopy) cancer; and whether they reported receiving mammograms regularly every 1 to 2 years. Results: Of the subjects, 16% had diabetes, 21% were Appalachian, and 32% were men. In multivariate analysis, women with diabetes had about half the odds of “regular” mammography screening (odds ratio, 0.56) compared with those without diabetes. Men and women in Appalachia had about half the odds of colonoscopy or sigmoidoscopy within the past 10 years (odds ratio, 0.54) compared with those living outside Appalachia. Conclusions: Both having diabetes and living in Appalachia were negatively associated with current and regular cancer screening. Less screening may explain late-stage diagnosis among these populations.

Access to care for the uninsured: is access to a physician enough?

OBJECTIVES This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services.

Factors Relating to Patient Visit Time With a Physician

This study sought to identify factors that increase or decrease patient time with a physician, determine which combinations of factors are associated with the shortest and longest visits to physicians, quantify how much physicians contribute to variation in the time they spend with patients, and assess how well patient time with a physician can be predicted. Data were acquired from a modified replication of the 1997–1998 National Ambulatory Medical Care Survey, administered by the Kentucky Ambulatory Network to 56 primary care clinicians at 24 practice sites in 2001 and 2002. A regression tree and a linear mixed model (LMM) were used to discover multivariate associations between patient time with a physician and 22 potentially predictive factors. Patient time with a physician was related to the number of diagnoses, whether non-illness care was received, and whether the patient had been seen before by the physician or someone at the practice. Approximately 38% of the variation in patient time with a physician was accounted for by predictive factors in the tree; roughly 33% was explained by predictive factors in the LMM, with another 12% linked to physicians. Knowledge of patient characteristics and needs could be used to schedule office visits, potentially improving patient flow through a clinic and reducing waiting times.

Cardiovascular Risk Education and Social Support (CaRESS): Report of a Randomized Controlled Trial from the Kentucky Ambulatory Network (KAN)

Purpose: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes. Methods: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters. Results: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high. Conclusion: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.

Discovering gender differences while teaching family genograms.

information management medical school curriculum theme. We identified 5 information management content areas: reasoning, judgement and clinical decision making; biostatistics ⁄epidemiology; medical informatics; applying information to individual patients, and applying information to groups. We have begun to integrate information management knowledge and skills throughout the curriculum, focusing first on the pre-clinical years. Why the idea was necessary Providing good health care requires focusing on systems of health care and on population-based approaches, while movements toward competency-based assessment focus on complexes of knowledge and skills. Information management addresses these developments by equipping medical students with knowledge and skills needed to acquire, assess and apply information to address a broad variety of problems. While some elements were already taught (e.g. biostatistics ⁄epidemiology), the content needed more logical placement and appropriate clinical contextualisation. What was done The first courses and information management content integration have been implemented in the first 2 years of the medical school curriculum. These include introductory lectures on clinical reasoning and cognition, and the foundations of biostatistics and epidemiology (B ⁄E). Clinical reasoning is integrated into the first semester Integrated Clinical Correlations course, while B ⁄E is a 2-block unit taught during the first 2 years of medical school. We use clinical vignettes in both segments to promote integration of clinical reasoning concepts with B ⁄E. Biostatistics ⁄epidemiology content is further integrated into a project-based integrative module called ‘Social Context of Clinical Decisions’ (SCCD), where Year 2 students formulate a patient care policy based upon ethical, economic, epidemiological and health policy considerations. Finally, B ⁄E content is integrated with students’ clinical training in formal courses and within clinical clerkships. In Year 3, a course called ‘Critical Appraisal ⁄Analytic Medicine’ (CAAM) integrates B ⁄E within its 2 main components. In the first component, students build on the foundation developed in B ⁄E by critiquing primary research articles. In addition to critically reading research literature, the students in CAAM learn to focus questions and hone their searching skills. In the second component of CAAM, the students are required to work in teams to develop a research proposal designed to answer a researchable question. Additionally, several clinical clerkships require the students to use critical analytic skills in support of formal and informal clinical presentations. Evaluation of results and impact Implementation of the new 2-course B ⁄E sequence resulted in no dropoff in student achievement as reflected in course grades, with an 82% examination first-take pass rate and a 100% second-take pass rate. We surveyed students to determine their perceptions of the usefulness of components of the information management curriculum theme. More students felt that the Year 1 B ⁄E course was useful (70Æ5%) compared with the Year 2 course (55Æ5%). Additionally, 63% of the students felt the application of B ⁄E content to the SCCD module was useful. These results indicate a possible need to strengthen the perceived relevance of the Year 2 biostatistics ⁄epidemiology course material. While development of the information management theme is a work in progress, other programmes with limited curricular time and resources may wish to adapt a similar process of infusion for their own curriculum revision efforts.