Availability of color fundus photographs from previous visit affects practice patterns for patients with diabetes mellitus

OBJECTIVE: To determine whether access to color fundus photographs from a patient's previous visit would alter the recommendations rendered to a cohort with diabetic retinopathy. PATIENTS AND METHODS: One hundred sixty patients with diabetic retinopathy returning for a follow-up visit and who had color fundus photographs obtained at a previous visit were evaluated by trained retina specialists. Their clinical impression and recommendations regarding management of diabetic retinopathy were recorded without reference to previous photographs. Color fundus photographs from the patient's most recent visit were then reviewed and new recommendations with regard to appropriate treatment and follow-up were recorded. RESULTS: In 21% of cases, after reviewing the patient's most recent color fundus photographs, the clinical recommendation changed. In 14% of cases, photographs clearly demonstrated that the patient's condition was stable or improved, resulting in a change from recommending treatment to recommending deferral of treatment. In 4% of cases, photographs clearly demonstrated clinical worsening and the recommendation was changed from observation to treatment. In 3% of cases, review of photographs prompted a change in the recommended follow-up interval. CONCLUSION: Access to color fundus photographs from a patient's previous visit frequently changed the clinical recommendations made to patients with diabetic retinopathy regarding appropriate treatment and follow-up. Availability of color fundus photographs therefore has implications about quality of care and may affect the cost of care.     

Clinical and radiographic findings that lead to intervention in diabetic patients with foot ulcers. A nationwide survey of primary care physicians

OBJECTIVE: To determine which elements of clinical history, physical examination, and diagnostic tests are important to primary care physicians in their management of foot ulcers in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted a national mail survey of 600 primary care physicians to determine which patient characteristics and diagnostic test results were important in their decisions to seek radiographic studies, surgical referrals, and hospitalization for diabetic patients with foot ulcers. RESULTS: The case characteristics most likely to influence physicians to order advanced diagnostic or therapeutic interventions are the presence of osteomyelitis on plain radiographs, the failure of the ulcer to improve with conservative therapy, and the presence of visible bone, crepitus, or necrosis within the ulcer (P < 0.001). Information from the initial clinical history was less likely to influence physicians to order advanced diagnostic or therapeutic interventions (P < 0.001) than was information from the physical examination. CONCLUSIONS: We conclude that 1) the patient's history is relatively unimportant to primary care physicians in their management of diabetic foot ulcers; 2) the failure of conservative management is a major reason that primary care physicians order surgical referral, hospitalization, or radiographic testing for diabetic patients with foot ulcers; and 3) primary care physicians rely heavily on plain X ray of the foot, a test with poor sensitivity and specificity, in deciding whether to order further interventions for their diabetic patients with foot ulcers.     

After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices

BACKGROUND: After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. OBJECTIVES: This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. METHODS: After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. RESULTS: In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. CONCLUSIONS: Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.     

Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care

Psychiatric disorders occur in 14% to 20% of American children and adolescents and are a leading cause of disability among them, yet fewer than one in five of these children are recognized. The most common psychiatric disorders presenting to pediatricians include ADHD, anxiety disorders, depression, substance-use disorders, and conduct disorder, Approaches to recognition include screening for psychosocial concerns using specific questions in the clinical interview, and using brief, written questionnaires. Case vignettes illustrate comprehensive treatment planning for children with psychiatric disorders in the primary care context. As psychopharmacologic treatments and the new subspecialty of pediatric psychopharmacology take on growing importance, the traditional oversight role of the pediatrician and effective communication among referring and consulting physicians remain critical to quality care.     

General pediatricians, pediatric subspecialists, and pediatric primary care

OBJECTIVE: To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care. DESIGN AND METHODS: A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care. RESULTS: Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001). CONCLUSION: Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

The disintegration of superEBA cement in solutions with adjusted pH and osmolarity

OBJECTIVE: To determine how physicians respond to a request for an expensive, unindicated test. DESIGN: Cross-sectional observational study. SETTING: Four sites of a group-model HMO. PARTICIPANTS: Thirty-nine internist volunteers. INTERVENTION: A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unannounced into physicians' regular schedules. The patient's only complaint was fatigue with no neurologic symptoms. MEASUREMENTS AND MAIN RESULTS: Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians "had no idea" that the patient they saw was the standardized patient, and the remaining four participants (10%) were only "somewhat suspicious." Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test's expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient's concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patient about their friend's experience with MS. A few physicians appeared to dismiss the patient's concerns, such as by telling the patient they were being "paranoid." CONCLUSIONS: Few physicians agreed to a standardized patient's request for a medically unindicated MRI, but more than half agreed to refer this patient to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction.     

Young adolescents' comfort with discussion about sexual problems with their physician

OBJECTIVE: To identify factors associated with young adolescents' sense of comfort about discussing sexual problems with their physician. DESIGN: Confidential, assisted self-report questionnaires on physician-adolescent communication developed by the investigators and completed by participants at visits for general health examinations. SETTING: Five primary care pediatric practices at health maintenance organizations in Washington, DC. PATIENTS: A consecutive sample of all adolescents 12 to 15 years old who received a general health examination. Of 412 eligible patients, 221 received parental consent and participated. MAIN OUTCOME MEASURE: Adolescents' sense of comfort about talking to their physician about a sexually transmitted disease or some other sexual problem. This outcome was chosen for a substudy of a larger longitudinal prevention trial. RESULTS: Most adolescents valued their physicians' opinions about sex (89%) and said it was easy to talk to the physician during their visit (99%), but about half said they would be uncomfortable talking to the physician if they had a sexually transmitted disease or some other sexual problem (43%) [corrected]. Adolescents' sense of comfort was greater when physicians discussed sexual issues in the general health examination, adolescents perceived their personal risk of sexually transmitted disease to be high, adolescents had high self-esteem, and physicians were adolescents' usual physicians. CONCLUSIONS: This study emphasizes the need for physicians to discuss sexual risks with young adolescents and suggests ways physicians can help young adolescents feel more comfortable talking with them about sexual concerns.     

A survey about management of febrile children without source by primary care physicians

BACKGROUND: The management of young children with fever without source is controversial, and differences between physician specialties have been noted previously. The emergence of penicillin-resistant Streptococcus pneumoniae, the sharp decline in invasive Haemophilus influenzae infections in immunized populations and publication of practice guidelines have potentially altered physician practices. OBJECTIVE: To determine the present practice preferences of pediatricians, family medicine physicians (FP) and emergency medicine physicians (EP). METHODS: We mailed a checklist survey to 1600 randomly selected pediatricians, family medicine practitioners (FP) and emergency medicine physicians (EP) in the United States and replicated the methodology of a 1991/1992 survey. Physicians were asked about their evaluation and management of children of various ages (3 weeks, 7 weeks, 4 months and 16 months) with fever without source. RESULTS: Most primary care physicians would admit the 3- and 7-week-old infants. For the 4-month-old infant 59% of EP, 45% of pediatricians and 28% of FP would give empiric antibiotic(s) as an outpatient (P=0.005 for FP compared with pediatricians and P=0.02 for EP compared with pediatricians). The majority of physicians would manage the 16-month-old child as an outpatient without antibiotic therapy. Ceftriaxone was the preferred antibiotic for outpatient empiric therapy. There was a 3-fold increase (28% vs. 9%) for pediatricians in the use of empiric outpatient antibiotics for the 7-week-old infant in the present survey compared with the 1991/1992 survey. CONCLUSIONS: Physicians in the United States generally agree in their management of the young febrile infant, but with increasing patient age there is considerable variation. FP were the least aggressive in their evaluation and EP were the most aggressive.     

Firearm injury prevention counseling by pediatricians and family physicians. Practices and beliefs

OBJECTIVES: To ascertain and compare beliefs, attitudes, and counseling practices of primary care physicians of children and adolescents regarding firearm injury prevention counseling. DESIGN: Cross-sectional survey. SETTING: State of Washington. SUBJECTS: All active members of the state chapters of the American Academy of Pediatrics and American Academy of Family Physicians. A total of 979 pediatricians and family physicians (53%) responded to the survey after two mailings. MAIN OUTCOME MEASURES: Attitudes, beliefs, and current practices with regard to firearm safety counseling among families of child and adolescent patients. RESULTS: Only 25% of pediatricians and 12% of family physicians currently counsel more than 5% of their patients. Pediatricians were more likely than family physicians (70% vs 46%, P < .001, chi 2 test) to believe that physicians have a responsibility to counsel families about firearm safety. Pediatricians recommended removing guns from the home more frequently than family physicians (32% vs 19%, P < .001, chi 2 test), but most physicians of both specialties perceived that parents are rarely receptive to this advice. However, 97% of physicians from both specialties agreed that firearms should be stored locked separately from ammunition, and a substantial majority believed that parents would be receptive to this advice. Compared with physicians who owned guns (32%), non-owners were 15 times more likely (odds ratio, 15; 95% confidence interval, 10 to 23) to agree that families with children should not keep firearms in the home. CONCLUSIONS: Few primary care physicians who see children and adolescents currently counsel families about firearm safety, although many agree that they have such a responsibility. At least half of these physicians would potentially benefit from an intervention to improve their knowledge of and counseling skills on this topic.     

Systemic pharmacologic therapy of ARDS

OBJECTIVE: Amid growing consumer demand and professional society recommendations for more information on early childhood development, current practices of pediatricians in regard to children's development remain largely unknown. We investigate whether there are differences in provider practices and satisfaction with regard to children's development (based on length of time in practice). DESIGN: A self-reported survey was conducted of physicians at 30 pediatric practices participating in the Healthy Steps for Young Children Program. Healthy Steps is a national program to enhance the developmental potential of young children. Comparisons were made among physicians categorized as in training (n = 88), recently in practice (completing residency from 1984 to 1996, n = 69), or more experienced (completing residency prior to 1984, n = 52). PRINCIPAL FINDINGS: Relative to those recently in practice and in training, more experienced pediatricians spend less time in well-baby visits in the first 2 months of life. One-third of physicians conduct family risk assessments, half complete routine developmental screening, and over half do safety risk assessments in the first 2 months of life. There were few differences by provider experience in the topics covered under anticipatory guidance for new parents. Nearly all discussed infant car seats, sleep position, feeding practices, and temperament, but less than half routinely discussed domestic violence, and between half and three-quarters discussed infant bathing, maternal depression, and appropriate discipline practices. While all three groups of physicians were satisfied with the amount of time to discuss growth and development and parenting issues, more experienced physicians were more satisfied with their own and their staff's abilities to meet new parents' needs on these issues. Factors that over one-third of physicians reported affected their ability to deliver the best-quality care were shortage of support staff, limited referral sources, managed-care restrictions on referrals for special services, excessive paperwork, and lack of time for follow up, teaching parents, and answering questions. Physicians in recent practice were more likely than more experienced physicians to cite reimbursement concerns and limited staff to address the needs of parents regarding development. CONCLUSIONS: Most pediatricians do not conduct routine developmental screening in the first 2 months of life, and most discuss safety, as opposed to developmental and mental health, concerns with parents of newborns. Pediatricians with more experience believe they are better meeting new parents' needs and are less likely to cite systems and organizational factors as limiting their ability to deliver high-quality care.     

Effectiveness of an organized follow-up system for elder patients released from the emergency department

OBJECTIVES: To determine whether an effective telephone callback system can be successfully implemented in a busy ED and to quantify the benefits that can be obtained related to the follow-up care of elder patients. METHODS: This was a prospective, cohort study conducted at a community teaching hospital during a 6-month period. Consecutive patients > or = 60 years old and released from the ED were selected for telephone follow-up. Calls were made by a research nurse within 72 hours after the patient's ED visit. Follow-up information included current medical status, problems encountered during the ED visit, compliance, and impact of the illness on self-care capabilities. RESULTS: Seventy-nine percent (831/1,048) of the patients selected for telephone follow-up were successfully contacted. The calls lasted an average of 4 +/- 2.5 minutes. Although 94% (778/831) of these patients had a regular physician, 14% failed to make their recommended follow-up arrangements. Compliance was significantly improved when a follow-up physician was contacted during the patient's ED visit. Approximately 96% of the patients were either satisfied or very satisfied with their ED care. However, 13% (109/831) had moderate deterioration in their ability to care for themselves. Of the patients contacted, 333 (40%) required further clarification of their home care instructions, 31 were advised to return to the ED for reevaluation, and 26 were referred to a medical social worker for psychosocial concerns. CONCLUSION: A telephone callback system is a feasible and effective method to improve follow-up care of elder patients released from the ED.     

The formation of the Medical and Scientific Section of the British Diabetic Association

James (Jim) Jackson was the first administrative secretary to the Medical and Scientific Section of the British Diabetic Association (BDA). He played an important part in the creation of the Section and its development, bringing order into what had been rather haphazard medical meetings of the Diabetic Association. He has written this history of the Medical and Scientific Section of the BDA, based upon personal recollection with historical data taken from minutes of meetings. He writes: 'The Medical and Scientific Section emerged from a feeling of dissatisfaction among diabetologists and research workers about the post-war activities and aims of the Medical Advisory and Research Grant Committees of the British Diabetic Association. There was also a perceived need to involve physicians in charge of diabetic clinics countrywide more closely in the activities of the Association as a means of increasing its lay membership. This history is based upon personal recollection, with historical data taken from minutes of meetings'. Jim Jackson's history is accompanied by footnotes provided by Dr David Pyke (DAP), former physician in charge of the diabetes service at King's College Hospital, London, and onetime registrar of the Royal College of Physicians of London.     

Entry into primary care and continuity: the effects of access

OBJECTIVES: This study examined the relationship between access and use of primary care physicians as sources of first contact and continuity with the medical system. METHODS: Data from the 1987 National Medical expenditure Survey were used to examine the effects of access on use of primary care physicians as sources of first contact for new episodes of care (by logistic regression) and as sources of continuity for all ambulatory visits (by multi-variate linear regression). RESULTS: No after-hours care, longer office waits, and longer travel times reduced the chances of a first-contact visit with a primary care physician for acute health problems. Longer appointment waits, no insurance, and no after-hours care were associated with lower levels of continuity. Generalists provided more first-contact care than specialists acting as primary care physicians, largely because of their more accessible practices. CONCLUSIONS: These data provide support for the linkage between access and care seeking with primary care physicians.     

The role of the primary care physician in the care of children with serious heart disease

OBJECTIVE: To determine the roles of primary care physicians and specialists in the medical care of children with serious heart disease. SETTING: Pediatric Cardiology Division; Tertiary Care Children's Hospital. SUBJECTS: Convenience sample of parents, primary care physicians, and pediatric cardiologists of 92 children with serious heart disease. DESIGN: Questionnaire study; questionnaires based on 16 medical care needs, encompassing basic primary care services, care specific to the child's heart disease and general issues related to chronic illness. RESULTS: All children had a primary care physician (PCP), and both they and the parents (P) reported high utilization of PCP for basic primary care services. However, there was little involvement of PCP in providing care for virtually any aspect of the child's heart disease. Parents expressed a low level of confidence in the ability of PCP in general or their child's own PCP to meet many of their child's medical care needs. Both PCP and pediatric cardiologists (PC) were significantly more likely than parents to see a role for PCP in providing for care specific to the heart disease as well as more general issues related to chronic illness. PC and PCP generally agreed about the role PCP should play, although PC saw a bigger role for PCP in providing advice about the child's activity than PCP themselves did. PC were less likely to see the PCP as able to follow the child for long term complications than PCP did. PC were more likely than PCP to believe that PCP were too busy or were inadequately reimbursed to care for children with serious heart disease. Only about one-third of parents reported discussing psychosocial, family, economic, or genetic issues with any provider, and PCP were rarely involved in these aspects of chronic illness. CONCLUSIONS: Primary care physicians do not take an active role in managing either the condition-specific or the more general aspects of this serious chronic childhood illness. With appropriate information and support from their specialist colleagues primary care physicians could provide much of the care for this group of children. Generalists and specialists are both responsible for educating and influencing parents about the role primary care physicians can play in caring for children with serious chronic illness.     

The use of retinoids in the pediatric patient

Oral retinoids are molecules derived from vitamin A that represent one of the most important steps forward in dermatologic therapeutics in the present century. The treatment of acne, severe psoriasis, and severe disorders of keratinization, prevalent diseases in children and adolescents, have radically changed since the advent of oral retinoids. Like most highly-effective medications, oral retinoids also have important untoward effects. Specialists, and in particular, dermatologists and pediatricians should be prepared to maneuver the delicate balance between therapeutic efficacy and side effects in order to give the pediatric patient the maximum benefit with the lowest possible risk.     

The JEVIN trial: a population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990

Since 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90% (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbA1c (HbA1c/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54 +/- 0.27, n = 47) to 1989/1990 (1.52 +/- 0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 +/- 0.38, n = 80, p = 0.0087). In the total group of NIDDM patients there was no significant change in HbA1c (1994/1995: 1.75 +/- 0.4, n = 117, vs 1989/1990: 1.78 +/- 0.4, n = 59, p = 0.67), but with a tendency to higher HbA1c under non-specialized (1.81 +/- 0.4, n = 79) compared to specialized care (1.66 +/- 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35%) and neuropathy (24%; 38%) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM.     

Pediatric HIV infection and the primary care physician. Meeting unique needs

The number of HIV-infected children and adolescents is expected to increase during the next decade. Most of these patients are likely to receive nearly all of their healthcare from primary care physicians. Management must be multifaceted and consist of medical care for acute illnesses, routine pediatric care that includes immunizations, and social service intervention.     

Telemedicine for diabetes care: the DIABTel approach towards diabetes telecare

Telemedicine is modifying classical health care by providing effective solutions to an increasing number of new situations. This article summarizes the potential benefits made available by this technology in diabetes care, and describes in detail how the new DIABTel Telemedicine Service complements the daily care of diabetic patients. The basic functions of the telemedicine system include telemonitoring of patient's blood glucose data and self-management actions, and remote care from doctors to diabetic patients. The system's architecture comprises two main components: the Medical Workstation, a PC-based system to be used by physicians and nurses in Diabetes Day Centre units in hospitals, and the Patient Unit, a palmtop-computer to be used by patients in their day to day activities. Both components, in an integrated approach, offer tools to doctors and patients for data collection and management, viewing and interpretation modules, data/message exchange services and an interactive glucose/insulin simulator for educational purposes. The DIABTel telemedicine diabetes care procedure aims: (1) to improve communication of the patient with the hospital-based diabetologist, in between the patient's visits to the clinic; (2) to allow doctors to assess the patient's condition on a frequent basis (every week); (3) to help patients with management in the daily care of diabetes, and (4) to provide patients with a service of 'supervised autonomy', to increase patient's independence without decreasing the necessary continual support and supervision from the doctor. Finally, we discuss the practical problems, limitations and vital issues regarding implementation of the telemedicine service.     

A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic

BACKGROUND: Simple distribution of clinical practice guidelines to physicians does not change practice behavior. A low-cost, continuous peer review feedback method was used to promote resident physicians' compliance with nine preventive care guidelines at the ambulatory care clinic at the Marshall University School of Medicine (Huntington, West Virginia). METHODS: Preventive care guidelines were distributed and a peer review feedback program was instituted in the resident physician primary care practice. The frequency of resident physician use of nine preventive care services was assessed and compared during three periods: preguideline (September 1, 1993, to March 1, 1994; 148 patients), guideline (September 1, 1994, to March 1, 1995; 148 patients), and one-year follow-up (September 1, 1995, to March 1, 1996; 150 patients). The patients in the three periods were similar in age, gender, and risk for influenza and pneumococcal infection. RESULTS: During the guideline period, resident physicians offered patients four preventive care services-tetanus toxoid immunization, clinical breast examination, Papanicolaou smear testing, and hemoccult testing significantly more often than during the preguideline period. All services were offered significantly more often during the one-year follow-up period compared with the preguideline period and as often as in the guideline period. CONCLUSION: A low-cost, continuous peer review feedback program significantly and durably improves resident physician compliance with clinical practice guidelines on preventive care services. However, the effectiveness of the poor review feedback method may not generalize to private practice or other settings. Research on other methods to promote compliance with clinical practice guidelines and to influence physician behavior in general should continue.