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Am Fam Physician. 1999;59(6):1616-1618

Collaborative Care Can Improve Health Status of Elderly Patients

(26th Annual Meeting of the North American Primary Care Research Group) An office-based program that offers collaborative care with a primary care physician, a nurse and a social worker to elderly patients with chronic conditions and functional deficits living in the community may reduce their need for medical services and improve their health status, according to results of a prospective, randomized study conducted in 18 primary care practices. The study included 543 patient volunteers over the age of 65 years. The patients were randomized to a treatment group that received 18 months of collaborative primary care or a control group that received care as usual. Collaborative care practice was defined as a nurse and a social worker working in cooperation with a physician to provide patients with monitoring between office visits, training in self-management and contact with community-based services. After 18 months, the hospitalization rate in the treatment group had not changed, but the hospitalization rate in the control group had increased by 44 percent. The mean number of office visits among the patients in the treatment group decreased by 1.5 visits, compared with an increase of 0.4 visits among patients in the control group. The patients in the intervention group reported fewer physical symptoms, more social activities and had a more stable perception of their overall health, compared with the patients in the control group. The investigators believe that more contact with nurses and social workers was associated with the need for fewer services and improved health status.—lucia s. sommers, ph.d., et al., St. Mary's Medical Center, San Francisco.

Obesity Before Pregnancy Is a Risk Factor for Cesarean Delivery

(North American Primary Care Research Group) A retrospective chart review of patients delivering in a rural hospital between January 1990 and June 1997 indicates that women who are obese before they become pregnant are at increased risk for cesarean delivery. The charts were reviewed for method of delivery, associated risk factors and incidence of cesarean section. Obesity was defined as a body mass index greater than 29. The mean body mass index among women who had primary and repeat cesarean sections was 31.9 and 32.5, respectively; the mean body mass in patients who delivered vaginally and patients who had a vaginal delivery after cesarean section was 28.3 and 26.5, respectively. However, the women who delivered vaginally had gained significantly more weight than the women who received repeat cesarean sections (28.9 lb versus 27.6 lb). Other risk factors associated with an increase in cesarean sections included older age, diabetes mellitus, gestational hypertension and previous delivery of an infant over 4,000 g (8 lb, 13 oz). The investigators believe that the possible relationship between obesity and cesarean section is very complex and will require continued investigations.—loren a. crown, m.d., et al., University of Tennessee, Memphis.

Study Evaluates Use of Universal Newborn Hearing Screening

(North American Primary Care Research Group) Universal hearing screening in infants at low risk for hearing loss can be accomplished with an acceptable false-positive rate when a two-staged approach is used. This was the conclusion of a study evaluating the use of the Distortion Product Otoacoustic Emissions test in a nursery for normal newborns. All of the infants were cared for by family physicians. Parents of infants who failed the initial screen were asked to bring them back to the family practice residency clinic at approximately two months of age for repeat hearing testing. Of 589 infants who were tested, 61 failed the initial screen (10.4 percent); 42 infants were returned for the repeat screening, and all of them passed the repeat screen. The amount of time to do the test averaged 20 minutes; the cost of each test was $19. In this program, infants who fail the second screen will be referred for tympanometry. Infants who fail both the screen and the tympanometry will be referred for further evaluation and treatment of middle ear disease and screened again in one to two months. Infants who fail the screen and pass the tympanometry will be referred for diagnostic auditory brain stem response. Assuming an incidence of one per 1,000 infants born with hearing loss, the screening would cost about $20,000 for each infant diagnosed. The investigators point out that as the operators of the test became more experienced during the study, the percent of failed first screens decreased.—kurt a. stone, m.d., et al., Rapid City Regional Hospital, Rapid City, S.D.

Routine Data Can Identify Patients with Type 2 Diabetes Mellitus

(North American Primary Care Research Group) Medical data routinely collected in a family practice setting can be used to identify patients with undiagnosed type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes mellitus), according to a study of two cohorts of patients in England. The first cohort was made up of 1,122 persons aged 40 to 65 years who were randomly selected from one practice. The patients were not known to have diabetes. They completed questionnaires, glucose tolerance tests and clinical examinations. The second cohort consisted of 197 newly diagnosed patients with type 2 diabetes from 41 practices whose clinical data were reported. These patients were 40 to 65 years of age. Data from one half of the subjects in the first cohort were entered stepwise into a logistic model producing a risk score. The score was tested for sensitivity and specificity in identifying subjects with undiagnosed type 2 diabetes from the remaining one half of the cross-sectional survey. Variables significantly contributing to the score were age, sex, body mass index, use of steroid and antihypertensive medication, family and smoking history. The investigators believe that these data should facilitate the identification of persons with type 2 diabetes, resulting in earlier use of treatment interventions.—simon griffin, et al., University of Cambridge, England.

Survey Results Show Students Need Sexual Education Early

(North American Primary Care Research Group) Results of a survey of eighth-grade students in a Midwestern junior high school indicate that an educational program on sexually responsible behavior and sexually transmitted diseases (STDs) should be presented to students at an early age, because many of the students surveyed were already sexually active by the eighth grade. A total of 340 students completed a questionnaire before participating in a three-day school-based program on sexually responsible behavior and STDs. The students were asked about sources of information on sexuality, their sexual behavior and concerns regarding the consequences of sexual activity. Students were also given a 25-item pre- and post-test to evaluate the program's effectiveness. One hundred eleven students reported that they had ever had sex. Sexual activity began at the average age of 12.2 years with an average of 2.4 partners. Boys were more likely than girls to report ever having sex (48.2 percent versus 22.7 percent). Black students were more likely to ever have had sex than Hispanic or white students (46.5 percent, 26.7 percent and 23.2 percent, respectively). Students cited school and parents as their major sources of information about sexuality. After participating in the education program, the students demonstrated improved cognitive knowledge. The investigators believe that school is an appropriate setting for this type of program on sexual education.—sanford r. kimmel, m.d., et al., Medical College of Ohio, Toledo.

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