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Objective: To perform a meta-analysis on existing randomized controlled trials to investigate the efficacy of patient letter reminders on increasing cervical cancer screening using Pap smears.Methods: A search was conducted for all relevant published and unpublished studies between the years 1966 and 2000. Eligibility criteria included randomized controlled studies that examined populations due for Pap smear screening. The intervention studied was in the form of a reminder letter. The Mantel-Haenszel method was used to measure the summary effect of the intervention. A test for homogeneity using the Mantel-Haenszel method was performed.Results: Ten articles fulfilled the inclusion criteria, including one unpublished study. The test for homogeneity showed evidence of heterogeneity (chi2 = 31, 9 df, P <.001). An analysis for causes of heterogeneity was pursued. Division into subpopulations based on socioeconomic status resolved the heterogeneity (chi2 = 5.2, 8 df, P =.75). The studies evaluating those in lower socioeconomic groups had a smaller response (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.99 to 1.35) than those studies using mixed populations (OR, 2.02; 95% CI, 1.79 to 2.28). The pooled odds ratio showed that patients who received the intervention were significantly more likely to return for screening than those who did not (OR, 1.64; 95% CI, 1.49 to 1.80).Conclusions: Patient reminders in the form of mailed letters increase the rate of cervical cancer screening. Patient letter reminders have less efficacy in lower socioeconomic groups. [ABSTRACT FROM AUTHOR]

Introduction: Data on the epidemiology and management of anorexia nervosa (AN) in the intensive care unit (ICU) are scarce. The aim of this study was to evaluate the prevalence and associated morbidity and mortality of AN in French ICUs., Methods: We randomly selected 30 ICUs throughout France. Thereafter, we retrospectively analyzed all patients with AN admitted to any of these 30 ICUs between May 2006 and May 2008. We considered demographic data, diagnosis at admission and complications occurring during the stay, focusing on refeeding syndrome and management of refeeding., Results: Eleven of the 30 ICUs participated in the retrospective study, featuring 68 patients, including 62 women. Average body mass index at the admission was 12 ± 3 kg/m2. Twenty one were mechanically ventilated, mainly for neurological reasons. The reported average calorie intake was 22.3 ± 13 kcal/kg/24 h. Major diagnoses at admission were metabolic problems, refeeding survey and voluntary drug intoxication and infection. The most common complications were metabolic, hematological, hepatic, and infectious events, of which 10% occurred during refeeding. Seven patients developed refeeding syndrome. At day one, the average calorie intake was higher for patients who developed refeeding syndrome (23.2 ± 5 Kcal/kg/j; n = 7) versus patients without refeeding syndrome (14.1 ± 3 Kcal/kg/j; n = 61) P = 0.02. Seven patients died, two from acute respiratory distress syndrome and five from multiorgan-failure associated with major hydroelectrolytic problems., Conclusions: The frequency of AN in ICU patients is very low and the crude mortality in this group is about 10%. Prevention and early-detection of refeeding syndrome is the key point.

Background: Previous studies of nonresponders have not assessed the effects of nonresponse on the accuracy of clinician behavior measurements. Knowledge of these effects is critical to both research and quality improvement., Objective: To evaluate the hypothesis that nonresponders to a survey would not adversely affect the ability to measure rates of preventive services., Research Design: Four primary-care medical practices participating in a randomized clinical trial provided an unusual opportunity to compare the medical record-documented care of both responders and nonresponders to a survey of their patients., Subjects: Three hundred forty-five nonresponders and 321 responders to a questionnaire requesting participation in the study., Measures: Differences in patient characteristics and diseases and documentation of screening and management of tobacco use, hypertension, and hypercholesterolemia., Results: Although the survey process resulted in a response rate of only 52.5% and some statistically significant differences in responder and nonresponder characteristics, there were no differences in management behavior regarding cardiovascular risk factors. Responders were more likely to have adjusted documentation of tobacco use (OR = 1.4), blood pressure measurement (OR = 9.8), and cholesterol testing (OR = 2.0), but not family history of cardiovascular disease. The most striking difference in subject characteristics was that 22.0% of nonresponders and only 12.1% of responders were tobacco users (P = 0.002)., Conclusions: This study confirms that survey nonresponders may have some different characteristics and risk factor screening rates than responders. However, if confirmed by others, nonresponders who have risk factors identified may not be managed differently than responders.

Chronic pain is a widespread, difficult problem facing clinicians. This study assessed the current medical management of a general population of patients with chronic pain in 12 family medicine practices located throughout the state of Wisconsin. Medical record audits were conducted on a sample of 209 adults. Sixty-seven percent were female with an average age of 53 years. The most common pain diagnoses included lumbar/low back (44%), joint disease/arthritis (33%), and headache/migraine (28%) pain. The most frequently prescribed opioids were oxycodone/acetaminophen (31%), morphine ERT (19%), Tylenol #3 (15%), and hydrocodone/acetaminophen (14%). Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%), and alcohol abuse (3%). Written drug contracts were utilized by 42% (n = 31) of the practitioners, pain scales 25% (n = 29), and urine toxicology screens 8% (n = 6). This study suggests that primary care practitioners have unique opportunities to identify and successfully treat patients with chronic pain.

A total of 684 primary care physicians in Wisconsin participated in a survey designed to explore their experiences of consulting with and referring patients to mental health care professionals. The respondents indicated that they had only moderate access to mental health care professionals, and even less access when a patient was covered by Medicare or Medicaid or had no insurance. Physicians in group practices that included at least one mental health professional reported having better access to care than those in practices that did not include mental health services. Perceived access to mental health care services was not related to community size or to a managed care setting.

Objective: Our goal was to determine how often primary care providers discussed osteoporosis prevention and calcium intake with women during their health maintenance examinations., Methods: A total of 449 women aged 18 to 65 years participated in exit interviews immediately following a health maintenance examination at 1 of 8 Wisconsin family practice clinics., Results: Forty-six percent of these women reported discussing osteoporosis with their providers during their visit, and 51% reported discussing calcium intake. A total of 61% reported discussing either osteoporosis or calcium intake during the visit. Some providers were able to discuss these topics with more than 90% of their patients. A logistic regression model showed that providers were less likely to discuss either of these issues with women younger than 40 years (P=.019); they were more likely to discuss them with women older than 60 years (P=.002) than with women aged 40 to 60 years; and women providers were significantly more likely to discuss either issue (P=.004)., Conclusions: Primary care providers are in a good position to counsel women of all ages about their potential for avoiding osteoporosis and to recommend prevention strategies. The United States Preventive Services Task Force recommends that all women be counseled on adequate calcium intake yearly after the age of 18 years. Provider education and institutional changes may increase the frequency of this counseling for all primary care physicians.

Background: The Health Education and Research Trial (HEART) was a multicenter clinical trial designed to test methods to improve primary care practice systems for heart disease prevention services. We present the trial methodology, the practices' use of medical record tools, and changes in documentation of cardiovascular risk factor screening and management., Methods: Primary care practices were recruited from 4 Midwestern states. The factorial design resulted in 4 study groups: conference only, conference and quality improvement consultations, conference and prevention coordinator, and all interventions combined. Medical record audits and physician, staff, and patient surveys assessed practice change in cardiovascular disease risk factor documentation., Results: Practices participated fully in this project, set goals to improve preventive services, and implemented recommended medical record tools. The number of goals set and the increase in the use of medical record tools were greatest in the combined intervention group, with improvements noted in all groups. The use of patient history questionnaires, problem lists, and flow sheets was significantly higher in the combined intervention group when compared with the conference-only group. Documentation of risk factor screening in a recommended-medical record location improved in all intervention groups, with significant sustained improvements in the practices that received the combined intervention. Documented risk factor management significantly improved in all intervention groups compared with the conference-only control., Conclusion: Primary care practices are interested in improving prevention systems and can change these systems in response to supportive external interventions. Promoting organizational change to produce sustained improvement in preventive service clinical outcomes is a complex process that requires further research.

Background: Recruitment of community primary care practices for studies to improve health service delivery is important to many health care organizations. Prior studies have focused on individual physician recruitment or academic settings., Methods: This descriptive study evaluated the efficiency and utility of three different recruitment methods to encourage community practice participation in a preventive services research trial. Primary care practices in four midwestern states were recruited using different sources for initial mailings (physician lists, practice lists, and a managed care organization's primary care network) and different recruiting methods. Outcome measures included response rates, participation rates, and comparative costs of each method., Results: Of the 86 eligible practices contacted, 52 (60%) consented to participate. Mailing to individual physicians was the most cumbersome and expensive method and had the lowest response rate. Initial contacts with practice medical directors increased the participation rate substantially, and practice recruitment meetings improved both study participation and practice-project communication., Conclusions: Experience with these three methods suggests that the most efficient way to recruit practices for participation in a preventive services research trial involves targeted mailings and phone calls to medical directors, followed by on-site practice meetings.