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PURPOSE To determine the proportion of regional primary care physicians who would attend grand rounds on preventive services and their interest in and use of free follow-up enabling and reinforcing assistance to implement changes in their practice routines. METHOD From January to July 1992 grand rounds on early detection of cancer were offered by Dartmouth Medical School at 38 acute care community hospitals in New Hampshire and Vermont. The target audience of 679 family physicians and general internists was identified through state medical society and hospital attending lists. The hour-long grand rounds program described preventive service guidelines and an office system that promoted their implementation. Follow-up practice support with planning, office staff training, and materials were offered to augment the effects of the grand rounds. Attendance was determined by sign-in documents. In addition, all attendees were asked to complete a survey regarding practice and personal characteristics and interest in follow-up assistance. Statistical comparisons were made using chi square and Fisher's exact tests. RESULTS In all, 261 family medicine physicians and general internists (38.4%) attended. Certain categories of physicians were more likely to have attended: internists, those younger than 55 years, and physicians on the staffs of hospitals located in small towns. Assistance was requested by 70.1% of the attendees; many requested more than one type of assistance. Physicians from hospitals in smaller towns were more likely to show interest in follow-up assistance and use it when offered. CONCLUSION Many of the grand rounds attendees were receptive to follow-up assistance that could improve the preventive services they provided. Most hospitals offer grand rounds, and many organizations have interest in and resources for helping physicians provide high-quality care. Future research should establish the best linkage to the actual care provided in practices and explore the relevance of similar approaches to clinical areas beyond prevention.

This project demonstrates the effect of increasing the skills of Community Health Aides (CHAs) on the use of specific preventive health services by women in remote Alaska villages. Eight CHAs were trained in specimen collection for Pap and sexually transmitted disease testing, and in clinical breast examination. Skill competency was monitored. Computerized medical records of all women between the ages of 18 and 75 in the four villages with trained CHAs and in four comparison villages (n = 1093) were checked for Pap status prior to CHA training and again 12 months later. All eight CHAs achieved competency and provided services in their village clinics with telephone support from an experienced clinician. The post-training year Pap test rate of women who were overdue for a Pap test was 0.44 in the villages with trained CHAs; the rate among the women in the comparison villages was 0.32 (p = .079).

The provision of preventive services holds a central place in primary care. Achievement of prevention standards offers a challenge. The authors address the efficacy of an office systems approach to improving cancer prevention and early detection services, provide a guide to assessing the appropriateness of office systems dissemination in practices targeted for improvement, and describe the range of dissemination strategies available.Preventive service office systems depend on establishing practice routines, using tools such as flow sheets, and sharing responsibilities among practice clinicians, staff, and patients. Systems have been shown to be efficacious in a variety of settings. Computers provide a significant enhancement to paper-based tools. Some practices develop office systems themselves, whereas others require external support. Before attempting to disseminate preventive services offices systems, disseminators should ensure that adequate assistance can be provided, that assistance follows a format that is acceptable to target practices, and that target practices are receptive to assistance and able to cooperate. Dissemination strategies include journal articles, continuing education programs, manuals and tool kits, facilitation, and academic detailing. The relative expense and efficacy of these approaches require further assessment.Office systems hold promise in enhancing provision of cancer prevention services in primary care. The practice should be approached as a team, and should include practice clinicians as well as nonclinical staff members. Current research should provide answers over the next few years about the cost-effectiveness of various approaches and the most feasible ways to promote dissemination to practices that need it.

To define the risks of disseminated bacille Calmette-Guérin (BCG) or disseminated Mycobacterium tuberculosis in adults with AIDS who were immunized with BCG in childhood.HIV-infected patients with CD4200 x 10(6)/l were enrolled from five study sites (New Hampshire, Boston, Finland, Trinidad and Kenya). Prior BCG immunization was determined and blood cultures for mycobacteria were obtained at study entry and at 6 months. Acid-fast bacilli were identified as Mycobacterium tuberculosis complex (MTBC) using DNA probes. MTBC isolates were then typed by both IS6110 restriction fragment length polymorphism and polymerase chain reaction/restriction enzyme analysis.Most patients in New Hampshire and Finland were outpatients; most patients in Trinidad were inpatients with terminal illness; and most patients in Kenya were outpatients, although 44 were inpatients with terminal illness.A total of 566 patients were enrolled, including 155 with childhood BCG immunization; 318 patients had a single study visit and culture, and 248 patients had two study visits and cultures.Isolation and identification of mycobacteria from blood cultures.Blood cultures were positive for MTBC in 21 patients; none were positive for M. bovis BCG, and 21 were M. tuberculosis-positive. In Trinidad, seven (87%) out of eight isolates of M. tuberculosis were indistinguishable by IS6110 typing; BCG immunization was associated with a decreased risk of bacteremic infection with M. tuberculosis (P = 0.05).The risk of disseminated BCG among adult AIDS patients with childhood BCG immunization is very low. Childhood BCG immunization is associated with protection against bacteremia with M. tuberculosis among adults with advanced AIDS in Trinidad.

To determine rates of disseminated Mycobacterium avium complex (MAC) infection among AIDS patients in developed and developing countries, and to determine whether different rates reflect differences in exposure or immunity, or both.Prospective cohort study.University hospitals and outpatient AIDS programs.HIV-infected subjects with CD4 counts200 x 10(6)/l were interviewed and had CD4 lymphocyte counts, blood cultures for mycobacteria (baseline and at 6 months), and skin tests with purified protein derivative (PPD) and M. avium sensitin.Among 566 study patients rates of disseminated MAC were 10.5-21.6% in New Hampshire, Boston and Finland compared to 2.4-2.6% in Trinidad and Kenya (P0.001). PPD skin test reactionsor = 5 mm were present in 20% of patients from Kenya compared to 1% at other sites (P0.001). Among patients from the United States and Finland, multiple logistic regression indicated that occupational exposure to soil and water was associated with a decreased risk of disseminated MAC, whereas the following were associated with an increased risk of disseminated MAC: low CD4 count, swimming in an indoor pool, history of bronchoscopy, regular consumption of raw or partially cooked fish/shellfish and treatment with granulocyte colony-stimulating factor.Rates of disseminated MAC in AIDS are higher in developed than developing countries and are due to both differences in exposure and differences in immunity. These data provide a rationale for prevention of MAC through both active immunization and reduction in exposure to the organism.

In light of the increasing problem of perinatal human immunodeficiency virus (HIV) transmission, the issue of screening women for HIV is receiving considerable attention. We analyzed the costs and benefits of screening women of childbearing age for HIV. The analysis was based on a dynamic model of the HIV epidemic that incorporated disease transmission and progression, behavioral changes, and effects of screening and counseling. We found that the primary benefit of screening programs targeted to women of childbearing age lies not in the prevention of HIV infection in their newborns but in the prevention of infection in their adult contacts. Because of this benefit, screening medium- and high-risk women is likely to be cost-beneficial over a wide range of assumptions about program cost and behavioral changes in response to screening.

P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider discontinuity and provider continuity. The outcome of the continuity group was significantly different from that of the discontinuity group. During an 18-month period, patients who had been randomized to the continuity group had fewer emergent admissions (20% v 39%) and a shorter average length of stay (15.5 v 25.5 days). These patients also perceived that the providers were more knowledgeable, thorough, and interested in patient education. We conclude that continuity of outpatient provider care for men aged 55 years and older results in more patient satisfaction, shorter hospitalizations, and fewer emergent hospital admissions.

P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider discontinuity and provider continuity. The outcome of the continuity group was significantly different from that of the discontinuity group. During an 18-month period, patients who had been randomized to the continuity group had fewer emergent admissions (20% v 39%) and a shorter average length of stay (15.5 v 25.5 days). These patients also perceived that the providers were more knowledgeable, thorough, and interested in patient education. We conclude that continuity of outpatient provider care for men aged 55 years and older results in more patient satisfaction, shorter hospitalizations, and fewer emergent hospital admissions.