Copyright (c) 2009 All rights reserved. http://works.bepress.com/judith_savageau Recent documents in Judith A. Savageau, MPH en-us Tue, 30 Jun 2009 12:33:45 PDT 3600 http://works.bepress.com/judith_savageau/127 http://works.bepress.com/judith_savageau/127 Mon, 29 Jun 2009 07:24:21 PDT OBJECTIVE: To extend the findings of the first Development and Assessment of Nicotine Dependence in Youth study by using diagnostic criteria for tobacco dependence and a biochemical measure of nicotine intake. The first study found that symptoms of dependence commonly appeared soon after the onset of intermittent smoking. DESIGN: A 4-year prospective study. SETTING: Public schools in 6 Massachusetts communities. PARTICIPANTS: A cohort of 1246 sixth-grade students. INTERVENTIONS: Eleven interviews. MAIN OUTCOME MEASURES: Loss of autonomy over tobacco as measured by the Hooked on Nicotine Checklist, and tobacco dependence as defined in International Classification of Diseases, 10th Revision (ICD-10). RESULTS: Among the 217 inhalers, 127 lost autonomy over their tobacco use, 10% having done so within 2 days and 25% having done so within 30 days of first inhaling from a cigarette; half had lost autonomy by the time they were smoking 7 cigarettes per month. Among the 83 inhalers who developed ICD-10-defined dependence, half had done so by the time they were smoking 46 cigarettes per month. At the interview following the onset of ICD-10-defined dependence, the median salivary cotinine concentration of current smokers was 5.35 ng/mL, a level that falls well below the cutoff used to distinguish active from passive smokers. CONCLUSIONS: The most susceptible youths lose autonomy over tobacco within a day or 2 of first inhaling from a cigarette. The appearance of tobacco withdrawal symptoms and failed attempts at cessation can precede daily smoking; ICD-10-defined dependence can precede daily smoking and typically appears before consumption reaches 2 cigarettes per day. Joseph R. DiFranza Adolescent Behavior, Addictive Child Cotinine Female Humans Incidence International Classification of Diseases Interviews as Topic Male Massachusetts Personal Autonomy Prospective Studies Psychological Tests Risk Assessment Risk Factors Saliva Schools Smoking Smoking Cessation Students Time Factors Tobacco Use Disorder http://works.bepress.com/judith_savageau/126 http://works.bepress.com/judith_savageau/126 Mon, 29 Jun 2009 07:24:18 PDT BACKGROUND AND OBJECTIVES: Group visits have the potential to benefit patients with chronic illnesses. Our objective was to implement resident-run diabetic group visits that would improve patient education and help patients become more involved in their care. METHODS: We developed systems to promote, coordinate, and lead the visits. Residents' responsibilities were delegated through a preparation checklist. A standardized progress note was developed to encourage patient goal setting and to track relevant laboratory test results. To evaluate our program, we conducted surveys to determine patients' behavioral changes and satisfaction levels and assessed the effect on group visit participants' glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels. RESULTS: Group visit patient survey results showed that 72% of the patients in the group visit cohort reported making a lifestyle change; 88% felt that the group visit helped them achieve better control of their diabetes, and 100% stated that they would come to a group visit again. However, no significant changes were noted in HbA1c or LDL levels. CONCLUSIONS: Residents can overcome challenges and implement, organize, and run effective group visits that increase patients' self-reported self-management abilities, but we could demonstrate no statistically significant improvement on measurable biochemical parameters of glucose or lipid control. Chris Wheelock Adult Aged Diabetes Mellitus Family Practice Female Goals *Group Processes *Health Behavior Hemoglobin A, Glycosylated Humans *Internship and Residency Life Style Lipoproteins, LDL Male Massachusetts Middle Aged Outcome and Process Assessment (Health Care) Patient Satisfaction Program Evaluation Urban Population http://works.bepress.com/judith_savageau/125 http://works.bepress.com/judith_savageau/125 Mon, 29 Jun 2009 07:24:15 PDT Data from a nationally representative sample of smokers (ages 12-22 years, n=2,091) was examined to investigate the prevalence of symptoms of diminished autonomy over cigarettes. Six symptoms were assessed: failed cessation, smoking despite a desire to quit, and a need or urge to smoke, irritability, restlessness, or disrupted concentration attributed to nicotine withdrawal. One or more of the six symptoms were present in 18.9% of subjects who smoked less often than once per week. Among subjects who had not smoked 20 cigarettes in their lifetime, 12.6% had symptoms of nicotine withdrawal, and 25% had made an unsuccessful quit attempt. Judith A. Savageau Smoking Adolescent Tobacco Tobacco Use Disorder Substance-Related Disorders http://works.bepress.com/judith_savageau/124 http://works.bepress.com/judith_savageau/124 Mon, 29 Jun 2009 07:24:12 PDT PURPOSES: Job lock (inability to leave a job due to financial or benefits needs) has been found to significantly restrict job mobility. However, it has not been studied in terms of inability to retire. This study evaluated the relationship between health, work environment, and retirement-related job lock in workers > or =55 with recent occupational injuries. METHODS: Workers completed a mailed, self-report survey about their pre- and post-injury health and functioning, work environment, and retirement plans. Bivariate and multivariate analyses determined those factors associated with retirement-related job lock. RESULTS: Over half of the respondents wanted to retire but could not because they needed job-related income or benefits. Factors associated with retirement-related job lock were indicative of poorer health and mental function and dissatisfaction with the workplace social environment. No injury-related factors were significant. CONCLUSIONS: Retirement-related job lock was common in older workers with occupational injuries, and appears to be primarily due to difficulties at work, combined with health conditions that may impair work abilities. Workers wishing to retire but unable to do so may be at risk for work-related injuries, as well as decrements in work function and premature retirement resulting in insufficient income and health benefits. Katy L. Benjamin Age Factors Aged Aged, 80 and over Aging Comorbidity Employment Female Health Benefit Plans, Employee Health Status Humans Income Injury Severity Score Insurance Coverage Job Satisfaction Male Mental Health Middle Aged Multivariate Analysis New Hampshire Occupational Diseases Occupations Questionnaires Retirement Wounds and Injuries http://works.bepress.com/judith_savageau/123 http://works.bepress.com/judith_savageau/123 Mon, 29 Jun 2009 07:24:09 PDT CONTEXT: Small towns across the United States struggle to maintain an adequate primary care workforce. PURPOSE: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. METHODS: A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. FINDINGS: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. CONCLUSIONS: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities. Joseph Stenger Adult Attitude of Health Personnel Confidence Intervals Data Collection Education, Medical Family Practice Female Humans Job Satisfaction Logistic Models Massachusetts Medically Underserved Area Middle Aged Multivariate Analysis Odds Ratio Personnel Selection Physicians, Family Professional Practice Location Rural Health Services Social Environment http://works.bepress.com/judith_savageau/122 http://works.bepress.com/judith_savageau/122 Mon, 29 Jun 2009 07:24:06 PDT BACKGROUND AND OBJECTIVES: Our objective was to assess practicing family physicians' confidence and participation in a range of community-related activities. Additionally, we assessed the strength of the relationship between the physicians' reported medical school and residency training in community-related activities and their current community activities, as well as whether they were practicing in an underserved location. METHODS: All 347 graduates of the University of Massachusetts Family Medicine Residency were surveyed about practice location and type, involvement and training in community work, confidence in community-related skills, and sociodemographic characteristics. Analyses were conducted by residency graduation decade (1976-1985, 1986-1995, and 1996-2005). RESULTS: Earlier graduates (19761985) were significantly more likely to engage in an array of community-related activities, but recent graduates (1996-2005) were more likely to report having been trained in these skills. There was a significant positive association between practice in an underserved area and confidence in issues related to sociocultural aspects of care. While recent graduates were more likely to locate both initial and current practices in a Health Professions Shortage Area (HPSA), 20.6% of all graduates reported an initial practice in a HPSA. CONCLUSIONS: While family physician involvement in community-related activities increases with years out of residency, a higher proportion of recent graduates report having learned community-related skills while in medical school. Physician relocation tends to be away from HPSA toward non-HPSA sites. Suzanne B. Cashman Adult Community Health Services Family Practice Female Humans Male Massachusetts *Medically Underserved Area Middle Aged Physicians, Family *Professional Practice Location http://works.bepress.com/judith_savageau/121 http://works.bepress.com/judith_savageau/121 Mon, 29 Jun 2009 07:24:03 PDT BACKGROUND AND OBJECTIVES: While some family medicine residency programs are designed to train residents in community health centers (CHCs) for future careers serving underserved populations, there are few outcome studies on such programs. Our residency program provides three options for ambulatory health center training, but otherwise residents participate in the same curriculum. We analyzed relationships between ambulatory training site and likelihood of practice in health professions shortage areas (HPSAs). METHODS: We sent a mail survey to all graduates of one family medicine residency about practice locations, types, and populations; influences on practice choice; and sociodemographic characteristics. RESULTS: Training in a CHC had a statistically significant association with the likelihood of practice in an HPSA for both initial and current practice. Training in a rural residency site was associated with initial and current rural practice. Logistic regression analysis showed that physicians who completed ambulatory training in the CHC were nearly six times more likely to report having practiced initially and four times more likely to cite current practice in an HPSA. CONCLUSIONS: Outpatient CHC residency training increases the likelihood of practice in an underserved setting. This finding has policy implications for supporting workforce training in practice settings that care for underserved populations. Warren J. Ferguson Family Practice Community Health Centers Internship and Residency Medically Underserved Area http://works.bepress.com/judith_savageau/120 http://works.bepress.com/judith_savageau/120 Mon, 29 Jun 2009 07:24:00 PDT OBJECTIVE: To determine whether the medical-legal advocacy screening questionnaire (MASQ), a simple 10-item questionnaire, is able to screen families in a primary care setting for possible referral to legal services more effectively than the clinical interview alone. METHODS: Family Advocates of Central Massachusetts (FACM) is a medical-legal collaboration that assists low-income families with legal issues that affect child health. A convenience sample of parents seen at each of 5 medical practices associated with FACM was recruited to complete the MASQ prior to a routine child health care visit. Physicians blinded to the result assessed family need for referral to FACM after their usual clinical encounter. The sensitivity and specificity of both the MASQ and provider assessment were calculated. RESULTS: Two hundred fifty-five parents from 5 practices participated in the study. The MASQ identified 85 patients in need of legal services. Prior to reviewing the MASQ, the primary care providers identified 35 families in need of referral to the FACM. After completion of both the MASQ and the medical encounter, 37 families agreed to referral. The MASQ had sensitivity of 0.81 and specificity of 0.75 in predicting program referral. Provider assessment had sensitivity of 0.65 and specificity of 0.95 of predicting program referral. CONCLUSIONS: Routine use of the MASQ would likely identify more patients in pediatric practices who would accept referral to legal assistance than reliance on provider impression alone after a routine clinical encounter. David Keller Adult Child Advocacy Child Welfare Child, Preschool Humans Massachusetts *Needs Assessment Patient Acceptance of Health Care Predictive Value of Tests Primary Health Care *Questionnaires Referral and Consultation http://works.bepress.com/judith_savageau/119 http://works.bepress.com/judith_savageau/119 Mon, 29 Jun 2009 07:23:57 PDT BACKGROUND AND OBJECTIVES: Medication mismanagement is a serious health issue affecting elders and people with disabilities, who often manage multiple medications. This project's goal was to educate medical and nursing students about the challenges patients face when managing complex medication regimens. METHODS: A total of 104 first-year medical students and 40 second-year nursing students were randomly assigned to participate in a 1-week regimen of mock prescriptions or to read a description of the regimen and make predictions about what the experience would be like had they participated. RESULTS: Quantitative results in combination with qualitative information suggest that the students taking the mock prescriptions gained important insights into the difficulty of managing a complicated medication regimen. DISCUSSION: This mock prescription exercise, well accepted by students and faculty, was easily incorporated into the curriculum and provided an experiential opportunity for students to learn of the difficulties of medication adherence. Darlene M. O'Connor Adolescent Adult Curriculum *Education, Medical, Undergraduate *Education, Nursing, Graduate Female Humans Male Massachusetts *Medication Adherence Teaching Young Adult http://works.bepress.com/judith_savageau/118 http://works.bepress.com/judith_savageau/118 Mon, 29 Jun 2009 07:23:53 PDT BACKGROUND: With a goal to reduce youth smoking rates, the U.S. federal government mandated that states enforce laws prohibiting underage tobacco sales. Our objective was to determine if state compliance with tobacco sales laws is associated with a decreased risk of current daily smoking among adolescents. METHODS: Data on tobacco use were obtained from a nationally representative sample of 16,244 adolescents from the 2003 Monitoring the Future survey. The association between merchant compliance with the law from 1997-2003 and current daily smoking was examined using logistic regression while controlling for cigarette prices, state restaurant smoking policies, anti-tobacco media, and demographic variables. RESULTS: Higher average state merchant compliance from 1997-2003 predicted lower levels of current daily smoking among adolescents when controlled for all other factors. The odds ratio for daily smoking was reduced by 2% for each 1% increase in merchant compliance. After controlling for price changes, media campaigns and smoking restrictions, a 20.8% reduction in the odds of smoking among 10th graders in 2003 was attributed to the observed improvement in merchant compliance between 1997 and 2003. A 47% reduction in the odds of daily smoking could be attributed to price increases over this period. CONCLUSION: Federally mandated enforcement efforts by states to prevent the sale of tobacco to minors appear to have made an important contribution to the observed decline in smoking among youth in the U.S. Given similar results from long-term enforcement efforts in Australia, other countries should be encouraged to adopt the World Health Organization Framework on Tobacco Control strategies to reduce the sale of tobacco to minors. Joseph R. DiFranza Smoking Adolescent Adolescent Behavior Tobacco Tobacco Industry Commerce Law Enforcement