RESUMEN
BACKGROUND: Increases in cesarean section frequency may be dependent on institutional or individual practitioner characteristics. The purpose of this study was to examine whether the diagnosis of fetal distress was influenced by time of day or institutional factors. METHODS: Chart review was performed on a random sample of women stratified by month of delivery at each institution (N = 8647). All women who gave birth by elective cesarean section or whose labor was induced were excluded from analysis (n = 2207), leaving a total population of 6440 for study. Women were stratified based on risk status, and comparisons were made between the time of delivery, maternal socioeconomic factors, and obstetric variables for those who had a cesarean section for fetal distress compared with women who gave birth vaginally. RESULTS: Large variations in rates of cesarean delivery for fetal distress were observed among the participating institutions (range 0.9% to 3.0% of all deliveries). Increased rates of cesarean delivery for fetal distress were observed in nonwhite women and those who had had a previous cesarean delivery. Also, a significant increase in rates of cesarean section for fetal distress was noted between the hours of 9:00 PM and 3:00 AM. When adjusted for risk status, previous cesarean delivery, race, use of pitocin augmentation, length of labor, and site, time of day was still a significant predictor (adjusted odds ratio = 1.56, 95% confidence interval 1.06 to 2.29) for cesarean delivery for fetal distress. CONCLUSIONS: Cesarean delivery for the diagnosis of fetal distress appears to vary depending on institutional and other nonclinical factors. The observation that cesarean deliveries for fetal distress peak during nighttime hours raises the possibility that the interpretation of fetal monitor tracing is influenced by physician and patient fatigue or other clinical factors.
Asunto(s)
Cesárea/estadística & datos numéricos , Sufrimiento Fetal/cirugía , Adulto , Distocia/cirugía , Femenino , Monitoreo Fetal , Humanos , Trabajo de Parto Inducido , Trabajo de Parto , Oxitocina , Embarazo , Embarazo de Alto Riesgo , Reoperación , Estudios Retrospectivos , TiempoRESUMEN
To determine the reliability of specimen interpretation by outpatient laboratories, 150 consecutive specimens from three family practice centers were analyzed by either two laboratory technicians (n = 99) or two family physicians (n = 51). The results showed good to excellent agreement for contamination (defined as five or more epithelial cells per high-power field) or significant pyuria (five or more white blood cells per high-power field) or hematuria (five or more red blood cells per high-power field). Agreement between laboratory technicians did not differ significantly from agreement between physicians for the interpretation of contamination or pyuria, but for hematuria, agreement was higher between technicians (P = .02). These results suggest that outpatient interpretation of microscopic urine specimens shows levels of interrater agreement similar to or better than other tests that have been evaluated.
Asunto(s)
Urinálisis/estadística & datos numéricos , Humanos , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Urinálisis/métodosRESUMEN
BACKGROUND: Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians. METHODS: A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865. RESULTS: During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. CONCLUSIONS: Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.
Asunto(s)
Medicina Familiar y Comunitaria , Servicios de Salud Materna , Obstetricia , Resultado del Embarazo , Anestesia Epidural , Cesárea , Estudios Transversales , Episiotomía , Femenino , Humanos , Recién Nacido , Trabajo de Parto Inducido , Trabajo de Parto , Complicaciones del Trabajo de Parto/diagnóstico , Embarazo , Atención Prenatal , Estudios RetrospectivosRESUMEN
OBJECTIVE: To evaluate the influence of socioeconomic factors and provider characteristics on the use of intrapartum epidural anesthesia. METHODS: A total of 8229 deliveries at five hospitals were reviewed retrospectively. Bivariate analysis was performed to identify potential biases in epidural use. Logistic regression was performed to control for confounding variables. RESULTS: Epidural use was predominantly related to parity, with nulliparous women more likely to use an epidural during labor. In hospitals where epidurals were used in a higher percentage of women, we found an association between the woman's insurance status and the specialty of the physician managing labor. Race also appeared to be associated with epidural use in the participating hospital that had a large non-white population. CONCLUSION: Use of intrapartum epidural analgesia varies considerably among sites and is associated with nulliparity, higher maternal age, and several nonclinical factors.
Asunto(s)
Analgesia Epidural/estadística & datos numéricos , Analgesia Obstétrica/estadística & datos numéricos , Anestesia Epidural/estadística & datos numéricos , Anestesia Obstétrica/estadística & datos numéricos , Trabajo de Parto , Etnicidad , Medicina Familiar y Comunitaria , Femenino , Humanos , Seguro de Salud , Modelos Logísticos , Obstetricia , Oportunidad Relativa , Pautas de la Práctica en Medicina , Embarazo , Estudios Retrospectivos , Factores SocioeconómicosRESUMEN
Diagnosis of myofascial pain syndrome may become less challenging as clinical criteria become better defined. The mechanisms are not well known, and the syndrome occurs in a wide variety of settings. Trigger points with referred pain are the most common feature. Treatment consists of physical modalities (spray-and-stretch techniques and trigger point block) combined with a program of graded muscle stretching and strengthening. Early, aggressive treatment yields an improved prognosis.