Office Surgery Safety and the Florida Moratoria

BACKGROUND

Office-based surgery has become an important method of healthcare delivery, but there is controversy about its safety. Since 2000, a series of articles were published in the lay media emphasizing the hazards of office surgery, leading to the Florida Board of Medicine restricting office procedures.

OBJECTIVE

The objective of this study was to determine the nature and scope of deaths resulting from office surgery.

METHODS

We reviewed the data on mandatory reporting by physicians to a central agency of all office surgical incidents that resulted in death, injury, or hospital transfer in the state of Florida from January 2000 to November 2004. E-mail, Internet, and telephone follow up were used to determine physician's board status, office accreditation, and hospital privileges. We reviewed data on medication interactions, anesthesia, and monitoring.

RESULTS

A total of 36 deaths related to office procedures were reported. Only 18 of those were related to surgical procedures that are within the realm of plastic surgery, although surgeons of other specialties did 3 of these. When these 18 were reviewed by type of anesthesia, there were 12 who had general anesthesia, 10 with an anesthesiologist and 2 with a Certified Registered Nurse Anesthetist. Of those 18, 7 died before discharge. Although all 7 of them survived long enough to be transferred to a hospital, we classified them as office deaths. The other 11 died after appropriate discharge. Of the 7 office deaths, one developed bronchospasm during induction by an anesthesiologist. Five were during deep sedation (level III anesthesia) and 4 appeared to be related to excessive sedation and/or inadequate monitoring; the fifth was probably related to illicit drug use and the sixth from a fat embolism. Of the 11 postoperative deaths, 7 were said to be the result of thromboembolism and the others were from unknown causes.

CONCLUSION

Although the total number of office operations during the study period is unknown, the fact that 7 deaths were reported would suggest that the location in which these procedures were done was not as much of a factor as the regulators have suggested. However, better patient screening, sedation management, deep vein thrombosis prophylaxis, and clinical judgment may have prevented some, if not most, of these deaths. The most frequent cause of death after discharge was thromboembolism, and some of these might have been prevented with better prophylaxis. More detailed findings and recommendations are presented.

Epidemiologic patterns of injuries treated in ambulatory care settings

STUDY OBJECTIVE

Epidemiologic studies of injury morbidity have relied primarily on data from emergency departments (EDs) and hospital admissions. We seek to assess the incidences and characteristics of acute injuries treated at EDs and other ambulatory care settings.

METHODS

Using data from the 2002 National Health Care Survey on initial visits for acute injuries to EDs, physician offices, and hospital outpatient departments, we estimated the frequencies and incidence rates of medically attended injury by patient characteristics and care setting.

RESULTS

In the United States in 2002, 76 million nonfatal acute injuries received initial medical attention at EDs (46.2%), physician offices (47.8%), and outpatient departments (6.0%). The overall annual incidence rate of medically attended injury was 26.8 per 100 population (95% confidence interval 24.4 to 29.7). Falls accounted for 16.7% of all medically attended injuries. Injury patients who were black or uninsured were significantly more likely to visit EDs than other care settings for treatment. More than 2.4 million (3.2%) injury patients were admitted to hospitals, 96.6% of them through EDs.

CONCLUSION

Fewer than half of all medically attended acute injuries in the United States receive initial treatment in EDs. Injury severity and characteristics vary among care settings.

Barrierefreiheit von Arztpraxen am Beispiel Essen

BACKGROUND

Constructional barriers often prevent persons who are only partially able, for example those requiring a wheel chair for pre-ambulation, from entering buildings where doctors practise. Even though many international and national resolutions have long been demanding free access to the environment for the partially able, this has not been specially prescribed in Germany. Hence, no one knows anything about outpatient health care facilities in this regard. The present study aimed at analysing accessibility to orthopaedic and neurological practices and surgeries for wheelchair patients.

METHOD

We chose Essen, the sixth largest town in Germany, as an example of an urban area, where orthopaedists and neurologists are frequently accessed by wheelchair patients. We performed on-site investigations of the exterior and interior zones of all orthopaedic and neurological surgery buildings in Essen (each n = 29). Criteria for our descriptive analysis were parking lots for the handicapped, shunting areas, entrances at-grade, steps/stories, banisters, ramps, bells and openers of front, elevator and surgery doors, their opening and width. Following the criteria of the DIN 18 024 standard part 2 ("accessibility") the surgeries were divided into four groups 1) fully accessible; 2) slight barriers; 3) considerable barriers; 4) massive barriers.

RESULTS

None of the 58 investigated surgeries was fully accessible, 21 of the 29 surgeries of each medical specialty had massive barriers, so that wheelchair patients could access these surgeries only with the help of at least two (strong) persons. Six of the 29 orthopaedic and three of the 29 neurological surgeries had slight barriers, whereas two orthopaedic and five neurological surgeries had distinct barriers. Main barriers were steps in the entrance area; front, elevator or surgery doors too narrow (width less than 80 cm), and elevators too small.

DISCUSSION

For wheelchair patients in Germany, free choice of doctors seems to be massively reduced. Since 80 % of orthopaedic and 90 % of neurological surgeries in Essen do not fulfil the quality feature "constructional accessibility", measures that have been taken in the past to help partially able persons to participate in this respective aspect of social life have not been effective. New measures to improve the present situation should be agreed upon by all the institutions involved (politics, local authorities/construction supervision, sickness funds, doctors and associations of sickness fund physicians, and concerned persons). If voluntary measures do not lead to free choice of doctors for wheelchair patients, further legal regulations appear to be mandatory.

Adverse event reporting: lessons learned from 4 years of Florida office data

BACKGROUND

Patient safety regulations and medical error reporting systems have been at the forefront of current health care legislature. In 2000, Florida mandated that all physicians report, to a central collecting agency, all adverse events occurring in an office setting.

PURPOSE

To analyze the scope and incidence of adverse events and deaths resulting from office surgical procedures in Florida from 2000 to 2004.

METHODS

We reviewed all reported adverse incidents (the death of a patient, serious injury, and subsequent hospital transfer) occurring in an office setting from March 1, 2000, through March 1, 2004, from the Florida Agency for Health Care Administration. We determined physician board certification status, hospital privileges, and office accreditation via telephone follow-up and Internet searches.

RESULTS

Of 286 reported office adverse events, 77 occurred in association with an office surgical procedure (19 deaths and 58 hospital transfers). There were seven complications and five deaths associated with the use of intravenous sedation or general anesthesia. There were no adverse events associated with the use of dilute local (tumescent) anesthesia. Liposuction and/or abdominoplasty under general anesthesia or intravenous sedation were the most common surgical procedures associated with a death or complication. Fifty-three percent of offices reporting an adverse incident were accredited by the Joint Commission on Accreditation of Healthcare Organizations, American Association for Accreditation of Ambulatory Surgical Facilities, or American Association for Ambulatory Health Care. Ninety-four percent of the involved physicians were board certified, and 97% had hospital privileges. Forty-two percent of the reported deaths were delayed by several hours to weeks after uneventful discharge or after hospital transfer.

CONCLUSIONS

Requiring physician board certification, physician hospital privileges, or office accreditation is not likely to reduce office adverse events. Restrictions on dilute local (tumescent) anesthesia for liposuction would not reduce adverse events and could increase adverse events if patients are shifted to riskier approaches. State and/or national legislation establishing adverse event reporting systems should be supported and should require the reporting of delayed deaths.

Urologic diseases in America project: trends in resource use for urinary tract infections in women

PURPOSE

Urinary tract infection (UTI) is one of the most common clinical diagnoses in women. In this study we examined epidemiological, economic and health care use trends for UTI in women in the United States.

MATERIALS AND METHODS

The analytical methods used to generate these results have been described previously.

RESULTS

The lifetime risk for UTI in women is high (greater than 50%). Between 1988 and 1994 the overall lifetime prevalence of UTI was estimated to be 53,067/100,000 women. Prescribing patterns demonstrated an increase in the trend toward using fluoroquinolones as first line therapy for UTI, which was associated with increased costs. Composite data revealed that overall expenditures for the treatment of UTIs in women in the United States, excluding spending on outpatient prescriptions, were approximately 2.47 billion dollars in 2000. Diagnosis and treatment of UTI in women is performed in various clinical settings. Inpatient hospitalization for UTI care has generally decreased in younger women but increased in elderly women. There has been a sharp increase in emergency room use by younger women, which may reflect disparities in access to health insurance or primary care providers. Most outpatient care of women with UTIs is performed in physician offices.

CONCLUSIONS

Analysis of health care use and economic data on UTIs in women revealed various interesting trends. These findings will help shape understanding of UTI treatment in relation to other urological disorders in women. The results raise various important future research questions.

Urologic diseases in America project: urinary incontinence in males--demographics and economic burden

PURPOSE

We quantified and describe the demographics and economic burden of male urinary incontinence in the United States of America.

MATERIALS AND METHODS

The analytic methods used to generate these results have been described previously.

RESULTS

Urinary incontinence (UI) affects men of all ages, including 17% of males older than 60 years in the United States, which is an estimated 3.4 million men. There is a strong trend toward an increasing prevalence of UI with increasing age as well as an increase in the prevalence of UI in males with time. Ethnicity has less of a role in prevalence estimates in men than in women. The largest impact of UI in elderly men is in physician office visits, followed by outpatient services and surgeries. Resource use is greatest in the nursing home setting, where more than half of men have UI and require assistance with toileting. The overall economic burden for male UI is estimated at 18.8 billion dollars in direct medical costs in 1998/1999 dollars. Medical expenditures for UI for male Medicare beneficiaries 65 years and older have doubled since 1992. Compared to persons without UI the presence of UI increases the annual expenditures per person yearly from 3,204 dollars to 7,702 dollars.

CONCLUSIONS

The direct and indirect costs of male UI increased throughout the 1990s with annual expenditures per person yearly in men with UI more than double that in men without UI. Given the aging population and staggering impact of UI in nursing home settings, there is a compelling need for further research into effective prevention, treatment and management strategies.

Urologic diseases in america project: trends in resource use for urinary tract infections in men

PURPOSE

Various types of urinary tract infection (UTI) occur in men. In this study we examined health care use trends, including epidemiological and economic factors, for UTI in men in the United States.

MATERIALS AND METHODS

The analytical methods used to generate these results have been described previously.

RESULTS

Approximately 20% of all UTIs occur in men. Between 1988 and 1994 the overall lifetime prevalence of UTI was estimated to be 13,689/100,000 men. Orchitis rates, particularly in older men, are generally higher than those of cystitis or pyelonephritis. Approximately 10% of all inpatient care of men with UTI is for orchitis (12 to 14/100,000 population). Rates of outpatient hospital and physician office care for male UTI have increased in the last decade. Rates for emergency room care for UTI in elderly men (85 to 94 years old) were almost twice those in men younger than 85 years. The adjusted mean health care expenditure for privately insured men with UTI was 5,544 dollars in 1999 compared to 2,715 dollars for men without UTI. Total annual health care expenditures for men and women with UTI were 5,544 dollars and 5,407 dollars, respectively. Mean time lost from work was slightly higher for men. Based on composite data overall medical expenditures for men with UTI in the United States were estimated to be approximately 1.028 billion dollars in 2000.

CONCLUSIONS

Health care use and economic data on UTIs in men revealed a number of intriguing trends. These results raise various important questions for future research.

Lower adverse event and mortality rates in physician offices compared with ambulatory surgery centers: a reappraisal of Florida adverse event data

BACKGROUND

A recent study using Florida adverse event data found an increased risk of mortality in offices as opposed to ambulatory surgical centers. A major limitation of Florida adverse event data is the lack of uniform collection of the number of cases performed.

OBJECTIVE

The objective was to reassess the risk of mortality from physician office and ambulatory surgical center procedures using improved estimates of the numbers of cases performed in these settings.

METHODS

Adverse incident reports from March 2000 to March 2003 were obtained from the Florida Board of Medicine. We used data from the National Ambulatory Medical Care Survey and from the Medicare Current Beneficiary Survey to estimate the number of office procedures in Florida for both the general and the Medicare populations. The number of procedures performed and the number of deaths in ambulatory surgical centers was obtained from the Florida Agency of Healthcare Administration for the years 2000 through 2002. These data were used to calculate adverse event and mortality rates.

RESULTS

For physician offices, the adverse event rates and mortality rates calculated per 100,000 procedures from National Ambulatory Medical Care Survey data were 2.1 and 0.41, respectively, and 0.24 and 0.10 using Medicare Current Beneficiary Survey data. For ambulatory surgical centers, the mean adverse event rate was 4.4 and the mean mortality rate was 0.90.

DISCUSSION

Florida's adverse event data do not show higher adverse event rates in physician offices compared with ambulatory surgical centers. Incident reporting and public availability of incidents are important, as is standardization of reporting rules for both adverse events and number of procedures performed in different settings.

Utilization of hospital and outpatient care for adverse cutaneous reactions to medications

PURPOSE

To quantify hospitalizations, visits to office based physicians, hospital clinics and emergency departments with primary diagnoses of skin conditions that are often due to drug reaction.

METHODS

I analyzed data from the National Hospital Discharge Summary (1997-2001), National Ambulatory Care Survey (1995-2000) and National Hospital Ambulatory Care Survey (1995-2000) to determine the number of hospitalizations and visits with primary diagnoses of skin conditions that are often attributed to drugs. Using statistical methods for surveys, I determined the demographic characteristics of patients with these diagnoses and compared them with patients seeking care for other reasons.

RESULTS

In the United States, there are about 5000 hospitalizations each year with a primary diagnosis of erythema multiform, Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis, of which 35% are specifically ascribed to drugs. Annually, there are more than 100,000 outpatient visits for these diagnoses and about two million visits for immediate hypersensitivity reactions that may be due to drugs. Outpatient visits for drug eruptions and drug allergies that include a skin component exceed 500,000 annually.

CONCLUSIONS

Skin conditions often attributed to drugs are frequent reasons for hospitalization and physician visits. Optimal care of the individual patients with these conditions requires careful attention to drugs as a possible cause.

Patient Injuries from Surgical Procedures Performed in Medical Offices: Three Years of Florida Data

BACKGROUND

Many state medical boards and legislatures are in the process of developing regulations that restrict procedures in the office setting with the intention of enhancing patient safety. The highest quality data in existence on office procedure adverse incidents have been collected by the state of Florida.

OBJECTIVE

The objective was to determine and analyze the nature of surgical incidents in office-based settings using 3 years of Florida data from March 2000 to March 2003.

METHODS

An incidence study with prospective data collection was performed. Individual reports that resulted in death or a hospital transfer were further investigated by determining the reporting physician's board certification status, hospital privilege status (excluding procedure specific operating room privileges), and office accreditation status.

RESULTS

In 3 years there were 13 procedure-related deaths and 43 procedure-related complications that resulted in a hospital transfer. Seven of the 13 deaths involved elective cosmetic procedures, 5 of which were performed under general anesthesia and 2 of which were performed with intravenous sedation anesthesia. Forty-two percent of the offices reporting deaths and 50% of the offices reporting procedural incidents that resulted in a hospital transfer were accredited by an independent accreditation agency. Ninety-six percent of physicians reporting surgical incidents were board-certified, and all had hospital privileges.

CONCLUSIONS

Restrictions on office procedures for medically necessary procedures, such as requiring office accreditation, board certification, and hospital privileges, would have little effect on overall safety of surgical procedures. These data also show that the greatest danger to patients lies not with surgical procedures in office-based settings per se, but with cosmetic procedures that are performed in office-based settings, particularly when under general anesthesia. Our conclusions are dramatically different from those of a recent study, which claimed a 12-fold increased risk of death for procedures in the office setting.

Variation in participation in health care settings associated with race and ethnicity

OBJECTIVE

To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care.

DESIGN

1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting.

SETTING

Physicians' offices, outpatient clinics, hospital emergency departments, hospitals, and people's homes.

MAIN MEASUREMENT

Number of people per 1,000 per month who had at least one contact in a health care setting.

RESULTS

Fewer blacks and Hispanics than whites received care in physicians' offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians' offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home.

CONCLUSIONS

Fewer blacks and Hispanics than whites received health care in physicians' offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.

Diagnostik und Therapie des Restless-Legs-Syndroms in der Arztpraxis

BACKGROUND

Restless legs syndrome (RLS) is a movement and sleep disorder with leg dysesthesias with a high prevalence (9-18% in Austria).

AIM OF THE STUDY

Determination of frequency, diagnosis and therapy of RLS in general practitioner and specialist offices.

METHODS

Telephone survey of a random sample of 120 general practitioners, 100 neurologists and 80 specialists in internal medicine.

RESULTS

69% of the whole sample of doctors reported seeing 1 to 10 RLS patients, but in proportion to the prevalence of these two conditions fewer cases of RLS than of Parkinson's disease are treated. In all three groups of doctors, 84% consider the 4 key symptoms (urge to move the legs accompanied or caused by dysesthesia; worsening of symptoms at rest or inactivity; relief by activity; worsening of symptoms in the evening/at night) the most important diagnostic criteria for RLS, followed by a complaint of disturbed sleep (75%), daytime tiredness (43%) and dopaminergic responsiveness in a therapeutic trial (29%). 83% of general practitioners and 86% of medical specialists refer their RLS patients to a neurologist, 19% to a polysomnographic examination. 75% of doctors decide for pharmacological treatment of RLS, 18% for psychotherapy, 15% for household remedies. 54% of all doctors (70% of the neurologists, 68% of the GPs, 48% of the medical specialists) prescribe dopamine agonists. L-Dopa is used by 49% (61% of the neurologists, 42% of the GPs, 44% of the medical specialists). 17% prescribe GABAergic drugs, 6% opiates. 51% would be highly interested in obtaining a drug specifically registered for the treatment of RLS.

CONCLUSION

RLS is not as well known as Parkinson's disease. Thus providing doctors with relevant information and further education programs on this subject seems desirable. In Austrian doctors' offices the diagnosis of RLS is usually obtained clinically on the basis of the 4 key symptoms. Patients suffering from insomnia of multifactorial pathogenesis should be referred to an outpatient clinic for sleep disorders with an associated sleep laboratory. Especially neurologists and GPs consider dopamine agonists the treatment of first choice, closely followed by L-Dopa.

Acute healthcare utilization by children after motor vehicle crashes

This study, describing the overall patterns of acute healthcare resource utilization by child crash victims (age 15 years and younger), was conducted between 28 July 1999 and 30 November 2000 as part of an on-going large-scale, child-specific crash surveillance system, Partners for Child Passenger Safety: insurance claims from 15 states and the District of Columbia function as the source of subjects, with telephone survey and on-site crash investigations serving as the primary sources of data. A probability sample of 4862 eligible crashes with 7368 child occupants formed the study sample. Our results suggest that for every 1000 children involved in crashes, 3 are hospitalized; 108 are treated and released from an emergency department (ED); 48 are evaluated in a physician's office, urgent care center, or other facility; and 841 receive no care at all. Comprehensive surveillance systems for motor vehicle crashes must capture children treated in physicians' offices, emergency departments, and other healthcare facilities in order to provide accurate estimates of the impact on the health care system related to motor vehicle trauma.

Changing medical doctor productivity and its affecting factors in rural China

Using the data collected from the health facility-based survey, part of the national health service survey conducted in 1993 and 1998, this paper tries to examine changes in labour productivity among the county-level hospitals and township health centres in rural China, and to analyse factors affecting the changes. The results presented in the paper show that the average number of outpatient visits per doctor per day and the average number of inpatient days per doctor per day declined significantly over the period from 1986 to 1997. The main factors resulting in the reduction of productivity are associated with the increase of inappropriate staff recruitment in these health facilities, the significant decline of rural population covered by health insurance, particularly rural cooperative medical schemes (CMS), and the rapid rise of health care costs. The latter two factors also have brought about a reduction in the use of these health facilities by the rural population. The paper suggests that the government should tighten up the entrance of health and non-health staff into the rural health sector and develop effective measures aimed to avoid providing pervasive financial incentives to the over-provision of services and over-use of drugs. In addition, other measures that help to increase the demand for health services, such as the establishment of rural health insurance, should be considered seriously.

Hygiene in der Arztpraxis

Nosokomiale Infektionen werden in der Regel als Problem für Spitäler betrachtet. Die ambulante medizinische Versorgung ist aber sowohl für Patienten als auch für Medizinalpersonen ebenfalls nicht ohne Risiko. Fälle iatrogener Infektionen nach invasiven Maßnahmen wie zum Beispiel nach intramuskulären Injektionen werden wiederholt beobachtet und haben auch schon zu Anklagen gegen die involvierten Ärzte wegen vermeintlichen Kunstfehlern geführt. Solche Ereignisse machen deutlich, dass auch Ärzte, die eine eigene Praxis führen, ein Konzept zur Prävention nosokomialer Infektionen in ihrer Praxis benötigen. Dieses Konzept sollte sowohl den Schutz der Patienten als auch des Personals zum Ziel haben und auf die jeweiligen Bedürfnisse der Praxis zugeschnitten sein. Nach Anwendung eines solchen Konzeptes wird es möglich sein, alle Patienten – den Routinepatienten, den Routinepatienten während eines invasiven Eingriffes, den mit einem resistenten Mikroorganismus kolonisierten Patienten, sowie auch den Patienten mit einer Infektionskrankheit – unter Bedingungen zu behandeln, welche das Risiko einer nosokomialen Infektion bei Patienten und Personal möglichst niedrig halten. Die wichtigsten Elemente eines solchen Konzeptes sind schriftliche Richtlinien zur Desinfektion, Sterilisation und zum Personalschutz. Je nach Art der Praxis müssen diese Richtlinien durch weitere ergänzt werden, welche beispielsweise in einer gastroenterologischen Praxis die Aufbereitung von Endoskopen regeln.

The primary care delivery system in New York's low-income communities: private physicians and institutional providers in nine neighborhoods

Despite a recent policy emphasis on managed care as the preferred method of financing and delivering care to Medicaid beneficiaries and other indigent populations, there is little information on the availability or the characteristics of primary care providers in low-income neighborhoods. Data from two independent surveys of primary care were analyzed. A 1998 street canvass of each of nine neighborhoods identified 367 primary care offices and 567 private-practice primary care physicians. Survey data on primary care were collected from a total of 280 ambulatory care sites across the city in 1997 and 1999. Information on services, hours, and other data on primary care offered at sites in these nine neighborhoods was compiled to develop a profile of the primary care delivery system. There are relatively few private practice physicians providing primary care in these neighborhoods. While there are considerably more primary care physicians at the ambulatory care sites, there is a wide variation in supply across neighborhoods, driven largely by the presence of sizeable safety-net facilities in several of the neighborhoods. Several indicators of access to primary care across these neighborhoods show similar neighborhood variations. Without primary care availability, managed care's promise of greater access to quality care for low-income populations may fall short.

Negotiating an innovative uniform infusion therapy fee: a managed care case study

The medical director of this health plan established an innovative uniform infusion therapy fee whereby the plan pays a uniform infusion fee across all sites of care and contracts separately for delivery of the drug itself. The concept works successfully on three levels: (1) for plan members; (2) for plan providers; and (3) for the plan itself. This case study sets forth the conceptual and operational decisionmaking sequences involved. Establishing the innovative process required two primary elements: (1) coordinated decision making within all departments that were affected by the model; and (2) a champion to carry the project to a successful conclusion.

A snapshot of tobacco-related messages relayed in pediatric offices in Delaware

OBJECTIVE

Much research exists demonstrating that pediatricians should counsel patients and families about tobacco. However, few data are available about tobacco-related messages relayed in pediatric offices. Since an anti-tobacco office environment can be a strong component of an active tobacco prevention program, we evaluated pediatric offices in Delaware to characterize tobacco-related messages.

METHODS

A convenience sample of 32 of 63 (51%) pediatric offices in Delaware was directly evaluated for the presence of tobacco-related messages. Fifty-five of 63 (87%) pediatric practices in Delaware were contacted by telephone to inquire about the presence of a tobacco coordinator.

RESULTS

The 32 practices represented 71 physicians, were located in all three counties throughout the state, and were urban and non-urban in setting. The same investigator evaluated practices in a single site visit. All were located in smoke-free buildings. At one office, people were seen smoking outside; however, the presence of discarded cigarettes was much more common. Thirteen practices (41%) employed smokers, most of whom smoked outside during work hours. Twenty-one of 28 practices (75%) had waiting room magazines containing tobacco advertisements. Fifteen practices (47%) offered anti-tobacco literature while six practices (19%) displayed visual media, none exclusively addressing tobacco. Nine practices (28%) use chart flags to identify smokers. None of 55 pediatric practices in Delaware contacted by telephone identified an office tobacco prevention coordinator.

CONCLUSIONS

Our data indicate that, in Delaware, the pediatric offices we visited overall convey a limited message about tobacco and could strengthen tobacco prevention strategies. Research measuring the impact of office-based anti-tobacco messages is needed. If these messages are effective in preventing tobacco use, practitioners can supplement active counseling with indirect interventions that require minimal maintenance once established and that place no additional demands on their time.

Patient Satisfaction for Homeless Women

BACKGROUND

Patient satisfaction is a key quality of care indicator for which little is known for the homeless women population. We hypothesized that homeless women who last visited homeless-focused healthcare sites (shelter/outreach clinics and mobile vans) will have higher satisfaction ratings than homeless women who last visited county/government clinics. This association was also tested using the Gelberg-Andersen Behavioral Model for Vulnerable Populations.

METHODS

Data were gathered on 974 homeless women aged 15-44 in a probability cluster sample of 60 shelters and 18 meal programs in Los Angeles County. The homeless women participated in 45-minute interviews.

RESULTS

Our hypothesis was partially supported, as shelter and outreach clinics were positively and significantly associated with greater quality satisfaction (beta = 10.2, p < 0.001). Healthcare at private doctors' offices was also associated with quality, access, and appointment satisfaction when compared with care received at county/government clinics (beta = 15.9, p < 0.001; beta = 8.6, p < 0.05; beta = 16.3, p < 0.01).

CONCLUSIONS

Policymakers should encourage healthcare sites that serve homeless women to improve their care by learning from shelter/outreach clinics and private doctors.

Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers

HYPOTHESIS

This study compared outcomes to determine whether patient safety is similar in Florida ambulatory surgery centers and offices.

DATA SOURCES

All adverse incident reports to the Florida Board of Medicine for procedure dates April 1, 2000, to April 1, 2002 were reviewed. The numbers of office procedures performed during a 4-month period were used to estimate the total number of procedures. Ambulatory surgery death summaries, adverse incident data, and volumes of procedures for 2000 were procured from the Florida Agency for Health Care Administration.

STUDY SELECTION/DATA EXTRACTION

Adverse incident reports were reviewed by multiple parties; only reports that involved an office surgical procedure and resulted in injury or death were included in the outcomes calculation. Reports were extracted independently by multiple reviewers.

DATA SYNTHESIS

Adverse incidents occurred at a rate of 66 and 5.3 per 100,00 procedures in offices and ambulatory surgery centers, respectively. The death rate per 100,000 procedures performed was 9.2 in offices and 0.78 in ambulatory surgery centers. The relative risks for injuries and deaths for office procedures vs ambulatory surgery centers were 12.4 (95% confidence interval, 9.5-16.2) and 11.8 (95% confidence interval, 5.8-24.1), respectively.

CONCLUSIONS

In this review of surgical procedures performed in offices and ambulatory surgery centers in Florida during a recent 2-year period, there was an approximately 10-fold increased risk of adverse incidents and death in the office setting. If all office procedures had been performed in ambulatory surgery centers, approximately 43 injuries and 6 deaths per year could have been prevented.

Health care utilization among older adults with arthritis

OBJECTIVE

To evaluate the effect of arthritis on subsequent 2-year use of health care services and out-of-pocket costs among older adults and determine if comorbidities or economic resources mitigate that effect.

METHODS

Data were analyzed from 6230 participants interviewed in 1993 and 1995 in the Asset and Health Dynamic Survey Among the Oldest Old (AHEAD), a national probability sample of community-dwelling adults. Baseline arthritis status was ascertained from the report of an arthritis-related physician's visit or a joint replacement not associated with a hip fracture. The effect of baseline arthritis on the odds of subsequent 2-year health care utilization and high out-of-pocket expenses were estimated from multiple logistic regression controlling for demographic factors, comorbidity, and economic resources.

RESULTS

Older adults with arthritis are significantly more likely to have a physician visit (odds ratio [OR] 3.0), hospital admission (OR 1.6), outpatient surgery (OR 1.3), receive home health care (OR 1.6), and have out-of-pocket cost >5000 US dollars (OR 1.6) compared with contemporaries having similar demographics (age, sex, racial/ethnic group, marital status), comorbid conditions, and economic resources (education, income, wealth, health insurance), but not reporting arthritis.

CONCLUSIONS

Older adults with symptomatic arthritis reported greater medical utilization and cost compared with people not reporting arthritis. These disparities persisted after accounting for differences in demographics, comorbidities, and economic factors. These findings document greater economic burdens on a personal and societal level among people with arthritis. As individuals, older adults with arthritis spend more out-of-pocket dollars for health care than their contemporaries without arthritis. On a societal level, these findings of greater health care utilization among people with arthritis point to increasing future demands on the US health care system due to demographic increases in the numbers of older adults with arthritis and support policies aimed at improving arthritis prevention and treatment as well as reducing the economic disparities between those with and without arthritis.

Needle sticks and adverse outcomes in office-based allergy practices

BACKGROUND

In 1984 the first case of needle stick transmitted human immunodeficiency virus was reported. In 1986 Occupational Safety and Health Administration was petitioned by various unions representing health care employees to develop a standard which protects employees from occupational exposure to blood-borne diseases. Congress passed the Needle Stick Safety and Prevention Act. This specifies that "safer medical devices, such as sharps with engineered sharps injury protections and needle-less systems" constitute an effective engineering control, and must be used where feasible. This has been mandated in California as part of the labor code. Blood-borne pathogens of concern in needle stick injuries are human immunodeficiency virus, hepatitis virus B, and hepatitis virus C.

OBJECTIVE

The objective of this study was to determine the incidence of accidental needlesticks (ANSs) and disease transmission in the allergy setting.

METHODS

A retrospective survey of most California allergy practices and a few large multi-physician allergy practices. We received and used 121 of 400 surveys.

RESULTS

Analysis of the survey data showed an overall incidence of 45 ANSs with 7.026 million 26-/27-gauge needles reported. There was zero rate of disease transmission; 6.41 ANSs per million compares favorably with an estimated 267 ANSs per million in the general medical setting.

CONCLUSIONS

The rate of ANSs in the allergist's office is 2% that of general medical ANSs. The current "safety" needles have no proven effectiveness. There is no reported disease transmission in the allergist's office setting using existent methods. This solution needs further study before there is generalized implementation of the engineering devices of no proven effectiveness that may in fact increase ANSs.

Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997

OBJECTIVE

To describe ambulatory medical care utilization, defined to exclude injury-related visits, for persons with arthritis and other rheumatic conditions.

METHODS

National estimates, rates, and other characteristics of ambulatory care visits were calculated from a national sample of patient visits to physician offices and acute care hospital outpatient and emergency departments.

RESULTS

An estimated 36.5 million ambulatory care visits were related to arthritis and other rheumatic conditions. Visit rates increased with age and, overall, were twice as high among women as men. Rates of visits by race varied by ambulatory care setting. Soft tissue disorders (9.3 million), osteoarthritis (7.1 million), nonspecific joint pain/effusion (7.0 million), and rheumatoid arthritis (3.9 million) were the most common diagnoses.

CONCLUSIONS

Arthritis and other rheumatic conditions account for about as many ambulatory care visits as cardiovascular disease or essential hypertension. These visits serve as excellent opportunities to counsel patients regarding prevention messages for arthritis.

Relationship of health-related quality of life to health care utilization and mortality among older adults

BACKGROUND AND AIMS

This investigation examined the ability of a four-item Health-Related Quality of Life (HRQOL) scale to predict short-term (30-day) and long-term (1-year) physician visits, hospitalization, and mortality among older adults.

METHODS

Subjects included 84065 individuals aged 65 and older who completed a mail version of the Centers for Diseases Control's Behavioral Risk Factor Surveillance System (BRFSS) Core HRQOL Module. HRQOL dimensions represented by the module include global self-rated general health, recent physical health, recent mental health, and recent activity limitation.

RESULTS

In analysis of covariance models controlling for demographic factors and comorbidity, the number of physician visits within 30 days and 1 year differed significantly across categories of each HRQOL item. In Cox regression models controlling for the same covariates, all four HRQOL questions were significant predictors of 30-day and 1-year hospitalization and mortality.

CONCLUSIONS

These results signify that all four dimensions of HRQOL represented by the BRFSS Core HRQOL Module are important predictors of both short-term and long-term adverse health events among older adults. This brief scale may be particularly useful for assessing the health of older adults in clinical settings and large-scale epidemiological studies.

The safety of liposuction: results of a national survey

BACKGROUND

Liposuction procedures are increasing in frequency and may be performed in hospitals, ambulatory surgery centers, or physician offices. Deaths associated with liposuction and previous surveys of liposuction safety have raised concern about the safety of office-based surgery.

OBJECTIVE

To determine the safety of office-based, tumescent liposuction among dermatologic surgeons.

METHODS

A survey mailed out to dermatologic surgeons in August 2001 requested retrospective information regarding the number of patients undergoing liposuction, the setting in which the procedures were performed, and the complications that occurred during the 7-year period from 1994 to 2000. A detailed complication record was requested for each serious adverse event or death reported. Surveys were mailed to 517 worldwide members of the American Society for Dermatologic Surgery (ASDS) listed as performing liposuction; 505 had adequate contact information. The main outcome mesure was the rate of serious adverse events (SAEs) or deaths per 1000 liposuction procedures for each service setting and for each level of conscious sedation.

RESULTS

The overall response rate was 89% (450/505), and of these, 78% (349/450) perform liposuction. A total of 267 dermatologic surgeons completed the survey; 261 provided data on 66,570 liposuction procedures. No deaths were reported. The overall serious adverse event rate was 0.68 per 1000 cases. The SAE rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. SAE rates were also higher for tumescent liposuction combined with intravenous or intramuscular sedation than combined with oral or no sedation.

CONCLUSION

Office-based tumescent liposuction performed by dermatologic surgeons is safe, with a lower complication rate than hospital-based procedures. Future legislation should recognize the proven safety of this procedure as performed by dermatologic surgeons in their offices.

Office surgical incidents: 19 months of Florida data

BACKGROUND

In 1999-2000 a series of sensational articles were published in the lay media emphasizing the hazards of office surgery. Since then 31 state medical boards or legislatures have, or are in the process of drafting regulations restricting office procedures.

OBJECTIVE

To determine the nature, incidence and scope of injuries and deaths resulting from office procedures.

METHODS

Mandatory reporting by physicians to a neutral central agency of all office surgical incidents that resulted in death, serious injury, or transfer to a hospital in the State of Florida from February 2000 to September 2001. Telephone and Internet follow up to determine reporting physician board status, hospital privilege status, and office accreditation status.

RESULTS

In 19 months there were 43 procedure related-complications and eight deaths. Liposuction under general anesthesia was the single most common cause of incidents and deaths. There were no injuries or deaths reported with liposuction with tumescent anesthesia. 50% of offices reporting incidents or deaths were accredited by an independent accrediting agency. There were no incidents or deaths reported due to the anesthesia when using conscious sedation anesthesia, or intramuscular sedation or analgesia 98% of physicians reporting incidents or deaths had hospital privileges and were board certified. Anesthesiologists or nurse anesthetists provided all general anesthesia, and deep sedation. There were no physicians performing procedures outside their scope of specialty training.

CONCLUSION

Liposuction under general anesthesia deserves closer scrutiny. Office accreditation is not associated with fewer patient injuries and deaths. Restrictions on tumescent liposuction, conscious sedation and intramuscular sedation and analgesia would not yield any saved lives or fewer injuries since these modes of anesthesia resulted in no injuries or deaths. Board certification and hospital privilege requirements for office practice would have very little effect since the vast majority of reporting physicians already had these credentials. These data do not show an emergent hazard to patients from office surgery This data strongly contradicts the lay media portrayal of the dangers of office procedures. Mandatory reporting of office incidents should be strongly supported, and this data should be available for analysis after protecting patient confidentiality.

National Ambulatory Medical Care Survey: 2000 summary

OBJECTIVE

This report describes ambulatory care visits made to physician offices within the United States. Statistics are presented on selected characteristics of the physician's practice, the patient, and the visit. Highlights of trends in physician office visit utilization from 1997 through 2000 are also presented.

METHOD

The data presented in this report were collected from the 2000 National Ambulatory Medical Care Survey (NAMCS). NAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NAMCS is a national probability sample survey of visits to office-based physicians in the United States. Sample data are weighted to produce annual national estimates. Trends are based on NAMCS data from 1997 through 2000.

RESULTS

During 2000, an estimated 823.5 million visits were made to physician offices in the United States, an overall rate of 300.4 visits per 100 persons. Approximately half of the visits were made to the patient's primary care physician. The proportion of office visits where a physician or physician group was the owner of the practice has steadily increased since 1997 (74.3 percent in 1997 versus 88.1 percent in 2000). Of all visits made to these offices in 2000, approximately 57 percent listed private insurance as the primary expected source of payment, and 29 percent were made by patients belonging to a health maintenance organization. There were an estimated 89.9 million injury-related visits during 2000, or 32.8 visits per 100 persons. Blood pressure check was the leading diagnostic screening test (45.3 percent) and males were more likely than females to have no diagnostic or screening services mentioned. The proportion of visits with at least one prescription for cardiovascular-renal drugs, hormones, or metabolic/nutrient drugs has increased since 1997.

An English-language clinic-based literacy program is effective for a multilingual population

OBJECTIVE

To assess the effectiveness of a clinic-based pediatric literacy intervention on a multilingual population.

BACKGROUND

Clinic-based literacy interventions are effective among English- and Spanish-speaking children. No data exist for multilingual populations.

SETTING

Pediatric clinic in an urban county hospital. Design/Methods. Reading practices of 2 cross-sectional groups were assessed by standardized interview before and after the intervention. The intervention consisted of waiting-room volunteers reading to children, literacy counseling, and gift of a children's book at each well-child visit from 6 months to 5 years. Outcomes were assessed separately for primary English-speaking and primary non-English-speaking families.

RESULTS

The baseline (N=85) and postintervention (N=95) groups were similar with respect to child age and sex, parental education, and length of time in the United States. Fourteen languages were represented in total, the most common being English (41%), Somali (28%), Spanish (9%), Vietnamese (7%), Oromo (3%), and Tigrinyan (3%). Compared with baseline, postintervention respondents were more likely to report reading as a favorite activity for the child (10% vs 25%) and parent (18% vs 40%), to read to their child before bed at least weekly (45% vs 71%), and to possess over 10 children's books at home (49% vs 63%). Among English-speaking families (N=30 baseline, N=40 postintervention), weekly bedtime reading increased (63% to 93%), reading as child's favorite activity increased (7% vs 30%), and reading as the parent's favorite activity to do with child increased (33% vs 58%). The proportion of English-speaking families possessing over 10 books at home and those reading with their children at least weekly showed no difference between the baseline and postintervention groups. Among non-English-speaking families (N=55 baseline, N=55 postintervention), weekly bedtime reading increased (36% vs 56%), reading as the parent's favorite activity increased (11% vs 27%), and the number of families to possess >10 children's books in the home increased (31% vs 49%). Reading as child's favorite activity (13% vs 24%) and weekly book sharing (60% vs 76%) showed nonsignificant trends between the non-English-speaking baseline and postintervention groups.

CONCLUSIONS

This clinic-based literacy intervention influences home literacy behavior in this multiethnic setting, in both English-speaking and non-English-speaking families. Although efforts should be made to make such programs more appropriate for linguistic minorities, non-English-speaking families do stand to benefit from English-language-oriented programs. literacy, Reach Out and Read, pediatrics, reading, child development.

Quality of care for uninsured patients with diabetes in a rural area

OBJECTIVE

We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs).

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional medical record review in a convenience sample of eight physician offices and three C/MHC sites in rural North Carolina. Billing systems generated lists of self-pay patients with diabetes. Abstraction of the medical records (n = 142) yielded data on process and intermediate outcome measures of diabetes care, which were derived from the Diabetes Quality Improvement Project.

RESULTS

Medical records of patients in C/MHCs demonstrated higher rates on four of six process measures of quality of care, including measurement of HbA(1c) (98 vs. 75%; P < 0.001), cholesterol (82 vs. 51%; P < 0.001), and urine protein (90 vs. 25%; P < 0.001). Nonsignificant trends in documented eye examinations and the intermediate outcome of blood pressure control were found in medical records of C/MHC patients. No differences were seen in the intermediate outcomes of glucose or lipid control. Notable differences in provider type, time since training, and use of flow sheets were found.

CONCLUSIONS

In our sample, uninsured patients with diabetes in C/MHCs had higher quality of care as suggested by higher rates of processes of care. Outcomes were similar in the two settings and well below targets. Further work is required to replicate these findings and to understand which features of C/MHCs may facilitate quality care for the uninsured and are replicable in other settings.

Frequency of pathogen occurrence and antimicrobial susceptibility among community-acquired respiratory tract infections in the respiratory surveillance program study: microbiology from the medical office practice environment

Continuing problems of antimicrobial resistance have prompted the initiation of several surveillance programs. Few, if any, of these programs focus on community-acquired respiratory tract infections seen in routine office-based practices. The Respiratory Surveillance Program (RESP; 1999-2000) in 674 community-based physician office practices in the United States determined the frequency of potential bacterial pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in patients diagnosed clinically with community-acquired pneumonia, acute exacerbations of chronic bronchitis, and sinusitis throughout all 9 US census/geographic regions. Susceptibility to the penicillins (ampicillin, penicillin), oral cephalosporins, fluoroquinolones (gatifloxacin, levofloxacin, ciprofloxacin), macrolides (erythromycin, azithromycin, clarithromycin), tetracycline, and trimethoprim/sulfamethoxazole was determined by reference methods. Patients were required to have a culturable focus of infection, and specimens were immediately sent to a reference laboratory. Among 22,689 total specimens (610 community-acquired pneumonia, 4,779 acute exacerbation of chronic bronchitis, 16,213 sinusitis, 1,087 other), H influenzae was the most commonly isolated organism from patients with community-acquired pneumonia (38%) and acute exacerbation of chronic bronchitis (35%) in all nine geographic regions. S pneumoniae was isolated in 18% of community-acquired pneumonia cases, 13% of acute exacerbation of chronic bronchitis cases, and 11% of sinusitis cases. M catarrhalis was most commonly isolated from the nasopharynx of patients with sinusitis (29%). High-level resistance to penicillin (2 microg/mL or greater; 16% overall) and the macrolides (32% to 35%) among S pneumoniae varied both with site of infection and with geographic region. The greatest resistance was observed among isolates from the nasopharynx of patients with sinusitis and from patients from the East South Central or South Atlantic regions of the United States. Although the susceptibility of H influenzae and M catarrhalis to the tested antimicrobials did not vary with the type of infection, beta-lactamase-mediated resistance to ampicillin among H influenzae ranged from 15% in New England to 32% in the East South Central region. The fluoroquinolones were highly active against these cultured isolates from community-acquired respiratory tract infection patients, with >99% of all S pneumoniae, H influenzae, and M catarrhalis strains susceptible to gatifloxacin (MIC(90), 0.5 microg/mL) and levofloxacin (MIC(90), 2 microg/mL). The extended-spectrum fluoroquinolones appear well suited for community-acquired respiratory tract infection therapy, including pathogens other than pneumococcus, H influenzae, and M catarrhalis.

What impact on PA education? A snapshot of ambulatory care visits involving PAs

This study uses data from the 1997 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to describe nonfederal physician office, hospital outpatient, and emergency department visits involving physician assistants (PAs). Of an estimated 959 million visits to health care practitioners, 2.55% (an estimated 24,532,000) involved PAs. Diagnoses associated with ambulatory care visits involving PAs included well-infant and well-child examinations and the care of uncomplicated injuries or wounds and respiratory tract infections. On average, 3.1 medications were ordered or provided at a visit with a PA. The problems that PAs address are similar across the 3 ambulatory care settings analyzed, with some expected variation between physician office and emergency department visits. Generally, ambulatory care visits with PAs mirror visits with all health care providers who practice ambulatory care medicine. PA education programs should ensure that students can competently perform the skills needed for typical ambulatory care practice.

Ambulatory surgery outcomes: a survey of office-based delivery

Due to a few well-publicized stories about patient injury and death, office-based ambulatory surgery has recently been thrust upon the forefront of current discussions about clinical outcomes. This has stimulated interest among ambulatory surgery stakeholders, including physicians, patients, and elected officials. An analysis of medical office-based surgical facilities in Florida indicates that office-based surgeons tend to work independently, with limited peer oversight, although as a whole, they professionally subscribe to a high level of ethical standards and offer patients an expected high quality level of clinical expertise. The results did not definitively indicate a relationship between unaccredited medical offices and unacceptable surgical procedures. The paper concludes by offering fifteen medical office standards that can aid in developing office surgery oversight policies.

Risk factors for improper vaccine storage and handling in private provider offices

CONTEXT

Preventing loss of vaccine potency during storage and handling is increasingly important as new, more expensive vaccines are introduced, in at least 1 case requiring a different approach to storage. Little information is available about the extent to which staff in private physicians' offices meet quality assurance needs for vaccines or have the necessary equipment. Although the National Immunization Program at the Centers for Disease Control and Prevention (CDC) in 1997 developed a draft manual to promote reliable vaccine storage and to supplement published information already available from the CDC and the American Academy of Pediatrics, the best ways to improve vaccine storage and handling have not been defined.

OBJECTIVES

To estimate the statewide prevalence of offices with suboptimal storage and handling, to identify the risk factors for suboptimal situations in the offices of private physicians, and to evaluate whether the distribution of a new National Immunization Program draft manual improved storage and handling practices.

DESIGN

Population-based survey, including site visits to a stratified, random sample of consenting private physicians' offices. At least 2 months before the site visits, nearly half (intervention group) of the offices were randomly selected to receive a draft CDC manual entitled, "Guideline for Vaccine Storage and Handling." The remainder was considered the control group. Trained graduate students conducted site visits, all being blinded to whether offices were in the intervention or control groups. Each site visit included measurements of refrigerator and freezer temperatures with digital thermometers (Digi-thermo, Model 15-077-8B, Control Company, Friendswood, TX; specified accuracy +/- 1 degrees C). Their metal-tipped probes were left in the center shelf of cold storage compartments for at least 20 minutes to allow them to stabilize. The type of refrigerator/freezer unit, temperature-monitoring equipment, and records were noted, as were the locations of vaccines in refrigerator and freezer, and the presence of expired vaccines. Other information collected included the following: staff training, use of written guidelines, receipt of vaccine deliveries, management of problems, number of patients, type of office, type of medical specialty, and the professional educational level of the individual designated as vaccine coordinator.

PARTICIPANTS

Two hundred twenty-one private physicians' offices known by the Georgia Immunization Program in 1997 to immunize children routinely with government-provided vaccines.

OUTCOME MEASURES

Estimates (prevalence, 95% confidence interval [CI]) of immunization sites found to have a suboptimally stored vaccine at a single point in time, defined as: vaccine past expiration date, at a temperature of </=1 degrees C or >/=9 degrees C in a refrigerator or >/=-14 degrees C (recommended for varicella vaccine) in freezer, and odds ratios (ORs) for risk factors associated with outcomes. We performed chi(2) analysis and Student's t tests to compare the administrative characteristics and quality assurance practices of offices with optimal vaccine storage with those with suboptimal storage, and to compare the proportion of offices with suboptimal storage practices in the groups that did and did not receive the CDC manual.

RESULTS

Statewide estimates of offices with at least 1 type of suboptimal vaccine storage included: freezer temperatures measuring >/=-14 degrees C = 17% (95% CI: 10.98, 23.06); offices with refrigerator temperatures >/=9 degrees C = 4.5% (95% CI: 1.08, 7.86); offices with expired vaccines = 9% (95% CI: 4.51, 13.37); and offices with at least 1 documented storage problem, 44% (95% CI: 35.79, 51.23). Major risk factors associated with vaccine storage outside recommended temperature ranges were: lack of thermometer in freezer (OR: 7.15; 95% CI: 3.46, 14.60); use of freezer compartment in small cold storage units (OR: 5.46; 95% CI = 2.70, 10.99); lack of thermometer in refrigerator (OR: 3.07; 95% CI: 1.15,8.20); and failure to maintain temperature log of freezer (OR: 2.70; 95% CI: 1.40, 5.23). Offices that adhered to daily temperature monitoring for all vaccine cold storage compartments, compared with those that did not, were 2 to 3 times more likely to assign this task to staff with higher levels of training, have received a recent visit from the state immunization program, and be affiliated with a hospital or have Federally Qualified Health Center status. In addition, sites using >1 refrigerator/freezer for vaccine storage were more likely to have at least 1 cold storage compartment outside recommended temperature ranges. We found no significant differences in the data reported above between the intervention group (received copy of the draft manual) and the control group (did not receive copy of draft manual), even when controlling for the annual number of immunizations given or the type of office. (ABSTRACT TRUNCATED)

Physician perceptions about administration of immunizations outside of physician offices

BACKGROUND

Expanding nonphysician participation in the administration of immunizations has been suggested as a means of increasing immunization rates. However, there is little information about physician interest in collaborating with nonphysicians to provide out-of-office immunizations.

METHODS

All active members of the Iowa Academy of Family Physicians were surveyed by mail. Physicians reported on their collaboration histories, their willingness to collaborate in the future, their concerns with collaboration, and whether they approved of their patients' using nonphysicians for immunizations.

RESULTS

Of 898 eligible physicians, 476 (53%) returned questionnaires that were analyzed. Seventy-five percent (n = 357) of the physicians reported that they had voluntarily collaborated with a person outside their office to provide immunizations. Ninety-five percent (n = 452) of physicians indicated a willingness to collaborate in some form in the future. However, physicians had concerns about (a) being able to be kept informed about immunizations their patients receive outside of their offices, (b) adequate training of the nonphysician to administer immunizations and respond to complications of immunization, and (c) loss of preventive health opportunities if patients ceased coming to physicians for routine immunizations.

CONCLUSION

The majority of family physicians have collaborated to deliver immunizations and indicate support for nonphysician participation. Almost all physicians would consider future collaborative arrangements although they have concerns about record keeping and the safety of out-of-office immunization programs.

Clinical laboratory test menu changes in the Pacific Northwest: an evaluation of the dynamics of change

To characterize changes in on-site test volumes and test menus and to identify the factors influencing these changes, we gathered information from a network of clinical laboratories in the Pacific Northwest in 1996 and again in 1999. The two studies allow for a snapshot of these changes for specific periods and also an evaluation of the dynamics of change in clinical laboratory practices between 1994 and 1999. Throughout this 5-year span, business-related decisions have had the primary influence in determining where testing is performed. The overwhelming factor in deciding to retain certain tests on-site is whether the patient test volume is adequate to be cost-effective. Decisions to add or delete tests also are closely tied to marketplace competition, costs of testing equipment and supplies, and ability to obtain adequate reimbursement. Laboratory regulations have had a decreasing influence on on-site test menus in the network laboratories and particularly in physician office laboratories (POLs). The use of waived tests has increased dramatically, with POLs accounting for the majority of laboratories that added waived tests.

Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians' offices

CONTEXT

The US primary care safety net is composed of a loose network of community health centers, hospital outpatient departments, and physicians' offices. National data on how the mix of patients and services differ across sites are needed.

OBJECTIVE

To develop and contrast national profiles of patient and service mix for primary care.

DESIGN, SETTING, AND PATIENTS

Comparative analyses of 3 national surveys of primary care visits occurring in 1994: for data on physician's office visits, the National Ambulatory Medical Care Survey (NAMCS); for hospital outpatient department data, the National Hospital Ambulatory Medical Care Survey (NHAMCS); and for data on community health centers, the Bureau of Primary Health Care's 1994 Survey of Visits to Community Health Centers. A time trend analysis also was conducted using the 1998 NAMCS and NHAMCS.

MAIN OUTCOME MEASURES

National estimates of primary care visit rates, types of patient presentation, patient case-mix, disposition of patients, and management interventions in 1994, and compared with 1998 data.

RESULTS

The US population made 1.3 primary care visits per person in 1994, which accounted for 43.5% of all ambulatory visits to physicians' offices, community health centers, and hospital outpatient departments. Primary care visits per person were 20% lower for Hispanics and 33% lower for black, non-Hispanic persons compared with white, non-Hispanic persons. Visits to community health centers were more likely to be made by ethnic minorities, patients with Medicaid or no insurance, and rural dwellers than visits made to the other delivery sites. Visits at hospital outpatient departments were made by sicker populations and were characterized by less continuity than the other delivery sites. Controlling for patient mix, visits made to hospital outpatient departments were more commonly associated with imaging studies, minor surgery, and specialty referrals than those made to physicians' offices. In 1998, the US population made an estimated 3. 4 visits per person, 45.6% of which were primary care visits. National estimates of primary care visit rates and patient mix and practice pattern comparisons between hospital outpatient departments and physicians' offices were similar in 1998 and 1994.

CONCLUSIONS

Expanding community health centers will likely improve access to primary care for vulnerable US populations. However, enhancing access to of physicians' offices is also needed to bolster the safety net. The greater service intensity and poorer continuity for primary care visits in hospital outpatient departments that we observed raises concern about the suitability of these clinics as primary care delivery sites. JAMA. 2000;284:2077-2083.

The prevalence of pain complaints in a general population in Israel and its implications for utilization of health services

OBJECTIVE

To determine the prevalence of pain complaints, specifically of chronic widespread pain, in the general population; and to explore the utilization of health services by various pain groups.

METHODS

Cross sectional population survey of 2210 adults in the southern part of Israel, who were classified into 5 pain groups: no pain, transient pain, chronic regional pain, chronic widespread pain, and other. Participants were interviewed about pain patterns and utilization of health services.

RESULTS

Forty-four percent reported pain on the day of the interview. The prevalence of chronic widespread pain in the study population was 9.9%, 14% in women and 3% in men (p<0.01). The prevalence in the Israeli adult population was estimated after adjusting for sex and age as 10.2%. The prevalence of any chronic pain (regional or widespread) increased with age. The prevalence of chronic widespread pain was significantly higher in women than in men across all age groups (p<0.01). Persons with chronic widespread pain reported most frequent visits to their physicians (10.8 visits/year) and most frequent use of antiinflammatory and analgesic drugs. They were more frequently referred to specialists and tended to be hospitalized slightly more often.

CONCLUSION

In the general population in Israel, widespread pain is common, and its prevalence is comparable with reports from USA, UK, and Canada.

Open drops in ophthalmology offices: expiration and contamination

OBJECTIVE

To determine the relationship between eye drop use and contamination rate in ophthalmology offices.

DESIGN

Following permission request, open bottles were examined and the nozzle tip and one drop of content was cultured on solid media.

OUTCOME MEASURES

Drug category, volume, weight compared to full, clean legible label, expiration date; 2 or more bacterial colonies along the inoculation site.

RESULTS

In 18 offices, of 1,485 open bottles (mean 12.2, range 4 to 23 per lane) on average 19.8% (range 0% to 88%) were expired (16.2 of 82.5 bottles per office). The frequency of occurrence (%) and expiration (%E) were 40.3% cycloplegics (19.4%E); 16.4% glaucoma (33.7%E); 10.8% anesthetics (8.8%E); and 4% steroids (8.8%E; or 42.2%E including one outlier). Most likely expired were glaucoma (P < 0.001); small 2-3 ml (P < 0.02), nearly empty (P < 0.05), or dirty (P < 0.001) bottles. Only one (5 ml cyclopentolate, not expired) grew a Micrococcus (0.07%).

CONCLUSIONS

Drops in ophthalmology offices may be expired but are not contaminated.

Does the location of the surgery or the specialty of the physician affect malpractice claims in liposuction?

BACKGROUND

There is increasing national dialogue on who should perform liposuction and where it should be performed.

OBJECTIVE

To determine the effect of the location of liposuction surgery and the specialty of the physician on the incidence of malpractice claims.

METHODS

Physicians Insurance Association of America malpractice data from 1995-1997 was analyzed.

RESULTS

Hospital-based liposuction had more than 3 times the rate of malpractice settlements than office-based liposuction. Dermatologists accounted for less than 1% of malpractice claim settlements in liposuction.

CONCLUSION

Dermatologic liposuction education has emphasized small volume cases performed under local anesthesia using the tumescent technique. The safety of this approach appears to be validated in terms of decreased malpractice settlements.

Changes in usual sources of medical care between 1987 and 1992

This study is a secondary analysis of data from the 1987 and 1992 National Health Interview Surveys. Analyses compared adults who do not have a usual source of care and those who identified usual sources of care in 1987 and 1992. Between these years, the estimated number of adult Americans without a usual source of care rose from 29.7 to 39.4 million. Adults were 0.75 times less likely to identify a physician's office and 1.8 times more likely to identify an outpatient clinic as that source of care in 1992 than they were in 1987. These changes were observed among Americans of all demographic and socioeconomic backgrounds. Increasing numbers of adult Americans without a usual source of care and shifts in care from physicians' offices to outpatient clinics may reflect deteriorating access to care. This may affect quality and costs of medical care, demanding continued surveillance of sources and access to care.

Medication therapy in ambulatory medical care. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1992

OBJECTIVES

This report describes medications provided or prescribed during ambulatory medical care visits in 1992. Total ambulatory care medication therapy combines data from office-based physicians, hospital outpatient departments (OPD's), and hospital emergency departments (ED's). Drug therapy is described along three dimensions: number of drugs provided or prescribed (drug mention), whether a visit had any drugs mentioned (drug visit), and average number of drugs mentioned per 100 visits (drug mention rate). Utilization in ambulatory care settings is compared in terms of patient, drug, provider, and visit characteristics.

METHODS

Annual use of medication therapy was determined using data collected in the 1992 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). NAMCS includes office visits to nonfederal physicians principally engaged in office practice. The target universe of NHAMCS includes visits to ED's and OPD's of non-Federal, short-stay, or general hospitals. Sample data were weighted to produce annual estimates. Drug mentions are defined as the number of drugs mentioned on the patient record from.

RESULTS

An estimated 1.1 billion medications were provided or prescribed at ambulatory care visits in 1992. The setting with the greatest percent of visits with medication therapy was the ED; OPD's had the lowest percent with medications. Patients at the ED were provided more pain relief type drugs. The rate of drug mentions and percent of visits with medications were significantly higher in OPD clinics of general medicine and pediatrics compared with other types of OPD clinics. In office-based settings, physicians specializing in cardiovascular diseases were most likely to prescribe medications. Also, cardiovascular-renal type drugs accounted for the largest percent of office-based drug mentions. Visits with illness diagnoses are most likely to receive medication therapy. Trend data comparing 1980 to 1992 office-based mentions showed significant changes on several characteristics: single-ingredient drug status, physician specialty, and patient age.

CONCLUSIONS

The profile of patients using office- and hospital-based ambulatory care settings are quite different as is the case-mix of conditions. These differences play an important role in medications utilized. The aging of the U.S. population from 1980 to 1992 appeared to have significant effects on several drug mention characteristics.

Ambulatory care visits of physician offices, hospital outpatient departments, and emergency departments: United States, 1995

OBJECTIVES

This report describes ambulatory care visits in the United States across three ambulatory care settings-physician offices, hospital outpatient departments, and hospital emergency departments. Statistics are presented on selected patient and visit characteristics for aggregated ambulatory care visits and for each setting.

METHODS

The data presented in this report were collected by means of the 1995 National Ambulatory Medical Care Survey (NAMCS) and the 1995 National Hospital Ambulatory Medical Care Survey (NHAMCS). These surveys are part of the ambulatory care component of the National Health Care Survey that measures health care utilization across a variety of providers. The NAMCS and NHAMCS are national probability sample surveys of visits to office-based physicians (NAMCS) and visits to the outpatient departments and emergency departments of non-Federal, short-stay and general hospitals (NHAMCS) in the United States. Sample data are weighted to produce annual estimates.

RESULTS

During 1995 an estimated 860.9 million visits were made to physician offices, hospital outpatient departments, and hospital emergency departments in the United States, an overall rate of 3.3 visits per person. Visits to office-based physicians accounted for 81.0 percent of ambulatory care utilization, followed by visits to emergency departments (11.2 percent) and outpatient departments (7.8 percent). Persons 75 years and over had the highest rate of ambulatory care visits. Females had significantly higher rates of visits to physician offices and hospital outpatient departments than males did. Less than two-thirds of ambulatory care visits by black persons were to physician offices. There were an estimated 126.1 million injury-related ambulatory care visits during 1995, or 48.2 visits per 100 persons.

Patient's choice of hospital or office for Medicaid ambulatory care in Alabama

The primary policy option that has been suggested to states over the years for shifting care for Medicaid beneficiaries away from hospital sites and toward office sites has been to raise Medicaid fees to physicians on the assumption that this increases the geographic availability of office-based care, which then naturally attracts Medicaid clients away from hospital sites. This study uses Medicaid claims data from the state of Alabama to assess the role of geographic provider availability relative to other factors in families' decisions to select a hospital or an office for an illness visit to a primary care or to a specialist physician. The authors examined the last ambulatory visit for an illness made by continuously enrolled children under age 8 in the first half of 1991. The authors found that both higher Medicaid office practice density and the presence of larger Medicaid office practices were associated with choice of an office for ambulatory care, whereas the presence of larger Medicaid hospital practices were associated with choice of a hospital for care. Controlling for provider availability, hospital users were less likely to have sought previous care for illness during the year, and were more likely to be rural residents, to have traveled away from their home counties for care, and to be eligible for Medicaid through Aid to Families with Dependent Children, rather than through the program's income expansions. We conclude that increased office-based provider availability must be coupled with improved access tor new, remote, and very low income families if Medicaid clients are to be expected to voluntarily shift their choice if site for ambulatory care.