Variations in Resource Utilization Among Medical Specialties and Systems of Care

Differences between internists and family practitioners in the diagnosis and management of the same patient with coronary heart disease

It has been suggested that internists and family practitioners have somewhat different "disease" perspectives, which may be generated by use of different explanatory models during medical training (pathophysiological vs. biopsychosocial, respectively). This article explores differences between internists and family practitioners in their suggested diagnoses, level of diagnostic certainty, test and prescription ordering, when encountering exactly the same "patient" with coronary heart disease (CHD). Internists were more certain of a CHD diagnosis than family practitioners and were more likely to act on this diagnosis. Family practitioners were more likely to diagnose (and were more certain of) a mental health condition. While many physicians simultaneously entertain several alternate diagnoses, diagnostic certainty has shown to have an important influence on subsequent clinical actions, such as stress testing and prescription of beta blockers. These results may inform future educational strategies designed to reduce diagnostic uncertainty in the face of life-threatening conditions, such as CHD.

Physician practice variation in the pediatric emergency department and its impact on resource use and quality of care

OBJECTIVE

To evaluate variation in case-mix adjusted resource use among pediatric emergency department (ED) physicians and its correlation with ED length of stay (LOS) and return rates.

METHODS

Resource use patterns at 2 EDs for 36 academic physicians (163,669 patients at ED1) and 45 private physicians (289,199 patients at ED2) from 2003 to 2006 were abstracted for common laboratory tests, imaging studies, intravenous therapy (fluids/antibiotics), LOS and 72-hour return rate for discharged patients, and hospital admissions for all patients. Case-mix adjustment was based on triage acuity, diagnostic category, demographics, and temporal measures.

OUTCOME MEASURES

(1) adjusted overall resource use for ED1 and ED2 physicians and (2) observed-to-expected ratios for ED1 physicians.

RESULTS

Case-mix adjusted hospital admission rates among physicians varied nearly 3-fold (6.3%-18%) for ED1 and 8-fold (2.5%-19.4%) for ED2. Intravenous therapy use varied 2-fold (4.9%-10.4%) at ED1 and 3-fold (3.6%-11.4%) at ED2. Emergency department 2 physicians had an almost 2-fold (10.9%-20.6%) variation in imaging use. Variation in head computed tomography use was 2-fold (1.1%-2.5%) at ED1 and 5-fold (0.9%-4.8%) at ED2. Physicians had longer than expected LOS if they had higher than expected use of laboratory tests (r, 0.41; 95% confidence interval [CI], 0.09-0.65; P < 0.05) and imaging (r, 0.48; 95% CI, 0.17-0.69; P < 0.01). Return rate was not significantly correlated with resource use in any category. Physicians with higher than expected use of laboratory tests had higher than expected use of imaging (r, 0.62; 95% CI, 0.36-0.78; P < 0.001), head computed tomography (r, 0.49; 95% CI, 0.19-0.70; P < 0.01), and intravenous therapy (r, 0.51; 95% CI, 0.20-0.71; P < 0.01).

CONCLUSIONS

Significant variation exists in physician use of common ED resources. Higher resource use was associated with increased LOS but did not reduce return to ED. Practice variation such as this may represent an opportunity to improve health care quality and decrease costs.

Prevalence of cancer visits by physician specialty, 1997-2006

Understanding the prevalence of cancer-related visits by physician specialty may help target educational and quality improvement initiatives. Using the 1997-2006 National Ambulatory Medical Care Survey, adult ambulatory visits (N = 161,278) were classified by cancer diagnosis and patients' characteristics and compared with physician specialty. The prevalence of cancer visits within each specialty varied from 0% to 62%. Aside from hematology/oncology (hem/onc) specialties, nine surgical specialties and four medical specialties had more than 1% cancer visits. Cancer patients with private insurance or Medicaid coverage were less likely to see hem/onc specialists compared to Medicare patients. Whereas hem/onc specialists primarily see cancer patients, general surgeons and primary care physicians provide a large amount of cancer services, particularly to underinsured patients. Thus, when trying to contact cancer patients or their physicians, health administrators, researchers, and practitioners should consider targeting general surgeons and primary care physicians in addition to hem/onc specialists.

Cost implications of organizing nursing home workforce in teams

OBJECTIVE

To estimate the costs associated with formal and self-managed daily practice teams in nursing homes.

DATA SOURCES/STUDY SETTING

Medicaid cost reports for 135 nursing homes in New York State in 2006 and survey data for 6,137 direct care workers.

STUDY DESIGN

A retrospective statistical analysis: We estimated hybrid cost functions that include team penetration variables. Inference was based on robust standard errors.

DATA COLLECTION

Formal and self-managed team penetration (i.e., percent of staff working in a team) were calculated from survey responses. Annual variable costs, beds, case mix-adjusted days, admissions, home care visits, outpatient clinic visits, day care days, wages, and ownership were calculated from the cost reports.

PRINCIPAL FINDINGS

Formal team penetration was significantly associated with costs, while self-managed teams penetration was not. Costs declined with increasing penetration up to 13 percent of formal teams, and increased above this level. Formal teams in nursing homes in the upward sloping range of the curve were more diverse, with a larger number of participating disciplines and more likely to include physicians.

CONCLUSIONS

Organization of workforce in formal teams may offer nursing homes a cost-saving strategy. More research is required to understand the relationship between team composition and costs.

Carotid artery stenting: Impact of practitioner specialty and volume on outcomes and resource utilization

OBJECTIVES

A variety of endovascular specialists perform carotid artery stenting (CAS), but little data exist on outcomes and resource utilization among these specialists. We analyzed differences in outcomes after CAS was performed by radiologists (RAD), cardiologists (CRD), and vascular surgeons (VAS).

METHODS

Secondary data analysis of the 2005-2006 State Inpatient Databases for New Jersey were analyzed. Patients with elective admission to the hospital who had CAS procedure <or=2 days after admission were identified. CAS outcomes were analyzed with respect to practitioner specialty and volume, associated complications, and hospital resource utilization.

RESULTS

We identified 625 CAS cases. CRD performed 378 (60.5%), VAS, 199 (31.8%); and RAD, 48 (7.7%). The overall stroke rate was 2.72% and by specialty was CRD, 3.17%; VAS, 2.01%, and RAD, 2.08% (P = .6880). The overall cardiac complication rate was 2.40% (CRD, 2.12%; VAS, 3.02%; RAD, 2.08%; P = .7899). Renal and pulmonary complications were low (0.64% and 0.32%, respectively). Mean hospital length of stay (LOS) in days was significantly shorter for VAS (1.64 +/- 1.40) compared with RAD (2.83 +/- 5.15; P = .0167) and had the same trend compared with CRD (2.14 +/- 3.37; P = .0649). Intensive care unit (ICU) LOS was shorter for VAS (0.52 +/- 0.97) and CRD (0.30 +/- 0.71) than for RAD (2.12 +/- 4.48; P < .0001). The mean total hospital cost was significantly greater for RAD ($20,987 +/- $26,603) and CRD ($18,182 +/- $16,364) than for VAS ($10,000 +/- $4947; P = .0011 and P < .0001, respectively). ICU cost for RAD ($5963 +/- $14,551) was also more than for VAS ($864 +/- $1514; P < .0001) and CRD ($473 +/- $1561; P < .0001). Medical supply costs were significantly greater for CRD ($8772 +/- $9546) than for VAS ($3354 +/- $2261; P < .0001) and RAD ($4964 +/- $2595; P = .0142). Total hospital cost, LOS, and medical supplies were significantly lower for high-volume practitioners vs low-volume practitioners (P < .0001).

CONCLUSION

Stroke rates after CAS did not vary significantly among practitioner specialties. Hospital resource utilization did vary significantly: Vascular surgeons had the lowest utilization of hospital resources for performing CAS. High practitioner volume was associated with lower hospital resource utilization. Elucidation of factors creating resource utilization disparities among endovascular practitioners may lead to improved patient outcomes and permit significant future cost savings for carotid interventions.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration

CONTEXT

Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P).

METHODS

This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration.

FINDINGS

The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians.

CONCLUSIONS

Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

[Innovative care models for treating depression]

Depressive disorders rank among the widespread diseases, and their relevance for the health care system is steadily increasing. Even though depressive disorders can generally be treated well, there is a further need to improve the care for depressive patients with regard to diagnostics, therapy, and cooperation of care sectors. Innovative and integrative models of care such as case management, disease management programs, and integrated care models are currently being discussed. They are expected to be useful in overcoming boundaries in the current care system and amending the course of disease and of patients' quality of life. Furthermore, changes in utilization of the health system are anticipated, leading to a diminishment of deficient care, undersupply and oversupply, and chronification. However, evidence is lacking to demonstrate the usefulness of these models of care in Germany now.

Older adults and chronic kidney disease decision making by primary care physicians: a scholarly review and research agenda

BACKGROUND

Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.

OBJECTIVE

This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD.

RESULTS

While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD.

CONCLUSIONS

More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.

The Changing Pattern of Hospital Care for Persons Living With HIV

OBJECTIVE

To compare inpatient utilization and costs by persons living with HIV in 2000 with inpatient utilization and costs in 2004.

DATA SOURCES

Data on 91,343 hospital discharge abstracts representing all HIV-related admissions in 6 states (California, Florida, New Jersey, New York, South Carolina, and Washington state) in 2000 and data from 72,829 hospital discharge abstracts representing all HIV-related admissions in the same states in 2004 are used. These data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, and they were combined with data on the number of persons living with HIV that were obtained from the Centers for Disease Control and Prevention and 2 state departments of health.

STUDY DESIGN

This study compares the hospital care received by persons living with HIV in 6 states in calendar year 2000 with the hospital care received by persons living with HIV in calendar year 2004 in the same 6 states. This study also compares population-based measures of hospital utilization (ie, to measure the average utilization of hospital care per person living with HIV in each state) across the 6 states.

RESULTS

This study found that the average age of a hospitalized patient with HIV rose from 41 to 44 years and that the average number of diagnoses rose from 6.0 to 7.4. Moreover, it was found that the average number of admissions per person living with HIV fell 39% and that the percentages of female and black patients with HIV remained the same.

CONCLUSIONS

Hospitalized patients living with HIV are getting older and sicker, although the average number of admissions per person living with HIV continues to fall.

Physician practice size and variations in treatments and outcomes: evidence from Medicare patients with AMI

Little is known about the relationships between physician practice size and patient treatments or outcomes. We examined whether the practice size of attending physicians was related to within-hospital differences in care for Medicare patients with acute myocardial infarction (AMI). We found that patients treated by solo physicians were less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics were taken into account. These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty.

Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements

BACKGROUND

The health care marketplace has changed substantially since the last assessment of demand for internal medicine physicians in 1996.

METHODS

We reviewed internal medicine employment advertisements published in 4 major medical journals between 1996 and 2004. The number of positions, specialty, and other practice characteristics (e.g., location) were collected from each advertisement.

RESULTS

Four thousand two hundred twenty-four advertisements posted 4,992 positions. Of these positions, jobs in the Northeast (31% of positions) or single specialty groups (36.8% of positions) were most common. The relative proportion of advertisements for nephrologists declined (P < .001), while the relative proportions of advertisements for critical care specialists (0.5% in 1996 to 1.7% in 2004, P = .004) and hospitalists (1.0% in 1996 to 12.1% in 2004, P < .001) increased. Advertisements for outpatient-based generalist positions (i.e., Primary Care and Internal Medicine) declined (-2.7% relative annual change, 95% confidence interval [95% CI] -4.1%, -1.2%) between 1996 and 2004, a decrease largely due to a substantial decline in advertisements noted between 1996 and 1998. However, over the entire time period, the combined proportion of advertisements for all generalists (hospitalists and outpatient-based generalists) did not change (0.5% relative annual change, 95% CI -0.8% to 2.0%).

CONCLUSIONS

Since 1996, demand for the majority of medical subspecialties has remained constant while relative demand has decreased for primary care and increased for hospitalists and critical care. Increase in demand for generalist-trained hospitalists appears to have offset falling demand for outpatient generalists.

Physician-attributable differences in intensive care unit costs: a single-center study

RATIONALE

Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs).

OBJECTIVE

To quantify within-ICU, between-physician variation in resource use in a single medical ICU.

METHODS

This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload.

MEASUREMENTS AND MAIN RESULTS

The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists.

CONCLUSIONS

There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.

The effects of specialist supply on populations' health: assessing the evidence

Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Improving the ICU: part 1

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.

Do Increases in the Market Share of Managed Care Influence Quality of Cancer Care in the Fee-For-Service Sector?

BACKGROUND

Increases in the market share of managed care in an area are associated with decreases in expenditures in the fee-for-service sector (i.e., a spillover effect). Given concerns that these decreases in expenditures result from reductions in necessary care, we examined associations between increases in managed care market share and changes in the quality of care delivered to cancer patients in the fee-for-service sector.

METHODS

We studied a population-based sample of fee-for-service Medicare beneficiaries aged 66 years or older who were diagnosed with breast (N = 41,394) or colorectal (N = 48,027) cancer during 1993-1999. We used fixed effects regression analysis of SEER cancer registry and Medicare claims data to assess whether county-level increases in the market share of managed care over time were associated with the quality of cancer care. All statistical tests were two-sided.

RESULTS

Increases in the market share of managed care were not associated with most quality indicators, including receipt of surveillance mammography after diagnosis for patients with breast cancer (P = .83), receipt of radiation after breast-conserving surgery among women who underwent breast-conserving surgery (P = .16), receipt of adjuvant chemotherapy for patients with stage III colorectal cancer (P = .94), or surveillance colonoscopy after treatment for colorectal cancer (P = .39). Increases in the market share of managed care were associated with increased rates of surveillance carcinoembryonic antigen testing for colorectal cancer patients (P = .001).

CONCLUSIONS

Increases in managed care market share had limited or no effect on the quality of care for cancer patients. Concerns that increases in managed care would have large negative spillover effects on the quality of cancer care appear to be unfounded; however, the potential for managed care to stimulate improved quality throughout the medical care system have not yet been realized.

Do neurologists and primary care physicians agree on the extent of specialty involvement of patients referred to neurologists?

OBJECTIVE

Understanding the roles and responsibilities of physicians who manage mutual patients is important for assuring good patient care. Among physicians expressing a preference to involve a neurologist in the care of a patient, we evaluated agreement between neurologists and primary care physicians for the extent of specialty involvement in the evaluation and management of the patient, and the factors influencing those preferences.

DESIGN AND SETTING

A self-administered survey containing 3 clinical scenarios was developed with the assistance of a multispecialty advisory board and mailed to a stratified probability sample of physicians.

PARTICIPANTS

Six hundred and eight family physicians, 624 general internists, and 492 neurologists in 9 U.S. states.

INTERVENTIONS

For each scenario, those respondents who preferred involvement of a specialist were asked about the preferred extent of that involvement: one-time consultation with and without test/medication ordering, consultation and limited follow-up, or taking over ongoing care of the specialty problem as long as it persists.

MAIN RESULTS

Survey response rate was 60%. For all 3 scenarios, neurologists preferred a greater extent of specialty involvement compared to primary care physicians (all P <.05). Other physician and practice characteristic factors, including financial incentives, had lesser or no influence on the extent of specialty involvement preferred.

CONCLUSIONS

The disagreement between primary care physicians and specialists regarding the preferred extent of specialist involvement in the care of patients with neurological conditions should raise serious concerns among health care providers, policy makers, and educators about whether mutual patient care is coordinated and appropriate.

The impact of managed eye care on use of vision services, vision costs, and patient satisfaction

OBJECTIVES

This study was designed to evaluate the impact of introducing a managed vision benefit program on the use and costs of vision services in a managed care setting and also to assess satisfaction with those services after the program was introduced.

METHODS

Utilization and costs were compared for two groups of patients. The comparison group (n = 36,168) included all patients enrolled for 18 months before implementation of the managed eye-care plan. The study group (n = 23,816) included those enrolled for 18 months following its implementation. Medical claims, survey, and administrative data were used to evaluate study outcomes.

RESULTS

The overall use of vision care was similar before and after the introduction of the managed eye-care programs, with 24% of each group receiving at least one vision service during the 18-month period. Nevertheless, an increase in the use of routine eye-care services and a decrease in medical eye-care services were observed following program implementation. The overall cost of providing eye-care services to patients decreased from 1.86 dollars to 1.36 dollars per member per month after the program started, largely owing to a reduction in spending associated with medical eye-care services. More than 90% of patients surveyed were satisfied with their vision care provided by the program.

CONCLUSIONS

Findings suggest that introducing routine and medical managed eye-care programs in a managed care setting allows for a reduction in medical costs while maintaining access to care and patient satisfaction.

Does managed care make a difference? Physicians' length of stay decisions under managed and non-managed care

Background

In this study we examined the influence of type of insurance and the influence of managed care in particular, on the length of stay decisions physicians make and on variation in medical practice.

Methods

We studied lengths of stay for comparable patients who are insured under managed or non-managed care plans. Seven Diagnosis Related Groups were chosen, two medical (COPD and CHF), one surgical (hip replacement) and four obstetrical (hysterectomy with and without complications and Cesarean section with and without complications). The 1999, 2000 and 2001 – data from hospitals in New York State were used and analyzed with multilevel analysis.

Results

Average length of stay does not differ between managed and non-managed care patients. Less variation was found for managed care patients. In both groups, the variation was smaller for DRGs that are easy to standardize than for other DRGs.

Conclusion

Type of insurance does not affect length of stay. An explanation might be that hospitals have a general policy concerning length of stay, independent of the type of insurance of the patient.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Provider payments and patient charges as policy tools for cost-containment: How successful are they in high-income countries?

In this paper, we focus on those policy instruments with monetary incentives that are used to contain public health expenditure in high-income countries. First, a schematic view of the main cost-containment methods and the variables in the health system they intend to influence is presented. Two types of instruments to control the level and growth of public health expenditure are considered: (i) provider payment methods that influence the price and quantity of health care, and (ii) cost-containment measures that influence the behaviour of patients. Belonging to the first type of instruments, we have: fee-for-service, per diem payment, case payment, capitation, salaries and budgets. The second type of instruments consists of patient charges and reference price systems for pharmaceuticals. Secondly, we provide an overview of experience in high-income countries that use or have used these particular instruments. Finally, the paper assesses the overall potential of these instruments in cost-containment policies.

Price elasticity and pharmaceutical selection: the influence of managed care

State Medicaid programs are turning increasingly to managed care to control expenditures, although the types of managed care programs in use have changed dramatically. Little is known about the influence of the shifting Medicaid managed care arena on treatment decisions. This paper investigates factors affecting the selection of treatments for depression by providers participating in either of two Medicaid managed care programs. Of particular interest is the influence of medication price on the choice of treatment, since one vehicle through which managed care organizations can reduce total expenditures is by increasing the price sensitivity of participating providers. We take a new approach by phrasing the problem as a discrete choice, using a nested multinomial logit model for the analyses. Contrary to earlier literature, we find some evidence that physicians in both programs do take price into consideration when selecting among treatment options. HMO providers in particular demonstrate increased price sensitivity in the two most commonly prescribed categories of antidepressants.

Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care

BACKGROUND

The appropriate roles for generalists and cardiologists in the care of patients with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care.

METHODS

We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering.

RESULTS

Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%; P <.001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P <.001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96; 95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42; 95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32; 95% CI, 1.14-4.72) care. Compared with patients who received generalist care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54; 95% CI, 0.34-0.86).

CONCLUSION

Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.

Effects of physician-related factors on adult asthma care, health status, and quality of life

PURPOSE

To study the association of physician characteristics, the characteristics of their practice settings, patient mix, and reported frequency of prescribing asthma medication with patients' health status and health-related quality of life in asthma.

METHODS

We conducted a mail-back survey of physicians (n = 147) that included demographic characteristics, practice and training characteristics, and reported prescribing frequencies for common asthma treatments. We also conducted structured telephone interviews with 317 of their patients, assessing demographic characteristics, health status (as measured by the Short Form-12 [SF-12] physical component score), and asthma-specific quality of life (as measured by the Marks questionnaire).

RESULTS

In adjusted analyses, pulmonary specialists were more likely to report using leukotriene modifiers (odds ratio [OR] = 4.7; 95% confidence interval [CI]: 1.2 to 18) and theophylline (OR = 3.0; 95% CI: 1.0 to 9.0) in adult patients with asthma. Working in a practice of >75% health maintenance organization (HMO)- or preferred provider organization (PPO)-insured patients was associated with a lower likelihood of prescribing leukotriene modifiers (OR = 0.1; 95% CI: 0.01 to 0.5). Adjusting for patient demographic characteristics and steroid dependence, physician prescribing tendencies were not associated with patients' perceived health status or quality of life. Although an HMO- or PPO-predominant practice was associated with better physical health status (mean difference in SF-12 physical component score, 3.1; 95% CI: 0.05 to 6.2; P = 0.05), there was no statistical association with quality of life.

CONCLUSION

The characteristics of physicians, their practices, and the asthma medication prescribing strategies that they adopt are not strongly associated with patients' perceived outcomes.

Impact of Managed Care on Clinical Outcome of Systemic Lupus Erythematosus in Puerto Rico

This study was designed to explore the impact of a managed care system on the morbidity and mortality rates in a systemic lupus erythematosus (SLE) cohort in Puerto Rico. The clinical manifestations and outcome measures of public SLE patients, before and after implementation of the managed care system, were compared with those of SLE patients treated in a private fee-for-service system. Of the cohort of 171 patients, 103 (60%) were treated in the public system and 68 (40%) in the private sector. Except for higher prevalence of hematuria, renal insufficiency, and serositis in the public group, both groups had a similar prevalence of clinical manifestations, Systemic Lupus Erythematosus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage score, and mortality rate before introduction of the managed care system. Six years after implementation of the managed care system, medically indigent patients were more likely to have photosensitivity (90% vs. 75%), malar rash (85% vs. 65%), hematuria (43% vs. 24%), nephrotic syndrome (17% vs. 6%), and end-stage renal disease (8% vs. 0%). They also had a higher mortality rate (10% vs. 2%) and SLICC/ACR damage index score (1.5 vs. 0.8). In summary, SLE patients treated in the public system of Puerto Rico demonstrated higher morbidity and mortality after being treated in a managed care system compared with patients managed in a private fee-for-service system. Different from the fee-for-service system, the managed care system seeks medical care cost reductions that could affect the management and outcome of SLE patients. These differences could also be related to the higher disease severity before implementation of the managed care system and lower socioeconomic status of the public group. Nevertheless, the public managed care system in Puerto Rico requires continuous evaluation to ensure SLE patients better access to specialty and subspecialty healthcare and optimal pharmacologic treatments.

Comorbidity and its change predict survival in incident dialysis patients

BACKGROUND

Few studies have performed a comprehensive comparison of the prognostic importance of comorbidity to that of other case-mix factors influencing incident dialysis patients' survival. Longitudinal change in the comorbid illness burden of incident dialysis patients has not been measured. Comorbidity severity and its change may serve as important prognostic markers of survival, independent of other case-mix factors.

METHODS

The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Cohort Study used the Index of Coexistent Disease (ICED) to assess comorbidity at the initiation of chronic dialysis treatment (1,039 incident patients) and during follow-up (733 patients). Using proportional hazards regression analyses, the relationship to survival of baseline ICED level and change in ICED level was examined.

RESULTS

At the initiation of chronic dialysis treatment, 36% of patients were at ICED level 0 to 1 (least comorbidity severity); 35%, level 2; and 29%, level 3. After multivariable adjustment, baseline ICED level was the strongest predictor of subsequent mortality. Compared with ICED level 0 to 1, relative risks for mortality were 1.9 (95% confidence interval, 1.3 to 2.6) for ICED level 2 and 2.8 (95% confidence interval, 2.0 to 3.9) for ICED level 3. The prevalence and severity of most comorbid conditions increased during follow-up. After controlling for baseline ICED level and other factors, change in ICED level over time was significantly associated with mortality (P = 0.01).

CONCLUSION

Indexing comorbidity when patients begin chronic dialysis therapy and recording the evolution of index scores yields a predictor of mortality risk that is independent of other case-mix factors.

Family practice in the United States: position and prospects

Family practice became the 20th U.S. medical specialty in 1969. It has delivered on its promise to reverse the decline of general practice and care for people with diverse problems in all areas of the country. But many important health care problems remain unsolved, in part because of poor role delineation for family physicians, poor differentiation of family practice from other fields, and insufficient changes in the cultural and political environment. Family practice's problems include confusion about whether it is a reform movement or an incumbent specialty; disagreement about its role in controlling and assuring care; confusion about whether family physicians are generalists or specialists; lack of clarity about family practice as vital for all versus a possible option for some; misunderstanding about the knowledge requirements for family practice; and inadequate business models. Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable.

Clinicians as advocates: an exploratory study of responses to managed care by mental health professionals

Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed that experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that managed care plans retaliate against advocacy behavior appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.

[Is there a place for otorhinolaryngology in primary care? Analysis of different areas]

Otolaryngological disorders do have a high incidence, and prevalence and require specific physical examinations amongst general population. As a result, it is believed that it would be efficient to have otorhinolaryngologists within the primary care system. The main aim of this study was to assess the differences in hospital referrals comparing primary care units with and without ENT specialists. The study was carried out in Osona County (Catalonia, Spain). We studied the referrals to the hospital from two different primary care units, one with otorhinolaryngology services and the other without them. We analysed the morbidity, follow up and demographic variables of first visits in the hospital ENT department referred by these two primary care units. The primary care organisation without ENT specialist tends to refer more patients (3.96 first visits more per 1000 inhabitants a year, CI 95% 2.84-5.09) with ENT problems than the primary care one with ENT specialist. The difference is mainly due to an higher number of referrals that do not require hospital treatment (i.e. acute otitis, patients without an ENT clear diagnosis). In the area with ENT specialist, GP's also tend to refer patients directly to the hospital, hampering the organisation efficiency. The referrral pattern of GPs from the two organisations is quite similar, and they refer a high percentage of patients that do not need ENT hospital care. The study shows that ENT specialists in primary care units refer less patients with ENT disorders that can be successfully diagnosed and treated outside the hospital.

Medicaid managed care prescription use and cost savings

OBJECTIVE

To evaluate the impact of Medicaid managed care (MC) enrollment on prescription use and costs.

DESIGN

Retrospective, cross-sectional analysis of claims submitted over a 6-month period.

SETTING

Ohio Medicaid.

PATIENTS AND OTHER PARTICIPANTS

Stratified, random selection of 2,932 MC and 1,335 fee-for-service (FFS) recipients.

MAIN OUTCOME MEASURES

Dependent variables were the probability of any prescription use and 6-month prescription counts and costs. Independent variables included age, plan enrollment (MC or FFS), county enrollment status (mandatory or voluntary), presence of a chronic comorbidity, and any outpatient medical visit.

RESULTS

After adjusting for comorbidities and outpatient medical visits, plan enrollment effects depended on age. FFS enrollees 8 to 12 and 12 to 18 years old were less likely (adjusted odds ratios 0.56 and 0.58, respectively) to receive a prescription, while enrollees over 30 years of age were 2.98 times more likely to receive a prescription. Among prescription users, level of use and costs were consistent across all ages for MC enrollees. FFS enrollees had 25% to 218% higher levels of prescription use than MC enrollees, depending on age. Prescription costs were 8% lower for FFS enrollees ages 4 to 8 but higher for all enrollees in other age groups (range, 22% to 311% higher).

CONCLUSION

Prescription use and costs were lower for Medicaid MC enrollees than they were for patients in traditional FFS plans. Further research is needed to examine the quality of care for both FFS and MC enrollees.

Location, race, and hospital care for AIDS patients: an analysis of 10 states

This study is the first statewide comparison of hospital utilization and inpatient mortality rates for people with acquired immune deficiency syndrome (AIDS). Data from 120,772 hospital discharge abstracts for all AIDS-related admissions in 10 states (California, Colorado, Florida, Iowa, Kansas, Maryland, New Jersey, New York, Pennsylvania, and South Carolina) in 1996 were combined with data on the number and the racial and ethnic characteristics of all people living with AIDS (PLWAs) in each state. These data were used to derive population-based estimates of the use of hospital services per PLWA and of inpatient mortality rates in each state. Multivariate analyses examined sources of variation in inpatient length of stay and inpatient mortality. The primary finding of this study is that hospital utilization rates and inpatient mortality rates for people with AIDS vary substantially across states and among racial and ethnic groups within states even after adjusting for severity of illness. Blacks and Hispanics had longer hospital stays and were more likely to die in the hospital than whites. State-level policies, such as home and community-based waiver programs and enhanced HIV reimbursement rates, significantly affected hospital use.

A comparison of ambulatory care-sensitive hospital discharge rates for Medicaid HMO enrollees and nonenrollees

With an increasing volume of Medicaid recipient enrollees in managed care, many states are developing tools for monitoring service quality and access of Medicaid recipients. This article explores the use of ambulatory care-sensitive (ACS) hospital discharge rates as a simple, practical indicator tool for monitoring the access of Medicaid health maintenance organization (HMO) enrollees through an empirical application in Massachusetts in 1995. Although unadjusted hospital discharge rates were lower, Medicaid HMO enrollees had higher age-gender-race adjusted total and ACS hospital discharge rates than Medicaid recipients enrolled in a primary care case management program under fee-for-service reimbursement. Higher HMO discharge rates for the specific ACS conditions of asthma and dehydration were suggestive of potential HMO access problems.

Comorbidity assessment using the Index of Coexistent Diseases in a multicenter clinical trial

BACKGROUND

The Hemodialysis (HEMO) Study is a multicenter trial designed to determine whether hemodialysis dose and membrane flux affect survival. Comorbid conditions are also important determinants of survival, and thus, an accurate and reliable method to assess comorbidity was required. Comorbidity was being assessed at baseline and annually in the HEMO Study using the Index of Coexistent Disease (ICED). We describe the instrument, its implementation in the HEMO Study, and the results of comorbidity assessment in the first 1000 randomized patients in the trial.

METHODS

The ICED aggregated the presence and severity of 19 medical conditions and 11 physical impairments within two scales: the Index of Disease Severity (IDS) and the Index of Physical Impairment (IPI). The final ICED score was determined by an algorithm combining the peak scores for the IDS and IPI. The range of the ICED was from 0 to 3, reflecting increasing severity.

RESULTS

Study personnel at 15 clinical centers were trained to update and abstract data from the dialysis medical records. Availability of data, measures of construct validity, and measures of reliability were adequate; 99.8% and 60.6% of patients had comorbid conditions in at least one IDS or IPI category, respectively. The distribution of patients by ICED level was 0 (0.2%), 1 (34.9%), 2 (31.2%), and 3 (33.7%). In multivariable analysis, the following factors were significantly associated with more severe comorbidity: older age, diabetes and other causes of renal disease, a lower level of education, employment status (unemployed and retired), longer duration of dialysis, and lower serum creatinine. There was a significant variation in the severity of comorbidity among clinical centers after adjustment for other factors. The R2 of the model was 25.3%, indicating that a substantial proportion of the variation in the ICED was not explained by these factors.

CONCLUSIONS

We conclude that comorbidity assessment using the ICED is feasible in multicenter clinical trials of dialysis patients. There is a large burden of comorbidity in dialysis patients, which is not well explained by the cause of renal disease, demographic, and socioeconomic factors and common clinical and laboratory measurements. These variables should not be considered substitutes for comorbid conditions in case-mix adjustment. Comorbidity assessment is useful to describe the sample population, to improve the precision of the treatment effect, and to use possibly as an outcome measurement.

Chiropractic and a new taxonomy of primary care activities

OBJECTIVE

To specify the procedural and cognitive content of primary care and to discuss potential chiropractic primary care roles.

DATA COLLECTION

Data were collected through use of two expert panels and a consensus process to create a list of primary care activities. The first panel was an interdisciplinary mix of physicians, mainly allopathic ones; most of the members of the second panel were chiropractors. Each panel rated primary care activities across a number of dimensions, such as importance for good health, frequency in a typical office-based practice, necessity for medical doctor involvement in the activity, competence of the majority of chiropractic physicians, and interest among chiropractors in performing the activity.

RESULTS

There was no real difference between the panels in terms of taxonomy scope or importance of the activities for good health. Many of the activities are performed more frequently in a typical medical office than in a typical chiropractic office. With respect to a set of primary care activities that occur daily in medical offices, chiropractors are able to make diagnoses in 92% of the activities and to make therapeutic contributions in more than 50% of the activities. Medical doctor involvement was perceived as required more frequently by the chiropractic panel than by the interdisciplinary panel. Moreover, chiropractors' interests and self-assessments of competence showed some limits with regard to their assumption of total care for some frequently occurring primary care activities.

CONCLUSIONS

The most important finding of this activity is the overriding sense of agreement between allopathic and chiropractic physicians in terms of the scope of primary care activities, suggesting that there is opportunity for chiropractors and medical doctors to work together on patient care and organizational strategy. However, the levels of self-assessed competence and interest on the part of chiropractors for many frequently occurring primary care activities reveal some important limits for assumption of total primary care.