The American health care system--physicians and the changing medical marketplace

Resection for anal melanoma: Is there an optimal approach?

BACKGROUND

Anal melanoma is a lethal disease, but its rarity makes understanding the behavior and effects of intervention challenging. Local resection and abdominal perineal resection are the proposed treatments for nonmetastatic disease. We hypothesize that there is no difference in overall survival between surgical therapies.

METHODS

The National Cancer Database (2004-2014) was queried for adults with a diagnosis of anal melanoma who underwent curative resection. Patients with metastatic disease were excluded. Patients were divided into 2 groups based on surgical approach (local resection versus abdominal perineal resection). Unadjusted and adjusted analyses were used to examine the association between surgical approach and R0 resection rate, short-term survival, and overall survival.

RESULTS

A total of 570 patients with anal melanoma who underwent resection were identified. The median age was 68 and 59% of patients were female. A total of 383 (67%) underwent local resection. Abdominal perineal resection was associated with higher rates of R0 resection rates (abdominal perineal resection 91% versus local resection 73%; P < .001). Overall 5-year survival for the entire cohort was 20%. There was no significant difference in 5-year overall survival (abdominal perineal resection 21% vs local resection 17%; P = .31). This persisted in a Cox proportional hazard multivariable model (odds ratio 0.84; 95% confidence interval 0.66-1.06; P = .15). Additionally, there was no improvement in overall survival for patients who underwent R0 resection (odds ratio 1.18; 95% confidence interval 0.90-1.56; P = .22).

CONCLUSION

Anal melanoma has a very poor prognosis, with only 1 of 5 patients alive at 5 years. Although local resection was associated with lower rates of R0 resection, there was no discernable difference in overall survival in both unadjusted and adjusted analysis.

Sexually Transmitted Diseases and Managed Care: An Inquiry and Review of Issues Affecting Service Delivery

To understand the potential role of managed care organizations (MCOs) in prevention and control of sexually transmitted diseases (STDs), we conducted a systematic review of articles on STDs and managed care and sought qualitative information from MCOs on STD-related activities. The review focused on prevention, risk assessment, patient education, counseling, screening, and costs of care, but revealed relatively few published articles. Barriers to STD service delivery included competing priorities, lack of time or supporting organizational structures, and differing mandates of health departments and MCOs. Facilitators included collaboration between health departments and MCOs, regulatory and performance incentives, buy-in from key stakeholders, availability of infrastructure to support data collection, and inclusion of chlamydia screening in the Health Employer Data and Information Set to monitor plan performance. Because of the shift of STD service delivery from the public to private sector, incentives need to maximize interest and cooperation of patients, clinicians, and MCOs in STD prevention.

Aligning provider incentives to improve primary healthcare delivery in the United States

BACKGROUND

The United States (US) is reforming primary care delivery systems, including the implementation of 'patient-centered medical homes.' Alignment of provider incentives with desired outcomes will likely be important to the success of these delivery system reforms.

METHODS

This critical review uses a theoretical framework from game-theory models to discuss some of the dominant primary care provider payment models and how they create 'prisoner's dilemmas' that have stalled past reform efforts. It then uses this framework to illustrate, hypothetically, how advantages from different models could be blended together to encourage cooperation and improve the quality of primary care services delivered, thus providing an escape from current prisoner's dilemmas faced by providers.

FINDINGS

Improvements in primary care delivery will largely hinge on blended payment mechanisms that can effectively combine the advantageous elements of fee-for-service, capitation, and incentive payments into a balanced equation that enables providers to escape the perverse financial incentives of current payment mechanisms and overcome collective action problems.

CONCLUSIONS

If balanced appropriately, a blend of guaranteed payment and selective incentives designed to encourage primary care providers to deliver high quality care, efficient and equitable care and to eliminate incentives towards over-servicing could reach outcomes leading to shared benefits for everyone involved.

What ever happened to N-of-1 trials? Insiders' perspectives and a look to the future

CONTEXT

When feasible, randomized, blinded single-patient (n-of-1) trials are uniquely capable of establishing the best treatment in an individual patient. Despite early enthusiasm, by the turn of the twenty-first century, few academic centers were conducting n-of-1 trials on a regular basis.

METHODS

The authors reviewed the literature and conducted in-depth telephone interviews with leaders in the n-of-1 trial movement.

FINDINGS

N-of-1 trials can improve care by increasing therapeutic precision. However, they have not been widely adopted, in part because physicians do not sufficiently value the reduction in uncertainty they yield weighed against the inconvenience they impose. Limited evidence suggests that patients may be receptive to n-of-1 trials once they understand the benefits.

CONCLUSIONS

N-of-1 trials offer a unique opportunity to individualize clinical care and enrich clinical research. While ongoing changes in drug discovery, manufacture, and marketing may ultimately spur pharmaceutical makers and health care payers to support n-of-1 trials, at present the most promising resuscitation strategy is stripping n-of-1 trials to their essentials and marketing them directly to patients. In order to optimize statistical inference from these trials, empirical Bayes methods can be used to combine individual patient data with aggregate data from comparable patients.

Health professionals: how much employee loyalty should we expect in a privatising system?

In recent years UK government policy has been drawing private companies into the operation of the British National Health Service as providers of health care. Hitherto the National Health Service has been the main employer of health care practitioners, but this may change as a result of this development. There is an issue as to whether professional health care practitioners owe the same moral commitment to an employer in the private sector as they would owe to an employer that is part of the state-run National Health Service. I explore some arguments around this issue, focusing on ways of identifying organisational commitment to good health care. With regard to the practitioners commitment to the organisation I consider two strengths of commitment, normative and calculative. I then undertake an analysis of performance, regulatory regimes, and organisational obligations for both sectors. I conclude that while performance and regulatory regimes show little difference between sectors, there is a reasonably compelling argument in favour of a stronger moral commitment to state bodies based on organisational obligations.

Should we have confidence if a physician is accredited? A study of the relative impacts of accreditation and insurance payments on quality of care in the Philippines

It is unclear whether health provider accreditation ensures or promotes quality of care. Using baseline data from the Quality Improvement Demonstration Study (QIDS) in the Philippines we measured the quality of pediatric care provided by private and public doctors working at the district hospital level in the country's central region. We found that national level accreditation by a national insurance program influences quality of care. However, our data also show that insurance payments have a similar, strong impact on quality of care. These results suggest that accreditation alone may not be sufficient to promote high quality of care. Further improvements may be achieved with properly monitored and well-designed payment or incentive schemes.

The corporate transformation of medical specialty care: the exemplary case of neonatology

The key to wealth in health care is the physician, who certifies to third-party payers that health care items and services are necessary for patient care. To compete more effectively for this wealth, physician specialists are organizing their practices into for-profit corporations and employing other physicians. Focusing on neonatology, this article describes the prevailing business model of these for-profit medical groups as controlling employed physicians through restrictive employment contract provisions, e.g., non-compete and mandatory arbitration clauses. With this business model and because of deficiencies in current law, for-profit medical groups eliminate competition from other physician specialists to the detriment of patients and consumers.

From shared care to disease management: key-influencing factors

Background

In order to improve the quality of care of chronically ill patients the traditional boundaries between primary and secondary care are questioned. To demolish these boundaries so-called ‘shared care’ projects have been initiated in which different ways of substitution of care are applied. When these projects end, disease management may offer a solution to expand the achieved co-operation between primary and secondary care.

Objective

Answering the question: What key factors influence the development and implementation of shared care projects from a management perspective and how are they linked?

Theory

The theoretical framework is based on the concept of the learning organisation.

Design

Reference point is a multiple case study that finally becomes a single case study. Data are collected by means of triangulation. The studied cases concern two interrelated Dutch shared care projects for type 2 diabetic patients, that in the end proceed as one disease management project.

Results

In these cases the predominant key-influencing factors appear to be the project management, commitment and local context, respectively. The factor project management directly links the latter two, albeit managing both appear prerequisites to its success. In practice this implies managing the factors' interdependency by the application of change strategies and tactics in a committed and skilful way.

Conclusion

Project management, as the most important and active key factor, is advised to cope with the interrelationships of the influencing factors in a gradually more fundamental way by using strategies and tactics that enable learning processes. Then small-scale shared care projects may change into a disease management network at a large scale, which may yield the future blueprint to proceed.

The effect of message type on physician compliance with disease reporting requirements

OBJECTIVE

Despite the existence of mandatory reporting laws, the underreporting of disease conditions to public health authorities is widespread. This article describes an evaluation of the effects of using different appeals to promote complete and timely reporting to the New York State Occupational Lung Disease Registry (NYS OLDR).

METHODS

Three-hundred sixty-eight physicians who had not reported patients were randomly assigned to receive correspondence emphasizing either the legal obligation to report, the public health benefits of reporting, or both. Chi-square tests were used to determine if the proportion of physicians who subsequently reported patients differed by message group. Chi-square tests and the Kruskall Wallis rank sum test were used to test for differences in the completeness and timeliness of reports received from physicians in the three message groups.

RESULTS

Physicians receiving correspondence describing the legal obligation to report were more likely to report patients than those receiving only the benefit message, while those receiving correspondence describing the public health benefits of reporting submitted more complete reports than those receiving only the obligation message.

CONCLUSIONS

To maximize physician reporting, it is important for public health agencies to emphasize both the legal and public health basis for reporting conditions in correspondence to physicians.

The Premedical Student: Training and Practice Expectations

Occupational burnout is a substantial and growing problem among current medical practitioners. Many practicing physicians lament the encroachment of managed care, infringement of physician autonomy by insurers, decreasing salaries, and decreasing prestige. In light of this unfavorable review of the profession, why are thousands of undergraduates all over the country still on the premedical track? Do these young men and women really know what kind of work environment awaits them at the end of their arduous training program? What motivates them to become physicians? In this case study, we explore the reasons for pursuing a career in medicine among a sample of premedical students at a liberal arts college on the East Coast. College administrators agree that the pre-medical curriculum is one of the most demanding and arduous study programs. What do these pre-medical students see as the ultimate goal? As a result of various volunteer, training, and shadowing experiences in the medical field, many of these students have a realistic perception of the current environment of medical practice. Although they recognize the challenges that await them, they are driven to become doctors by a deep vocational calling to serve. However, not all of the students expressed this calling. Results from this study suggest that eventual career satisfaction may be correlated with baseline career motivations. Students who are becoming doctors to fulfill parents' aspirations, for upward mobility, and/or for prestige and high salaries may be disenchanted once they complete their training program.

Effects of case characteristics on encounter time in a high-stakes standardized patient examination

BACKGROUND

Data from national surveys indicate that patient characteristics could influence the time spent by physicians interviewing and assessing patients. The purposes of this investigation were to gather information regarding the relationship between encounter time and case characteristics for simulated clinical encounters and to provide evidence that the time provided to gather data was adequate. Timing data was extracted from United States Medical Licensing Examination Step 2 Clinical Skills.

METHOD

To test the relative effects of case characteristics on encounter time, an analysis of variance was conducted with encounter time as the dependent variable and case characteristics as the independent variables.

RESULTS

Mean encounter times were computed based on the case characteristics. Station format (history only, history and physical examination, telephone cases) predicted the most variance in encounter time (16%).

CONCLUSIONS

The extent to which examination content is balanced from administration to administration ensures a mix of cases that provides adequate time limits for examinees.

Studying Optimal Healing Environments: Challenges and Proposals

The concept of optimal healing environments has strong face validity, but it is difficult to operationalize the complexity of the human dimensions that comprise the process of healing. Only rigorous evidence can justify the tremendous resources necessary to create optimal healing environments. This article outlines the current challenges of studying optimal healing environments from a clinical epidemiology perspective and discusses the major potential obstacles to include human resources, relationship-centered care competencies, dysfunctional educational and health care systems, research competencies, credibility, dispersed and unfocused current evidence base, and the actual logistical methodological difficulties. The concept of optimal healing environments is a paradigm shift in the delivery and study of medical care, and such an initiative will likely take decades to transition. However, there are feasible activities that can currently be undertaken to expedite this transition, chief of which is establishing a coalition of influential societies to forge an agenda on several fronts. Research activities presently should focus on validating and simplifying measurement tools for healing-related outcomes constructs, expanding the versatility and use of qualitative methods, as well as synthesizing research evidence to help clarify the current evidence base and the future research agenda.

Using the ecology model to describe the impact of asthma on patterns of health care

BACKGROUND

Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care.

METHODS

This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings.

RESULTS

In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas.

CONCLUSION

The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.

Growth Of Single-Specialty Medical Groups

Using site-visit data from the Community Tracking Study, we show that specialists are increasingly forming large single-specialty medical groups, particularly in orthopedics and cardiology, where new technologies have increased the number of diagnostic imaging and surgical services that can be provided in outpatient settings. Specialists are also forming large groups to gain negotiating leverage with health plans; the decline of managed care and the fading of the perception of a specialist surplus has made single- rather than multispecialty groups an attractive means to gain leverage. We explore possible consequences of this shift in physician practice organization and its policy implications.

Development of the breast cancer education and risk assessment program

PURPOSE/OBJECTIVES

To provide a description of the inception and evolution of the Breast Cancer Education and Risk Assessment Program.

DATA SOURCES

Computerized database (e.g., Personal Family History Risk Assessment Model, Knowledge Assessment Tool, risk perception, evaluation form) and author experience.

DATA SYNTHESIS

A total of 749 women participated in the group education and risk-assessment program from March 1999 through March 2002. Advanced practice nurses provided information about calculated risks, corrected misperceptions among participants, and highlighted options available to decrease breast cancer risk. Knowledge scores improved, and, in general, participants were very satisfied with the content and comprehensibility of the educational session.

CONCLUSIONS

Results from the evaluation of the Breast Cancer Education and Risk Assessment Program suggest that group education is a viable and acceptable way to bring new advances in breast cancer prevention to large groups of women. The data sources support the conclusion that women can be effectively taught general breast cancer risk information in a group setting and be placed into specific risk categories to streamline discussion of risk-management options and relevant research studies.

IMPLICATIONS FOR NURSING

Advanced practice nurses are a vital link in the assessment of women at high risk for breast cancer, education, and appropriate referrals for management options and relevant clinical trials.

The acupuncture wars: the professionalizing of American acupuncture--a view from Massachusetts

Since the 1970s acupuncturists in the United States have confronted the dilemma of how to define themselves not only as practitioners in relation to an evolving Americanized version of Chinese medicine but also with respect to definitions of biomedical professional identity, which are currently in flux. The central issue is that of professionalization. This study traces the process of professionalization through the initial reception of the modality; the first steps toward specialized training; and the further steps through professional associations, credentialing, and licensing. This process takes place within the broader social frame of fluctuating definitions of biomedical professionalism. It is within this context that acupuncturists are assessing role definition, status, and compensation. Part of the process also involves the renewed use of the clinical trial and the potential co-opting of acupuncture. The potential for resistance is tied in with alliances with holistic physicians and with acupuncturists' own defense of pluralism.

Variation in the ecology of medical care

BACKGROUND

We wanted to quantify how the location in which medical care is delivered in the United States varies with the sociodemographic characteristics and health care arrangements of the individual person.

METHODS

Data from the 1996 Medical Expenditures Panel Survey (MEPS) were used to estimate the number of persons per 1,000 per month in 1996 who had at least 1 contact with physicians' offices, hospital outpatient departments, or emergency departments, hospitals, or home care. These data were stratified by age, sex, race, ethnicity, household income, education of head of household, residence in or out of metropolitan statistical areas, having health insurance, and having a usual source of care.

RESULTS

Physicians' offices were overwhelmingly the most common site of health care for all subgroups studied. Lacking a usual source of care was the only variable independently associated with a decreased likelihood of care in all 5 settings, and lack of insurance was associated with lower rates of care in all settings but emergency departments. Generally, more complicated patterns emerged for most sociodemographic characteristics. The combination of having a usual source of care and health insurance was especially related to higher rates of care in all settings except the emergency department.

CONCLUSION

Frequency and location of health care delivery varies substantially with sociodemographic characteristics, insurance, and having a usual source of care. Understanding this variation can inform public consideration of policy related to access to care.

Effects of managed care on the length of time that elderly patients spend with physicians during ambulatory visits: National Ambulatory Medical Care Survey

OBJECTIVES

To examine the factors related to the length of time that elderly patients spend with physicians during ambulatory visits and explore specifically the association between managed care and visit duration.

DESIGN

Cross-sectional analysis of the 1998 National Ambulatory Medical Care Survey.

SUBJECTS

Four thousand nine hundred sixty-four office visits to nonfederally employed physicians by elderly patients who had face-to-face contact with physicians and had complete information on variables related to managed care.

MEASURES

Information was collected on the characteristics of patient, physician and clinic, visit duration, reasons for visit, diagnoses, clinical services performed, and medications ordered. Measures of managed care included patient's health maintenance organization (HMO) status, requirement of authorization, capitation, and HMO ownership of the clinic.

RESULTS

The mean visit duration was 19.2 minutes for elderly patients (27.0 minutes for new patients and 18.3 minutes for established patients; P <0.001). In bivariate analyses, the patient's HMO status was not associated with visit duration, but office visits for patients seen at clinics owned by HMOs were 4.2 minutes shorter than those seen in other settings (P <0.001). In multivariate analyses with mixed-effect models, HMO-owned clinic was an independent predictor for shorter visit duration, after adjusting for other patient, physician, and clinic characteristics and type of service provided.

CONCLUSIONS

The effects of managed care on the duration of ambulatory visits by elderly patients appear to be related to the structure of the managed care plan rather than managed care reimbursement per se.

Health care consumption among elderly patients in california: a comprehensive 10-year evaluation of trends in hospitalization rates and charges

PURPOSE

This report examines health care rates, charges, and patterns of consumption from a comprehensive California hospitalization data set covering 1986-1995. An improved understanding of current trends in health care consumption would facilitate the development of future resource allocation models.

DESIGN AND METHODS

We obtained discharge and charge data from all licensed nonfederal hospitals in California between 1986 and 1995 relating to inpatient discharges of individuals aged 55 years and older. We used the direct method of standardization to adjust discharge statistics for differing age and gender case mixes, and we adjusted all charges to 1990 dollars for cost comparisons.

RESULTS

Standardized to the 1990 population, annual discharge rates declined between 1986 and 1992, then leveled off to about 227 per 1,000 between 1993 and 1995. Rates of both discharges and charges for men consistently exceeded those for women, there being about a 5-year lag between female and male rates of discharge. The insurance payer mix shifted between 1986 and 1995, with dramatic declines in private insurance mirrored by increases in managed care.

IMPLICATIONS

Hospital care consumption among the elderly people in California demonstrates a trend of increasing adjusted total charges despite declining hospitalization rates. Overall, individuals aged 55 years and older comprise 18% of the California population and incur 52% of discounted total charges. Private insurance has virtually disappeared, replaced by HMO/PHP/PPO organizations; still, charges to governmental sources (primarily Medicare and Medi-Cal) account for about 78% of total billings. Absolute numbers of Californians aged 55 and older are projected to increase 54% by 2010 and 226% by 2025 compared with 1995, engendering a dramatic increase in the financial burden of health care to this segment of the population.

Managed care and the US health care system a social exchange perspective

Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.

Publicly disclosed information about the quality of health care: response of the US public

Public disclosure of information about the quality of health plans, hospitals, and doctors continues to be controversial. The US experience of the past decade suggests that sophisticated quality measures and reporting systems that disclose information on quality have improved the process and outcomes of care in limited ways in some settings, but these efforts have not led to the "consumer choice" market envisaged. Important reasons for this failure include limited salience of objective measures to consumers, the complexity of the task of interpretation, and insufficient use of quality results by organised purchasers and insurers to inform contracting and pricing decisions. Nevertheless, public disclosure may motivate quality managers and providers to undertake changes that improve the delivery of care. Efforts to measure and report information about quality should remain public, but may be most effective if they are targeted to the needs of institutional and individual providers of care.

Marketplace reforms and primary care career decisions

A dramatic shift in the postgraduate career choices of medical school graduates toward primary care occurred during the mid-1990s. While some attributed this shift to changes in medical school curricula, perceptions stemming from marketplace reforms were probably responsible. For the most part, these perceptions were probably generated through informal communications among medical students and through the media. More recently, additional marketplace influences, such as the consumer backlash toward managed care and unrealized gains in primary care physicians' personal incomes, may have fostered contrasting perceptions among medical students, leading to career choices away from primary care, particularly family practice. The authors offer two recommendations for enhancing the knowledge of medical students concerning workforce supply and career opportunities: an educational seminar in the second or third year of medical school, and a public-private partnership between the Bureau of Health Professions and the Association of American Medical Colleges to create a national database about the shape of the primary care and specialty workforces, accessible through the Internet for educators, students, and policymakers. The authors conclude that appropriate career counseling through these efficient methods could avoid future abrupt swings in specialty choices of medical school graduates and may facilitate a more predictable physician workforce supply.

Medical ethos and social responsibility in clinical medicine

The medical profession will face many challenges in the new millenium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists, and bioethicists may benefit from reflection on the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based, market-driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been removed completely from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities in health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the well-being of the patient and the primacy of the patient-physician relationship against the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to ensure quality health care for the individual patient while effecting societal changes to achieve "health for all."

A descriptive study of managed-care hassles in 26 practices

OBJECTIVES

To explore the nature of managed-care hassles in primary care physicians' offices and to determine the feasibility of practice-based research methods to study the problem.

METHODS

16 internists and 10 family physicians volunteered to collect data about managed-care hassles during or shortly after the office visit for 15 consecutive patients using preprinted data cards. Outcome measures Number of hassles, time required for hassles, and interference with quality of care and doctor-patient relationship.

RESULTS

Physicians adapted easily to using data cards. Before the pilot study, participants estimated a hassle rate of 10% and thought that interference with quality of care and the doctor-patient relationship was infrequent. Of 376 total visits for which the physicians completed data cards, 23% of visits generated 1 or more hassles. On average, a physician who saw 22 patients daily experienced 1 hassle lasting 10 minutes for every 4 to 5 patients. More than 40% of hassles were reported as interfering with quality of care, the doctor-patient relationship, or both.

CONCLUSIONS

The high hassle rate, in addition to the interference of hassles with quality of care and the doctor-patient relationship, suggests the need for further investigation into managed-care hassles using practice-based research methods.

Impact of the physician's participatory style in asthma outcomes and patient satisfaction

OBJECTIVES

To identify factors associated with asthma patients' perceptions of the propensity of pulmonologists to involve them in treatment decision-making, and its association with asthma outcomes.

DESIGN

Cross-sectional observational study performed from June 1995 to December 1997.

SETTING

Pulmonary unit of a university teaching hospital.

PATIENTS

Adult patients with asthma (n = 128).

MEASUREMENTS AND RESULTS

By patient self-report, mean physician's participatory decision-making (PDM) style score was 72 (maximum 100, 95% CI 65, 79). PDM scores were significantly correlated (P < .0001) with the duration of clinic visits (r = .63), patient satisfaction (r = .53), duration of tenure of doctor-patient relationship (r = .37), and formal education (r = .22, P = .023). Significantly higher PDM style scores were reported when visits lasted longer than 20 minutes and when a patient had a >6-month relationship with a particular doctor. PDM scores were also significantly correlated with possession of a written asthma action plan (r = .54, P < .0001), days affected by asthma (r = .36, P = .0001), asthma symptoms (r = .23, P = .017), and preferences for autonomy in asthma management decisions (r = .28, P = .0035). Those with PDM scores <50 reported significantly lower quality of life for all domains of a disease-specific instrument and the Short-Form 36 health survey version 1.0. In multiple regression analysis, PDM style was associated with the length of the office visit and the duration of tenure of the physician-patient relationship (R2 = 0.47, P = .0009). The adjusted odds ratio, per standard deviation decrease in PDM scores, for an asthma hospitalization was 2.0 (95% CI 1.2, 3.2) and for rehospitalization was 2.5 (95% CI 1.2, 4.2).

CONCLUSIONS

Patients' report of their physician's PDM style is significantly associated with health-related quality of life, work disability, and recent need for acute health services. Organizational factors, specifically longer visits and more time seeing a particular physician, are independently associated with more participatory visits. This has significant policy implications for asthma management.

Are patients' office visits with physicians getting shorter?

BACKGROUND

Many believe that managed care creates pressure on physicians to increase productivity, see more patients, and spend less time with each patient.

METHODS

We used nationally representative data from the National Ambulatory Medical Care Survey (NAMCS) of the National Center for Health Statistics and the American Medical Association's Socioeconomic Monitoring System (SMS) to examine the length of office visits with physicians from 1989 through 1998. We assessed the trends for visits covered by a managed-care or other prepaid health plan (prepaid visits) and non-prepaid visits for primary and specialty care, for new and established patients, and for common and serious diagnoses.

RESULTS

Between 1989 and 1998 the number of visits to physicians' offices increased significantly from 677 million to 797 million, although the rate of visits per 100 population did not change significantly. The average duration of office visits in 1989 was 16.3 minutes according to the NAMCS and 20.4 minutes according to the SMS survey. According to both sets of data, the average duration of visits increased by between one and two minutes between 1989 and 1998. The duration of the visits increased for both prepaid and nonprepaid visits. Nonprepaid visits were consistently longer than prepaid visits, although the gap declined from 1 minute in 1989 to 0.6 minute in 1998. There was an upward trend in the length of visits for both primary and specialty care and for both new and established patients. The average length of visits remained stable or increased for patients with the most common diagnoses and for those with the most serious diagnoses.

CONCLUSIONS

Contrary to expectations, the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians' availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix.

Pediatric cardiac intensive care: current state of the art and beyond the millennium

Pediatric cardiac intensive care has emerged as a distinct clinical entity to meet the unique needs of pediatric patients with congenital and acquired heart disease. This new subspecialty demands expertise and experience in the pediatric subspecialties of cardiology, intensive care, cardiac surgery, cardiac anesthesia, neonatology, and others. Ten recent developments will have an impact on pediatric cardiac intensive care for the coming decades: 1) emergence of new patient populations; 2) new clinical methodologies in the treatment of pulmonary hypertension; 3) innovations in techniques of respiratory support; 4) expanding research of single ventricle physiology; 5) advances in the treatment of heart failure; 6) improved noninvasive imaging; 7) new directions in interventional cardiac catheterization; 8) new techniques in pediatric cardiac surgery; 9) use of computer technology and intensive care monitoring; and 10) appreciation for global economics of intensive care. Finally, a multidisciplinary approach with a team esprit de corps remains vital to a successful pediatric cardiac intensive care program.

Disease management. A global cost-containing initiative?

Disease management has been marketed by healthcare industry providers as a way of improving resource allocation in healthcare and containing costs. However, to achieve improved efficiency in healthcare requires the guidelines and protocols in the disease management process to be based on sound evidence of effectiveness and cost effectiveness. This has not always been the case. The approach itself has an inadequate evidence base in terms of randomised controlled trials, other rigorous methods of evaluation and the results of economic evaluation. Disease management can be viewed as an attempt by pharmaceutical companies to undertake forward vertical integration into other parts of the healthcare process. This could reduce uncertainty for purchasers and reduce transaction costs, thereby potentially facilitating both healthcare expenditure control and efficiency. However, such cost savings may be outweighed by a concentration of power in disease management (pharmaceutical) companies, and the exploitation of such power to inflate expenditure and misallocate resources. Disease management must be appraised with care.