Management of COVID-19 ICU-survivors in primary care: - a narrative review

Many survivors of critical illness suffer from long-lasting physical, cognitive, and mental health sequelae. The number of affected patients is expected to markedly increase due to the COVID-19 pandemic. Many ICU survivors receive long-term care from a primary care physician. Hence, awareness and appropriate management of these sequelae is crucial. An interdisciplinary authorship team participated in a narrative literature review to identify key issues in managing COVID-19 ICU-survivors in primary care. The aim of this perspective paper is to synthesize important literature to understand and manage sequelae of critical illness due to COVID-19 in the primary care setting.

Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities

OBJECTIVE

Our goal was to compare the quality of diabetic care received by patients in rural and urban communities.

STUDY DESIGN

We performed a retrospective analysis of claims data captured by the Medicare program.

POPULATION

We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994.

OUTCOME MEASURES

The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination.

RESULTS

A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests.

CONCLUSIONS

Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

The role of gynecologists in providing primary care to elderly women

BACKGROUND

Federal legislation has recently been proposed to designate obstetrician-gynecologists (OBGs) as primary care physicians. The Institute of Medicine identifies care unrestricted by problem or organ system as an essential characteristic of primary care. We examined the degree to which OBGs in the state of Washington offer this aspect of primary care to their elderly patients by investigating the type and amount of nongynecologic care they provide.

METHODS

Using 1994 Part B Medicare claims data for Washington residents, we identified visits made by women aged 65 years and older to OBGs (N=10,522) and 9 other types of specialists. Diagnoses were classified as in or out of the domain of care traditionally provided by each specialty. Visit volumes, proportion of out of domain visits, and the frequency of diagnoses were reported.

RESULTS

Of the patient visits to obstetrician-gynecologists, 12.2% had nongynecologic diagnoses. The median percentage of nongynecologic visits for individual OBGs was 6.7%. Patients who saw OBGs received 15.4% of their overall health care from an OBG; patients who saw family physicians received 42.9% of their total health care from a family physician.

CONCLUSIONS

In 1994, a small amount of the care that Washington OBGs provided to their elderly patients was for nongynecologic conditions. Studies are needed to evaluate how the practices of OBGs have changed since the 1996 implementation of a primary care requirement in obstetrics-gynecology residencies, and if adopted, how legislation designating OBGs as primary care physicians affects the health care received by elderly women.

Emergency department use by the rural elderly

This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. Health Care Financing Administration's National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.

Is hospitalism new? An analysis of medicare data from Washington State in 1994

CONTEXT

Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology.

DATA SOURCE

1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State.

RESULTS

For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists."

CONCLUSION

Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists."

The effect of the doctor-patient relationship on emergency department use among the elderly

OBJECTIVES

This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician.

METHODS

The Health Care Financing Administration's National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994.

RESULTS

A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician.

CONCLUSIONS

The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician--regardless of specialty--may reduce emergency department use.

Rural and urban physicians: does the content of their Medicare practices differ?

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

Hospital peer review and the National Practitioner Data Bank: clinical privileges action reports

CONTEXT

The National Practitioner Data Bank (NPDB) is believed to be an important source of information for peer review activities by the majority of those who use it. However, concern has been raised that hospitals may be underreporting physicians with performance problems to the NPDB.

OBJECTIVE

To examine variation in clinical privileges action reporting by hospitals to the NPDB, changes in reporting over time, and the association of hospital characteristics with reporting.

DESIGN

Retrospective cohort study of privileges action reports to the NPDB between 1991 and 1995, linked with the 1992 and 1995 databases from the Annual Survey of Hospitals conducted by the American Hospital Association.

SETTING AND PARTICIPANTS

A total of 4743 short-term, nonfederal, general medical/surgical hospitals throughout the United States that were continuously open between 1991-1995 and registered with the NPDB.

MAIN OUTCOME MEASURES

(1) Reporting of 1 or more privileges actions during the 5-year study period and (2) privileges action reporting rates (numbers of actions reported per 100000 admissions).

RESULTS

Study hospitals reported 3328 privileges actions between 1991 and 1995; 34.2% reported 1 or more actions during the period. The range of privileges action reporting rates for these hospitals was 0.40 to 52.27 per 100000 admissions, with an overall rate of 2.36 per 100000 admissions. The proportion of hospitals reporting an action decreased from 11.6% in 1991 to 10.0% in 1995 (P=.008). After adjustment for other factors, urban hospitals had significantly higher reporting than rural hospitals (adjusted odds ratio [OR], 1.21 [95% confidence interval [CI], 1.02-1.43]), while members of the Council of Teaching Hospitals of the Association of American Medical Colleges had significantly lower reporting than nonmembers (adjusted OR, 0.54 [95% CI, 0.40-0.73]). There were notable regional differences in reporting, with the east south Central region having the lowest rate per 100000 admissions (1.49 [95% CI, 1.33-1.65]).

CONCLUSIONS

The results of this study indicate a low and declining level of hospital privileges action reporting to the NPDB. Several potential explanations exist, 1 of which is that the information reported to the NPDB is incomplete.

Do Medicare patients with disabilities receive preventive services? A population-based study

OBJECTIVE

To compare health maintenance procedure rates of Medicare patients with different levels of disability.

STUDY DESIGN

Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL).

RESULTS

Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community.

CONCLUSIONS

Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations

This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.

The effect of expanding Medicaid prenatal services on birth outcomes

OBJECTIVES

Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington State's expansion of such services on prenatal care use and low-birthweight rates.

METHODS

The change in prenatal care use and low-birthweight rates among Washington's Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state.

RESULTS

The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washington's low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorado's rate increased slightly (10.4% to 10.6%, P = .74). Washington's improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions.

CONCLUSIONS

A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

Influence of provider characteristics and insurance status on maternal serum alpha-fetoprotein screening

BACKGROUND

The maternal serum alpha-fetoprotein test (MSAFP) was developed to screen for neural tube defects. Little is known about the adoption of the MSAFP test. This study examines the effect of provider specialty and geographic location and patient insurance status on MSAFP test use in Washington State.

METHODS

We conducted a retrospective cohort study of MSAFP use in low-risk obstetric patients of five provider groups. MSAFP use was examined for Medicaid and privately insured patients, as well as for the patients of the five provider types.

RESULTS

Patients of urban and rural obstetrician-gynecologists were most likely to have MSAFP testing (80.4 percent and 77.0 percent, respectively); patients of urban certified nurse midwives and rural family physicians were least likely to have MSAFP testing (64.2 percent and 62.2 percent, respectively). Patients of certified nurse midwives were more likely to decline MSAFP testing when offered (26.1 percent). Medicaid-insured women were significantly less likely to have MSAFP testing than privately insured women (60.5 percent versus 79.1 percent, P < or = 0.05).

CONCLUSIONS

Providers and patients did not uniformly use MSAFP screening. Efforts should be made to ensure that all patients are adequately informed of screening tests for neural tube defects.

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies

OBJECTIVES

Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care.

METHODS

Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation.

RESULTS

Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different.

CONCLUSIONS

Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Influenza vaccinations of Washington state Medicare beneficiaries seen by physiatrists in the outpatient setting in 1994

OBJECTIVE

To compare influenza vaccination billing rates for patients seen by physiatrists with those of four other specialties: neurology, rheumatology, family practice, and internal medicine.

DESIGN

Retrospective cohort analysis using Medicare billing data.

PATIENTS

234,164 Medicare outpatients seen in Washington state between September 1 and December 31, 1994.

RESULTS

Based on Medicare's billing data, only 6 of 99 physiatrists ordered vaccinations, and they immunized only 159 (6%) of the patients seen. An additional 1,109 (42%) patients seen by physiatrists were vaccinated by other physicians. Physiatric patients were less likely to have been vaccinated than those seen by internists, family practitioners, or rheumatologists (p < .002), but equally likely as those seen by neurologists (p = .07). A significantly smaller percentage of physiatrists ordered vaccinations than all other specialties (p < .04). Utilizing pre-existing survey data, the misclassification rate (those immunized but not billed) was estimated at 22% of our original cohort. Thus, approximately 800 patients, one third of those seeing physiatrists, may not have been immunized. We estimated the increase in hospitalization costs to be $117 per nonvaccinated patient (total >$90,000).

CONCLUSIONS

Missed opportunities for vaccination by physiatrists appear to be more frequent than in other specialties and have potentially large health and economic costs.

The generalist role of specialty physicians: is there a hidden system of primary care?

CONTEXT

Despite increased emphasis on primary care in the United States, most care continues to be provided by specialists. The extent to which specialists incorporate elements of primary care in their approach to ambulatory patients is unknown.

OBJECTIVES

To examine the extent to which selected medical and surgical subspecialties provide generalist care to Medicare patients, and to compare patterns of care between specialists and generalists.

DESIGN

A cross-sectional study of all ambulatory care recorded in Part B of the Washington State Medicare Claims Database in 1994 and 1995.

SETTING

Ambulatory practices in Washington State.

PATIENTS

Medicare beneficiaries 65 years or older who made office visits to the study physicians.

MAIN OUTCOME MEASURES

The extent to which individual specialties accounted for the majority of visits made by patients to physicians (a measure of continuity), provided care outside the traditional domain of their specialty (a measure of comprehensiveness), and provided influenza immunization.

RESULTS

A total of 373 505 patients constituted the sample. Patients had an average of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and family physicians differ systematically from the practices of most specialists. Approximately half (49.8%) of all ambulatory visits to general internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medical specialist and 11.7% of surgical specialist visits. The rate of influenza immunization was 55.4% for patients who received the majority of their care from generalists, 47.7% from medical specialists, and 39.6% from surgical specialists. Pulmonologists, general surgeons, and gynecologists were more likely than other specialists to provide services outside their specialty.

CONCLUSIONS

Most specialists do not assume the principal care responsibility for elderly patients, although a substantial proportion of patients see only specialists for their care. Selected specialties assume the generalist role more often, particularly when they provide the majority of outpatient care for an individual patient.

Rural hospitals' experience with the National Practitioner Data Bank

OBJECTIVES

This study examined hospital administrators' experiences with the National Practitioner Data Bank.

METHODS

One hundred forty-nine rural hospital administrators completed questionnaires assessing their perceptions of the data bank.

RESULTS

Nearly 90% of respondents rated the data bank as an important source of information for credentialing. Three percent indicated it had directly affected privileging decisions; 43% and 34%, respectively, believed the costs exceeded or equaled the benefits. Twenty percent reported changes that could decrease disciplinary action reports to the data bank.

CONCLUSIONS

While the National Practitioner Data Bank is an important source of information to rural hospitals, it may, affect few credentialing decisions and motivate behavioral changes that could have a paradoxical effect on quality assurance.

The effect of a comprehensive Medicaid expansion on physicians' obstetric practices in Washington State

BACKGROUND

In 1989 Washington State implemented a comprehensive expansion of its Medicaid perinatal program, augmenting services, increasing provider reimbursement, and broadening eligibility. This study examines the influence of this legislation on physicians' obstetric practices and attitudes toward caring for pregnant Medicaid patients.

METHODS

Family physicians and obstetrician-gynecologists were surveyed at the start and 18 months after the Medicaid expansion. The study sample comprised physicians responding to the survey in both years.

RESULTS

A greater proportion of family physicians provided unlimited obstetric care to Medicaid patients after the expansion. Sixty percent of family physicians and 56 percent of obstetrician-gynecologists were more willing to provide prenatal care to Medicaid patients as a result of the expansion. Physicians and their office staff were more comfortable with Medicaid patients in the later time period. Many physicians felt that they were better able to link their patients to a variety of social services after the expansion.

CONCLUSIONS

A Medicaid expansion program can increase provider participation in Medicaid and increase provider comfort in caring for Medicaid patients.

Rural and urban differences in physician resource use for low-risk obstetrics

OBJECTIVE

To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties.

DATA SOURCES/STUDY DESIGN

A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed.

FINDINGS/CONCLUSIONS

Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia).

The geographic and temporal patterns of residency-trained family physicians: University of Washington Family Practice Residency Network

BACKGROUND

There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort.

METHODS

Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations.

RESULTS

Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier.

CONCLUSIONS

The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future.

The impact of extended maternity services on prenatal care use among Medicaid women

The goals of this study were to examine the use of maternity support services (MSS) and maternity case management (MCM) by Medicaid-eligible low-income pregnant women in Washington state, and to determine whether receipt of the services was associated with improved prenatal care use. We obtained data from linked birth certificates and Medicaid eligibility and claims files for women delivering between August 1989 and December 1991. Unconditional logistic regression was used to assess the programs' effects independent of other variables associated with prenatal care adequacy. The percentage of women receiving MSS and MCM was highest among women with demographic risks for adverse birth outcomes. Women receiving prenatal care from health departments or community clinics were more likely to receive MSS and MCM than those seen by private physicians or midwives. After adjustment for multiple confounding factors, we found that recipients of MSS, but not MCM, were significantly less likely than other women to receive an inadequate number of prenatal visits. Our findings suggest that public policies that pay for support services to low-income pregnant women can improve the use of prenatal care.

The role of magnesium in regulating CCK-8-evoked secretory responses in the exocrine rat pancreas

This study investigates the effect of magnesium (Mg2+) on the secretory responses and the mobilization of calcium (Ca2+) and Mg2+ evoked by cholecystokinin-octapeptide (CCK-8) in the exocrine rat pancreas. In the isolated intact perfused pancreas CCK-8 (10(-10) M) produced marked increases in juice flow and total protein output in zero and normal (1.1 mM) extracellular Mg2+ [Mg2+]o compared to a much reduced secretory response in elevated (5 mM and 10 mM) [Mg2+]o. Similar effects of perturbation of [Mg2+]o on amylase secretion and 45 Ca2+ uptake (influx) were obtained in isolated pancreatic segments. In pancreatic acinar cells loaded with the fluorescent bioprobe fura-2 acetomethylester (AM), CCK-8 evoked marked increases in cytosolic free Ca2+ concentration [Ca2+]i in zero and normal [Mg2+]o compared to a much reduced response in elevated [Mg2+]o. Pretreatment of acinar cells with either dibutyryl cyclic AMP (DB2 cAMP) or forskolin had no effect on the CCK-8 induced changes in [Ca2+]i. In magfura-2-loaded acinar cells CCK-8 (10(-8) M) stimulated an initial transient rise in intracellular free Mg2+ concentration [Mg2+]i followed by a more prolonged and sustained decrease. This response was abolished when sodium (Na+) was replaced with N-methyl-D-glucamine (NMDG). Incubation of acinar cells with 10 mM Mg2+ resulted in an elevation in [Mg2+]i. Upon stimulation with CCK-8, [Mg2+]i decreased only slightly compared with the response obtained in normal [Mg2+]o. CCK-8 caused a net efflux of Mg2+ in pancreatic segments; this effect was abolished when extracellular sodium [Na+]o was replaced with either NMDG or choline. The results indicate that Mg2+ can regulate CCK-8-evoked secretory responses in the exocrine pancreas possibly via Ca2+ mobilization. Moreover, the movement of Mg2+ in pancreatic acinar cells is dependent upon extracellular Na+.

Defensive medicine and obstetrics

OBJECTIVE

To test the hypothesis that physicians with greater malpractice claims exposure, either through personal experience or in their practice environment, will use more prenatal resources and have a higher cesarean delivery rate than physicians with lesser claims exposure.

DESIGN

Retrospective cohort study using county malpractice defendant rate data from the Washington State Physicians Insurance and Exchange Association and prenatal care, delivery method, and self-reported obstetric suit experience data from the Content of Obstetrical Care Study database.

SETTING

Washington State obstetric practices.

PARTICIPANTS

Stratified random samples of obstetrician-gynecologists and family physicians.

MAIN OUTCOME MEASURES

The rates of obstetric ultrasound use, referral and consultation, prenatal care resource use, and cesarean delivery.

RESULTS

After controlling for patient, physician, and sociodemographic characteristics, we found no difference in prenatal resource use or cesarean delivery rate for low-risk patients between physicians with more and less exposure to malpractice claims.

CONCLUSIONS

This study does not support an association between the malpractice experience or exposure of individual physicians and an increase in the use of prenatal resources or ceserean deliveries for the care of low-risk obstetric patients.

Do providers adhere to ACOG standards? The case of prenatal care

OBJECTIVE

To examine the extent to which obstetric providers abide by prenatal practice guidelines published by ACOG.

METHODS

The prenatal records were abstracted for low-risk patients initiating care with randomly selected urban obstetrician-gynecologists, rural obstetrician-gynecologists, urban family physicians, rural family physicians, and urban certified nurse-midwives in Washington state between September 1, 1988 and August 30, 1989. The prenatal care recorded in their medical charts was compared with the ACOG-recommended guidelines.

RESULTS

Overall, providers of all five types adhered closely to the published standards. Certified nurse-midwives recorded a standard of practice that most closely matched that recommended by ACOG. Overall, there was less complete adherence in the recording of maternal height, fetal activity after 30 weeks' gestation, and fetal presentation at or after 36 weeks' gestation. Those laboratory tests that ACOG has recommended most recently (serum alpha-fetoprotein and diabetes screening) and those not recommended for routine use were ordered less often on average by providers.

CONCLUSIONS

The cross-sectional nature of this study cannot demonstrate definitively that ACOG's guidelines have changed provider prenatal practices. However, these findings demonstrate that providers in varying specialties and geographic locations can adhere to a detailed set of clinical guidelines if they are appropriately disseminated and implemented.

The development of a clinical rating scale for the McMaster model of family functioning

This article describes the development and validation of the McMaster Clinical Rating Scale (MCRS). The MCRS is a 7-item scale designed to be completed by a trained rater after completion of an in-depth interview of the family. We present data from four new studies and review previously published articles concerning the reliability, validity, and clinical utility of the MCRS. Adequate interrater reliability and rater stability were obtained. The MCRS was found to correlate significantly with the self-report Family Assessment Device and to discriminate between families in different phases of a depressive disorder.

Access to obstetric care

Initially, this article examines the relationship between access to components of obstetric care and birth outcomes. It goes on to describe the significant decline in physician participation in obstetrics and its possible relationship to increasing rates of late or no prenatal care in the United States. The limitations of obstetric capacity and future access to providers of obstetric care in the United States versus Canada are explored. The article concludes with a discussion of strategies for improving access to obstetric care.

A comparison of student clerkship experiences in community practices and residency-based clinics

BACKGROUND

In our required family medicine clerkship, we used data from student logbook records of clinical experience to compare the learning experiences of students in community practices and residency-based clinics.

METHODS

Sixty-eight University of Washington students collected data on patients seen during the final two weeks of their family medicine clerkships. We compared patient demographics, location of patient encounters, and clinical problems seen at nine residency and eight community locations in a four-state area. National Ambulatory Medical Care Survey data were used to compare student experiences to national practices.

RESULTS

Log data documented that both community practices and residency sites met the course curriculum goals. Some variations occurred between the two types of clerkship sites, however. Students at community practices saw a higher mean number of patients and did more procedures than students at residency sites. Students at residencies were more likely to see patients for health maintenance and pregnancy care and less likely to see lacerations, sprains or strains, and some chronic diseases.

CONCLUSION

Episodic log data were successfully used to monitor the objective educational strategies for residency- and community-based student clerkship sites. Although all students met clerkship objectives, there were significant differences in certain aspects of students' clinical experiences at the two types of clerkship sites.

The effect of coordinated, multidisciplinary ambulatory care on service use, charges, quality of care and patient satisfaction in the elderly

This study evaluated a multidisciplinary care center, the Pike Market Clinic (PMC), whose physicians provide and coordinate inpatient and outpatient care for downtown low-income elderly in Seattle. We interviewed users of PMC and their near-neighbors with a 206 item questionnaire to compare their medical and social service use, quality of care, and satisfaction. We then estimated mean annual charges/person for inpatient, outpatient and emergency room services in the two groups. Demographic and health status characteristics were similar in the two groups. PMC patients made significantly more annual visits than neighbors to their primary physicians. Visits to non-primary physicians occurred at the same rate in both groups, but PMC patients were referred more often by their primary physicians. Both emergency room and inpatient use were higher in the neighbor group. Social services were used at the same rate by PMC patients and neighbors. Various indices suggested that quality of care and satisfaction were comparable or superior among PMC patients. Using utilization data, we estimated that neighbors generated charges over $1000/person/year greater than PMC patients. Coordination by PMC providers rather than the availability of multidisciplinary services may be largely responsible for utilization differences between PMC patients and their neighbors.

Differences in the obstetric malpractice claims filed by Medicaid and non-Medicaid patients

BACKGROUND

Many physicians believe Medicaid patients are more likely than non-Medicaid patients to file malpractice claims. This study examines the accuracy of this belief in regard to obstetric malpractice claims.

METHODS

Claims filed between January 1982 and June 1988 from the major malpractice insurer in Washington State were used to compare obstetric malpractice claims filed on behalf of Medicaid and non-Medicaid patients.

RESULTS

Eleven percent (7/62) of all closed obstetric claims were filed by Medicaid patients, whereas 19 percent of all births in Washington State were to Medicaid patients between 1982 and 1988. Failure to diagnose or treat a fetal condition was the most commonly alleged negligence in both Medicaid and non-Medicaid groups. Most claims in both groups were settled before the cases went to court; a substantial minority of claims were dropped. The mean cost of Medicaid claims ($406,984) was three times that of non-Medicaid claims ($133,743), suggesting that paid Medicaid claims were more severe than paid non-Medicaid claims.

CONCLUSIONS

Medicaid patients appear no more likely to file obstetric malpractice claims than non-Medicaid patients. The low likelihood of filing claims, coupled with large settlements, suggests that Medicaid patients may have less access to legal services than non-Medicaid patients.

Can physicians be induced to resume obstetric practice?

BACKGROUND

Decreased numbers of obstetric providers during the last decade have limited access to obstetrics care, especially for some groups of women. Increasing or stabilizing the number of providers could increase access.

METHODS

A questionnaire was mailed in 1989 to 1965 Washington State family physicians and obstetricians to determine their attitudes toward the practice of obstetrics. Sixty-six percent of physicians responded to the survey.

RESULTS

Of those who had quit obstetrics in the previous 3 years, 42 percent of responding family physicians and 19 percent of responding obstetricians would consider resuming. Those family physicians willing to consider resuming their obstetric practices were more likely to have been in practice fewer years, employed by a health maintenance organization (HMO), or located in a rural area. A majority of all respondents cited excessive malpractice premiums and fear of malpractice suit as reasons for stopping obstetric practice. Family physicians willing to consider resuming obstetrics were more concerned about the overall number of obstetric providers in their area. Rural family physicians willing to consider resuming obstetrics listed poor backup or shared call more often as a reason they had quit.

CONCLUSIONS

Attention targeted to the concerns of family physicians who have been in practice for a short time, who work for HMOs, or who are in rural practice might help induce some physicians to resume obstetrics.

Professional relationships between midwives and physicians: collaboration or conflict?

This study examines the professional relationships between midwives and physicians providing obstetrical care in Washington State. Four hundred ninety-six randomly sampled family physicians and obstetrician-gynecologists and 211 certified nurse, licensed, and lay midwives were surveyed to learn more about midwife/physician consulting relationships. Only certified nurse midwives have forged mutually satisfactory relationships with the physician community. Increased hospital-based training and practice opportunities are needed before licensed midwives can improve their professional relationships with physicians.

Characteristics of physicians with obstetric malpractice claims experience

This study compared the demographic and practice characteristics of physicians with and without obstetric malpractice experience. The sample consisted of 387 family physicians and 204 obstetricians in Washington state who were insured for obstetrics by a major malpractice carrier between January 1982 and June 1988. Fifty-three physicians (9%) had an obstetric malpractice claim during the study period. The approximate overall rate of obstetric malpractice claims was low: 0.32 per 1000 deliveries. The higher the total delivery volume (exposure), the greater the chance of having malpractice experience. Although physicians with practices of over 200 deliveries per year were more likely to have had malpractice experience, their risk of malpractice experience per delivery was lower than that of providers doing fewer than 200 deliveries per year. Our work suggests that insurers might consider basing obstetric malpractice premiums on numbers of deliveries rather than specialty.

Tort reform and the obstetric access crisis. The case of the WAMI states

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.

The relation of obstetrical volume and nursery level to perinatal mortality

We investigated the relation of hospital delivery volume and nursery technology level to perinatal outcome in 226,164 White singleton births in Washington State, 1980-83. Level III facilities (neonatal intensive care unit) were defined by the state licensing commission. We defined the Level II (intermediate) and Level I (normal newborn) facilities using published criteria. Infants under 2000 gm born in Level III facilities had half the risk of perinatal death compared to those born in a Level I or II facility. No significant improvement was noted among level or volume groupings for normal birthweight infants. A loglinear regression model of hospital perinatal death rates showed that when birthweight and maternal risk were controlled, obstetrical volume added minimal explanatory power to level of nursery care.

Outcomes of regionalized perinatal care in Washington State

We evaluated the extent to which the regionalization of perinatal care in Washington State has succeeded in concentrating high-risk pregnancies in technologically appropriate referral centers and in reducing differences in neonatal outcome among hospitals. Of all infants weighing less than 1,500 grams born between 1980 and 1983, nearly 68% were delivered in level III hospitals, although only 24% of all babies are born in these hospitals, indicating that the state is highly regionalized. Neonatal outcomes-as measured by standardized mortality ratios-are similar in level I, II and III hospitals and are not greatly influenced by the rural or urban location of the hospital. The most promising strategy for further reducing neonatal mortality is to decrease the number and proportion of very-low-birth-weight births.

Growth patterns of first-generation Southeast Asian infants

The growth patterns of Southeast Asian infants appear to differ from those of the National Center for Health Statistics standards for US children. This study examines the length, weight, and head circumference curves of 175 healthy, full-term, US-born Laotian and Cambodian infants seen periodically at a pediatric clinic from birth to 18 months of age. The median length, weight, and head circumference values of these infants were significantly lower than those of the National Center for Health Statistics standards for infants older than 6 months. These differences were more striking in girls than boys. A decision to observe rather than to pursue a diagnostic work-up in an otherwise healthy Southeast Asian infant who exhibits a slow growth pattern may be the most appropriate management style.

Copatient relationships on a short-term psychiatric unit

Emotional and physical relationships among copatients on a short-term psychiatric unit were assessed in a two-year prospective study. Sixty-four relationships involving 102 patients were reported; the incidence rate was estimated at 10.7 percent. Thirty-three percent of the relationships were characterized as emotional, 9 percent as physical, and 58 percent as both. Patients involved in the relationships tended to be young and unmarried and to have a diagnosis of eating disorder, personality disorder, or bipolar disorder. Although most of the relationships were reciprocal, half were judged to be destructive and to create management problems. Staff discussed the relationship with the patients when it was considered destructive or exploitative but ignored relationships felt to be positive and healthy. The authors urge further studies of such relationships to help clarify patient management issues.

Gender and psychiatric clerkship performance

This study compared the performance of male and female medical students on a psychiatric clerkship rotation. The women performed at a higher level than the men, although the difference was not significant. In general, the men scored significantly higher on national standardized medical examinations. Correlations between psychiatric clerkship evaluations and national examinations were low, suggesting that the two measures are independent. These findings for psychiatric clerkship are consistent with those for clerkships in medicine, surgery and obstetrics, implying that female clinical clerks are just as capable as male clinical clerks in providing high quality medical care.

Effect of vocal disguise on estimations of speakers' ages

To determine the effect of speakers' attempts to disguise their voices on listeners' accuracy in age judgments, 26 speakers, 13 females and 13 males, recorded six sentences under three conditions: (a) in a normal manner, actually were, and (c) in a manner in which they attempted to sound much older than they actually were. Three master tapes were constructed, one for each of the three conditions. A total of 20 judges, 10 females and 10 males, participated in three sessions, one for each of the three master tapes. In each session they were asked to judge the age of the speaker of each sentence and, using a seven-point confidence rating scale, to indicate the over-all confidence in their judgments at the end of each session. Although a majority of speakers yielded age estimates consistent with the conditions of intended disguise, the differences in listeners' estimates among all three conditions were relatively small. Moreover, differences between speakers' actual ages and listeners' age estimates in the control condition were also small. Implications of the findings and suggestions for research are discussed.

Structuring a family assessment interview

The Problem Centred Systems Therapy of the Family and the McMaster Model of Family Functioning on which it is based have been used by family physicians and a variety of health professionals. This paper outlines aspects of the models that are useful in structuring a family assessment, plus some of the benefits gained through using such a family oriented approach.