Primary Care Physician Compensation Method in Medical Groups: Does It Influence the Use and Cost of Health Services for Enrollees in Managed Care Organizations?

Context.— Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization. Objective.— To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician. Design.— Survey of medical groups contracting with selected managed care health plans, linked to 1994 plan enrollment and utilization data for adult enrollees. Setting.— Medical groups, major managed care health plans, and their patients/enrollees in the state of Washington. Study Participants.— Sixty medical groups in Washington, 865 primary care physicians (internal medicine, pediatrics, family practice, or general practice) from those groups and affiliated with 1 or more of 4 managed care health plans, and 200931 adult plan enrollees. Intervention.— The effect of method of primary care physician's compensation on the utilization and cost of health services was analyzed by weighted least squares and random effects regression. Main Outcome Measures.— Total visits, hospital days, and per member per year estimated costs. Results.— Compensation method was not significantly (P>.30) related to utilization and cost in any multivariate analyses. Patient age (P<.001), female gender (P<.001), and plan benefit level (P<.001) were significantly positively related to visits, hospital days, and per member per year costs. The primary care physician's age was significantly negatively related (P<.001) to all 3 dependent measures. Conclusions.— Compensation method was not significantly related to use and cost of health services per person. Enrollee, physician, and health plan benefit factors were the prime determinants of utilization and cost of health services.      

National Patterns in the Treatment of Smokers by Physicians

Context.— Routine treatment of smokers by physicians is a national health objective for the year 2000, a quality measure for health care plans, and the subject of evidence-based clinical guidelines. There are few national data on how physicians' practices compare with these standards. Objective.— To assess recent trends in the treatment of smokers by US physicians in ambulatory care and to determine whether physicians' practices meet current standards. Design.— Analysis of 1991-1995 data from the National Ambulatory Medical Care Survey, an annual survey of a random sample of US office-based physicians. Setting.— Physicians' offices. Patients.— A total of 3254 physicians recorded data on 145716 adult patient visits. Main Outcome Measures.— The proportion of visits at which physicians (1) identified a patient's smoking status, (2) counseled a smoker to quit, and (3) used nicotine replacement therapy. Results.— Smoking counseling by physicians increased from 16% of smokers' visits in 1991 to 29% in 1993 (P<.001) and then decreased to 21% of smokers' visits in 1995 (P<.001). Nicotine replacement therapy use followed a similar pattern, increasing from 0.4% of smokers' visits in 1991 to 2.2% in 1993 (P<.001) and decreasing to 1.3% of smokers' visits in 1995 (P=.007). Physicians identified patients' smoking status at 67% of all visits in 1991; this proportion did not increase over time. Primary care physicians were more likely to provide treatment to smokers than were specialists. All physicians were more likely to treat patients with smoking-related diagnoses. Conclusions.— US physicians' treatment of smokers improved little in the first half of the 1990s, although a transient peak in counseling and nicotine replacement use occurred in 1993 after the introduction of the nicotine patch. Physicians' practices fell far short of national health objectives and practice guidelines. In particular, patient visits for diagnoses not related to smoking represent important missed opportunities for intervention.      

Curbside Consultation Practices and Attitudes Among Primary Care Physicians and Medical Subspecialists

Context.— Informal (curbside) consultations are an integral part of medical culture and may be of great value to patients and primary care physicians. However, little is known about physicians' behavior or attitudes toward curbside consultation. Objective.— To describe and compare curbside consultation practices and attitudes among primary care physicians and medical subspecialists. Design.— Survey mailed in June 1997. Participants.— Of 286 primary care physicians and 252 subspecialists practicing in Rhode Island, 213 primary care physicians and 200 subspecialists responded (response rate, 76.8%). Main Outcome Measures.— Self-reported practices of, reasons for, and attitudes about curbside consultation. Results.— Of primary care physicians, 70.4% (150/213) and 87.5% (175/200) of subspecialists reported participating in at least 1 curbside consultation during the previous week. In the previous week, primary care physicians obtained 3.2 curbside consultations, whereas subspecialists received 3.6 requests for curbside consultations. Subspecialties most frequently involved in curbside consultations were cardiology, gastroenterology, and infectious diseases; subspecialties that were requested to provide curbside consultations more often than they were formally consulted were endocrinology, infectious diseases, and rheumatology. Curbside consultations were most often used to select appropriate diagnostic tests and treatment plans and to determine the need for formal consultation. Subspecialists perceived more often than primary care physicians that information communicated in curbside consultations was insufficient (80.2% vs 49.8%; P<.001) and that important clinical detail was not described (77.6% vs 43.5%; P <.001). More subspecialists than primary care physicians felt that curbside consultations were essential for maintaining good relationships with other physicians (77.2% vs 38.6%; P <.001). Conclusions.— Curbside consultation serves important functions in the practice of medicine. Despite the widespread use of curbside consultation, disagreement exists between primary care physicians and subspecialists as to the role of curbside consultation and the quality of the information exchanged.      

Relation between operator and hospital volume and outcomes following percutaneous coronary interventions in the era of the coronary stent

Context  Studies have found an association between physician and institution procedure volume for percutaneous coronary interventions (PCIs) and patient outcomes, but whether implementation of coronary stents has allowed low-volume physicians and centers to achieve outcomes similar to their high-volume counterparts is unknown. Objective  To assess the relationship between physician and hospital PCI volumes and patient outcomes following PCIs, given the availability of coronary stents. Design, Setting, and Participants  Analysis of data from Medicare National Claims History files for 167 208 patients aged 65 to 99 years who had PCIs performed by 6534 physicians at 1003 hospitals during 1997. Of these procedures, 57.7% involved coronary stents. Main Outcome Measures  Rates of coronary artery bypass graft (CABG) surgery and 30-day mortality occurring during the index episode of care, stratified by physician and hospital PCI volume. Results  Overall unadjusted rates of CABG during the index hospitalization and 30-day mortality were 1.87% and 3.30%, respectively. After adjustment for case mix, patients treated by low-volume (<30 Medicare procedures) physicians had an increased risk of CABG vs patients treated by high-volume (>60 Medicare procedures) physicians (2.25% vs 1.55%; P<.001), but there was no difference in 30-day mortality rates (3.25% vs 3.39%; P = .27). Patients treated at low-volume (<80 Medicare procedures) centers had an increased risk of 30-day mortality vs patients treated at high-volume (>160 Medicare procedures) centers (4.29% vs 3.15%; P<.001), but there was no difference in the risk of CABG (1.83% vs 1.83%; P = .96). In patients who received coronary stents, the CABG rate was 1.20% vs 2.78% for patients not receiving stents, and the 30-day mortality rate was 2.83% vs 3.94%. Among patients who received stents, those treated at low-volume centers had an increased risk of 30-day mortality vs those treated at high-volume centers, whereas those treated by low-volume physicians had an increased risk of CABG vs those treated by high-volume physicians. Conclusion  In the era of coronary stents, Medicare patients treated by high-volume physicians and at high-volume centers experience better outcomes following PCIs.      

Physicians' Experiences and Beliefs Regarding Informal Consultation

Context.— Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. Objective.— To understand physicians' use of and beliefs about informal consultation. Design.— Survey mailed in July 1997. Participants.— Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. Main Outcome Measures.— Self-reported use of and beliefs about informal consultation. Results.— Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P <.001) and were asked to provide fewer (2 vs 5 per week; P <.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). Conclusions.— Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.      

Comparison of performance of traditional Medicare vs Medicare managed care

Context  Since 2000, the Centers for Medicare & Medicaid Services (CMS) has been collecting information on beneficiaries' experiences with health care for Medicare managed care (MMC) and traditional fee-for-service (FFS) Medicare. Objectives  To compare beneficiary experiences with managed care and FFS arrangements throughout the country and to assess the stability of those differences over time. Design, Setting, and Participants  CMS administered managed care and FFS versions of the Consumer Assessment of Health Plans Study (CAHPS) survey to samples of beneficiaries (aged =" BORDER="0">65 years) from Medicare + Choice MMC organizations and from geographic strata within the traditional FFS Medicare program. We analyzed responses collected in 2000 and 2001 from 497 869 respondents: 299 058 beneficiaries enrolled in MMC plans (response rate, 82%) and 198 811 enrolled in FFS Medicare (response rate, 68%). Differences between MMC and FFS within states were assessed after adjustment for case mix and nonresponse. For estimates at the regional and national level, state estimates were combined after weighting by the MMC enrollment in the state. Main Outcome Measures  Four overall ratings (of the plan, personal physician, care received overall, and care received from specialists), 5 measures summarizing beneficiaries' experiences with care (getting care needed; getting care quickly; communication with clinicians; courtesy and respect of physician's office staff; and paperwork, information, and customer service), and reports of receipt of 3 preventive services (flu shots, pneumococcal vaccinations, and being advised to quit smoking) were assessed. Results  Respondents in MMC and FFS plans were similar to each other and to the Medicare population as a whole. Nationally, FFS Medicare beneficiaries rated experiences with care measured by the CAHPS survey higher than did MMC beneficiaries; for instance, in ratings of care received overall (scale of 1-10) (8.91 FFS vs 8.86 MMC, P<.001, in 2000; and 8.88 FFS vs 8.78 MMC, P<.001, in 2001). Differences between FFS and MMC varied across states, however. Managed care enrollees reported significantly fewer problems with paperwork, information, and customer service (2.62 FFS vs 2.55 MMC, P<.001, in 2000; and 2.59 FFS vs 2.51 MMC, P<.001, in 2001). Enrollees in MMC were also more likely to report having received immunizations for influenza and pneumococcus (from any source) (in 2000, 77% of MMC vs 63% of FFS respondents; P<.001), and smokers were more likely to report having received counseling to quit smoking. Conclusions  Our data suggest that managed care was better at delivering preventive services, whereas traditional Medicare was better in other aspects of care related to access and beneficiary experiences. These relative strengths should be considered when policy decisions are made that affect the availability of choice or influence beneficiaries to choose one model of care over another.      

Managed care and physicians' provision of charity care

Context  Health system changes may be affecting the ability of physicians to provide care with little or no compensation from patients who are uninsured and underinsured and may result in decreased access to physicians for uninsured persons. Objective  To examine the association between managed care and physicians' provision of charity care. Design  The 1996-1997 Community Tracking Study physician survey. Setting and Participants  A nationally representative sample of 10,881 physicians from 60 randomly selected communities. Main Outcome Measure  The number of hours in the month prior to the interview that the physician provided care for free or at reduced fees because of the financial need of the patient. Results  Overall, 77.3% of respondents provided an average of 10.3 hours of charity care per week. Physicians who derive at least 85% of their practice revenue from managed care plans were considerably less likely to provide charity care and spend fewer hours providing charity care than physicians with little involvement in managed care plans (P=.01). In addition, physicians who practice in areas with high managed care penetration provided fewer hours of charity care than physicians in other areas, regardless of their own level of involvement with managed care (P<.01). Differences in charity care provision were also shown for other important factors, including ownership of the practice and practice arrangements (more charity care occurred in solo and 2-physician practices; P<.01). Conclusion  Physicians involved with managed care plans and those who practice in areas with high managed care penetration tend to provide less charity care.      

Medical Care Delivery at the 1996 Olympic Games

Context.— Mass gatherings like the 1996 Olympic Games require medical services for large populations assembled under unusual circumstances. Objective.— To examine delivery of medical services and to provide data for planning future events. Design.— Observational cohort study, with review of medical records at Olympics medical facilities. Setting.— One large multipurpose clinic and 128 medical aid stations operating at Olympics-sponsored sites in the vicinity of Atlanta, Ga. Participants.— A total of 10 715 patients, including 1804 athletes, 890 officials, 480 Olympic dignitaries, 3280 volunteers, 3482 spectators, and 779 others who received medical care from a physician at an Olympic medical station. Main Outcome Measures.— Number of injuries and cases of heat-related illness among participant categories, medical use rates among participants with official Games credentials, and use rates per 10000 persons attending athletic competitions. Results.— Injuries, accounting for 35% of all medical visits, were more common among athletes (51.9% of their visits, P<.001) than among other groups. Injuries accounted for 31.4% of all other groups combined. Spectators and volunteers accounted for most (88.9%, P<.001) of the 1059 visits for heat-related illness. The rates for number of medical encounters treated by a physician were highest for athletes (16.2 per 100 persons, P<.001) and lowest for volunteers (2.0 per 100). Overall physician treatment rate was 4.2 per 10000 in attendance (range, 1.6-30.1 per 10000). A total of 432 patients were transferred to hospitals. Conclusions.— Organizers used these data during the Games to monitor the health of participants and to redirect medical and other resources to areas of increased need. These data should be useful for planning medical services for future mass gatherings.      

Possible Effectiveness of Clarithromycin and Rifabutin for Cryptosporidiosis Chemoprophylaxis in HIV Disease

Context.— Cryptosporidium parvum infection, a common cause of diarrhea in persons infected with the human immunodeficiency virus (HIV), is difficult to treat or prevent. Objective.— To evaluate relative rates of cryptosporidiosis in HIV-infected patients who were either receiving or not receiving chemoprophylaxis or treatment for Mycobacterium avium complex. Design.— Analysis of prospectively collected data from HIV-infected patients' visits to their physicians since 1992. Setting.— Ten (8 private, 2 publicly funded) HIV clinics in 9 US cities. Patients.— A total of 1019 HIV-infected patients with CD4⁺ cell counts less than 0.075x10⁹/L. Main Outcome Measures.— Incidence of clinical cryptosporidiosis during treatment with clarithromycin, rifabutin, and azithromycin. Results.— Five of the 312 patients reportedly taking clarithromycin developed cryptosporidiosis vs 30 of the 707 patients not taking clarithromycin (relative hazard [RH], 0.25 [95% confidence interval (CI), 0.10-0.67]; P =.004).Two of the 214 patients taking rifabutin developed cryptosporidiosis vs 33 of the 805 not taking rifabutin (RH, 0.15 [95% CI, 0.04-0.62]; P=.01). Prophylactic efficacy of either drug was 75% or greater. No protective effect was seen in the 54 patients reportedly taking azithromycin (RH, 1.48 [95% CI, 0.44-5.04]; P=.46). Conclusions.— Clarithromycin and rifabutin were highly protective against development of cryptosporidiosis in immune-suppressed HIV-infected persons in this analysis; further study is warranted.      

Physicians Disciplined for Sex-Related Offenses

Context.— Physicians who abuse their patients sexually cause immense harm, and, therefore, the discipline of physicians who commit any sex-related offenses is an important public health issue that should be examined. Objectives.— To determine the frequency and severity of discipline against physicians who commit sex-related offenses and to describe the characteristics of these physicians. Design and Setting.— Analysis of sex-related orders from a national database of disciplinary orders taken by state medical boards and federal agencies. Subjects.— A total of 761 physicians disciplined for sex-related offenses from 1981 through 1996. Main Outcome Measures.— Rate and severity of discipline over time for sex-related offenses and specialty, age, and board certification status of disciplined physicians. Results.— The number of physicians disciplined per year for sex-related offenses increased from 42 in 1989 to 147 in 1996, and the proportion of all disciplinary orders that were sex related increased from 2.1% in 1989 to 4.4% in 1996 (P<.001 for trend). Discipline for sex-related offenses was significantly more severe (P<.001) than for non–sex-related offenses, with 71.9% of sex-related orders involving revocation, surrender, or suspension of medical license. Of 761 physicians disciplined, the offenses committed by 567 (75%) involved patients, including sexual intercourse, rape, sexual molestation, and sexual favors for drugs. As of March 1997, 216 physicians (39.9%) disciplined for sex-related offenses between 1981 and 1994 were licensed to practice. Compared with all physicians, physicians disciplined for sex-related offenses were more likely to practice in the specialties of psychiatry, child psychiatry, obstetrics and gynecology, and family and general practice (all P<.001) than in other specialties and were older than the national physician population, but were no different in terms of board certification status. Conclusions.— Discipline against physicians for sex-related offenses is increasing over time and is relatively severe, although few physicians are disciplined for sexual offenses each year. In addition, a substantial proportion of physicians disciplined for these offenses are allowed to either continue to practice or return to practice.      

Early Inpatient Rehabilitation After Elective Hip and Knee Arthroplasty

Context.— Inpatient rehabilitation after elective hip and knee arthroplasty is often necessary for patients who cannot function at home soon after surgery, but how soon after surgery inpatient rehabilitation can be initiated has not been studied. Objective.— To test the hypothesis that high-risk patients undergoing elective hip and knee arthroplasty would incur less total cost and experience more rapid functional improvement if inpatient rehabilitation began on postoperative day 3 rather than day 7, without adverse consequences to the patients. Design.— Randomized controlled trial conducted from 1994 to 1996. Setting.— Tertiary care center. Participants.— A total of 86 patients undergoing elective hip or knee arthroplasty and who met the following criteria for being high risk: 70 years of age or older and living alone, 70 years of age or older with 2 or more comorbid conditions, or any age with 3 or more comorbid conditions. Of the 86 patients, 71 completed the study. Interventions.— Random assignment to begin inpatient rehabilitation on postoperative day 3 vs postoperative day 7. Main Outcome Measures.— Total length of stay and cost from orthopedic and rehabilitation hospital admissions, functional performance in hospitals using a subset of the functional independence measure, and 4-month follow-up assessment using the RAND 36-item health survey I and the functional status index. Results.— Patients who completed the study and began inpatient rehabilitation on postoperative day 3 exhibited shorter mean (±SD) total length of stay (11.7±2.3 days vs 14.5±1.9, P<.001), lower mean (±SD) total cost ($25891±$3648 vs $27762±$3626, P<.03), more rapid attainment of short-term functional milestones between days 6 and 10 (36.2±14.4 m ambulated vs 21.4±13.3 m, P<.001; 4.8±0.8 mean transfer functional independence measure score vs 4.3±0.7, P<.01), and equivalent functional outcome at 4-month follow-up. Conclusion.— These data showed that high-risk individuals were able to tolerate early intensive rehabilitation, and this intervention yielded faster attainment of short-term functional milestones in fewer days using less total cost.      

The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery

Context  Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown. Objective  To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals. Design  A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance. Setting  Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%). Patients  A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care. Main Outcome Measure  Probability of a patient receiving CABG surgery at a lower-mortality hospital. Results  Compared with patients with private FFS insurance (n=18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n=31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004). Conclusions  Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.      

Influence of a Child's Sex on Medulloblastoma Outcome

Context.— Aggressive treatment of medulloblastoma, the most common pediatric brain tumor, has not improved survival. Identifying better prognostic indicators may warrant less morbid therapy. Objective.— To investigate the role of sex on outcome of medulloblastoma. Design.— Retrospective study of significant factors for survival with a median follow-up of 82 months. Setting.— University medical center. Patients.— A total of 109 consecutive, pediatric patients treated for primary medulloblastoma from 1970 to 1995 with surgery and postoperative radiotherapy and, after 1979, chemotherapy. Main Outcome Measures.— Factors independently associated with survival. Results.— The final multivariate model predicting improved survival included sex (hazard ratio, 0.52; 95% confidence interval [CI], 0.29-0.92; P=.03; favoring female), metastases at presentation (hazard ratio, 2.01; 95% CI, 1.14-3.52; P=.02), and extent of surgical resection (hazard ratio, 0.60; 95% CI, 0.34-1.04; P=.07; favoring greater resection). The overall, 5-year freedom from progression was 40% and survival was 49%. Radiotherapy dose (P=.72), and chemotherapy (P=.90) did not significantly affect a disease outcome. Conclusions.— The sex of the child was an important predictor for survival of medulloblastoma; girls had a much better outcome. The difference in survival between sexes should be evaluated in prospective, clinical trials.      

Selection and Exclusion of Primary Care Physicians by Managed Care Organizations

Context.— Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory. Objective.— To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care. Design.— Cross-sectional mail survey of a probability sample of primary care physicians. Setting.— A total of 13 large urban counties in California. Participants.— Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice. Main Outcome Measures.— Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts. Results.— Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice. Conclusions.— Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.      

National Trends in the Outpatient Treatment of Depression

Context  Recent advances in pharmacotherapy and changing health care environments have focused increased attention on trends in outpatient treatment of depression. Objective  To compare trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997. Design and Setting  Analysis of service utilization data from 2 nationally representative surveys of the US general population, the 1987 National Medical Expenditure Survey (N = 34 459) and the 1997 Medical Expenditure Panel Survey (N = 32 636). Participants  Respondents who reported making 1 or more outpatient visits for treatment of depression during that calendar year. Main Outcome Measures  Rate of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of health care professional, and source of payment. Results  The rate of outpatient treatment for depression increased from 0.73 per 100 persons in 1987 to 2.33 in 1997 (P<.001). The proportion of treated individuals who used antidepressant medications increased from 37.3% to 74.5% (P<.001), whereas the proportion who received psychotherapy declined (71.1% vs 60.2%, P = .006). The mean number of depression treatment visits per user declined from 12.6 to 8.7 per year (P = .05). An increasingly large proportion of patients were treated by physicians for their condition (68.9% vs 87.3%, P<.001), and treatment costs were more often covered by third-party payers (39.3% to 55.2%, P<.001). Conclusions  Between 1987 and 1997, there was a marked increase in the proportion of the population who received outpatient treatment for depression. Treatment became characterized by greater involvement of physicians, greater use of psychotropic medications, and expanding availability of third-party payment, but fewer outpatient visits and less use of psychotherapy. These changes coincided with the advent of better-tolerated antidepressants, increased penetration of managed care, and the development of rapid and efficient procedures for diagnosing depression in clinical practice.      

Reorganizing an Academic Medical Service: Impact on Cost, Quality, Patient Satisfaction, and Education

Robert M. Wachter, MD; Patricia Katz, PhD; Jonathan Showstack, PhD, MPH; Andrew B. Bindman, MD; Lee Goldman, MD, MPH

JAMA. 1998;279:1560-1565.

Context.— Academic medical centers are under enormous pressure to improve quality and cut costs while preserving education.

Objective.— To determine whether a reorganized academic medical service, led by faculty members who attended more often and became involved earlier and more intensively in care, would lower costs without compromising quality and education.

Design.— Alternate-day controlled trial.

Setting.— Inpatient academic general medical service.

Patients.— The 1623 patients discharged from the Moffitt-Long medical service between July 1, 1995, and June 30, 1996.

Interventions.— We divided our 4-team inpatient general medical service into 2 managed care service (MCS) teams and 2 traditional service (TS) teams. The MCS faculty served as attending physicians more often and were required to provide early input into clinical decisions. Patients were assigned to teams based on alternate days of admission.

Main Outcome Measures.— Outcome measures included resource use and outcomes for MCS vs TS patients, and for MCS patients vs patients seen the previous year, adjusted for demographic characteristics and case mix. Satisfaction of patients, house staff, and faculty was also assessed, as was educational emphasis.

Results.— A total of 806 patients were admitted to the MCS and 817 to the TS. Demographic characteristics and case mix were similar. Clinical outcomes, including mortality and readmission rates, were also similar, as was patient satisfaction. Resident and faculty satisfaction were high on both services. The average adjusted length of stay of patients on the MCS was 4.3 days vs 4.9 days on the TS and 5 days in 1994-1995 (adjusted P=.01 for MCS vs TS; MCS vs 1994-1995, P<.001). Average adjusted hospital costs were $7007 on the MCS vs $7777 on the TS and $8078 in 1994-1995 (adjusted P=.05 for MCS vs TS; MCS vs 1994-1995, P=.002).

Conclusions.— A reorganized academic medical service, led by faculty members who attended more often and became involved earlier and more intensively, resulted in significant resource savings with no changes in clinical outcomes or patient, faculty, and house staff satisfaction.

     

Treatment of Irritable Bowel Syndrome With Chinese Herbal Medicine: A Randomized Controlled Trial

Context.— Irritable bowel syndrome (IBS) is a common functional bowel disorder for which there is no reliable medical treatment. Objective.— To determine whether Chinese herbal medicine (CHM) is of any benefit in the treatment of IBS. Design.— Randomized, double-blind, placebo-controlled trial conducted during 1996 through 1997. Setting.— Patients were recruited through 2 teaching hospitals and 5 private practices of gastroenterologists, and received CHM in 3 Chinese herbal clinics. Patients.— A total of 116 patients who fulfilled the Rome criteria, an established standard for diagnosis of IBS. Intervention.— Patients were randomly allocated to 1 of 3 treatment groups: individualized Chinese herbal formulations (n=38), a standard Chinese herbal formulation (n=43), or placebo (n=35). Patients received 5 capsules 3 times daily for 16 weeks and were evaluated regularly by a traditional Chinese herbalist and by a gastroenterologist. Patients, gastroenterologists, and herbalists were all blinded to treatment group. Main Outcome Measures.— Change in total bowel symptom scale scores and global improvement assessed by patients and gastroenterologists and change in the degree of interference in life caused by IBS symptoms assessed by patients. Results.— Compared with patients in the placebo group, patients in the active treatment groups (standard and individualized CHM) had significant improvement in bowel symptom scores as rated by patients (P = .03) and by gastroenterologists (P = .001), and significant global improvement as rated by patients (P=.007) and by gastroenterologists (P=.002). Patients reported that treatment significantly reduced the degree of interference with life caused by IBS symptoms (P=.03). Chinese herbal formulations individually tailored to the patient proved no more effective than standard CHM treatment. On follow-up 14 weeks after completion of treatment, only the individualized CHM treatment group maintained improvement. Conclusion.— Chinese herbal formulations appear to offer improvement in symptoms for some patients with IBS.      

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial

Context  Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. Objective  To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. Design  Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. Setting  Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. Patients  Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). Main Outcome Measures  Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. Results  No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05). Conclusions  In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.      

Oral Famciclovir for the Suppression of Recurrent Genital Herpes: A Randomized Controlled Trial

Context.— Recurrent genital herpes simplex virus (HSV) may be treated episodically, but this may not be sufficient for patients with frequent recurrences. Objective.— To determine the efficacy and safety of famciclovir in the suppression of recurrent genital HSV infection. Design.— A randomized, double-blind, placebo-controlled, parallel-group study. Setting.— Thirty university, hospital, or private outpatient referral centers in Canada and Europe. Patients.— A total of 455 patients (223 men, 232 women) aged 18 years or older with a history of 6 or more episodes of genital herpes during 12 of the most recent 24 months, in the absence of suppressive therapy, received study medication. Intervention.— Oral famciclovir, 125 mg or 250 mg 3 times daily or 250 mg twice daily, or placebo for 52 weeks. Main Outcome Measures.— Time to the first recurrence of genital HSV infection; the proportion of patients remaining free of HSV recurrence at 6 months; frequency of adverse events. Results.— In an intent-to-treat analysis, famciclovir significantly delayed the time to the first recurrence of genital herpes at all dose regimens (hazard ratios, 2.9-3.3;P< .001); median time to recurrence for famciclovir recipients was 222 to 336 days compared with 47 days for placebo recipients. The proportion of patients remaining free of HSV recurrence was approximately 3 times higher in famciclovir recipients (79%-86%) than in placebo recipients (27%) at 6 months (relative risks, 2.9-3.1;P <.001); efficacy was maintained at 12 months. Famciclovir was well tolerated with an adverse experience profile comparable to placebo. Conclusions.— Oral famciclovir (125 mg or 250 mg 3 times daily or 250 mg twice daily) is an effective, well-tolerated treatment for the suppression of genital HSV infection in patients with frequent recurrences.      

Modulation of Abnormal Colonic Epithelial Cell Proliferation and Differentiation by Low-Fat Dairy Foods: A Randomized Controlled Trial

Context.— Before the development of human colonic neoplasms, colonic epithelial cells showed altered growth and differentiation. These alterations characterized mucosa at risk for cancer formation and were termed intermediate biomarkers of risk. Modifications of the mucosa toward more normal features by nutrients or drugs are putative approaches to chemoprevention of colon cancer. Objective.— To determine whether increasing calcium intake via dairy products alters colonic biomarkers toward normal. Design.— Randomized, single-blind, controlled study. Setting.— Outpatient clinic. Participants.— Seventy subjects with a history of polypectomy for colonic adenomatous polyps. Intervention.— Low-fat dairy products containing up to 1200 mg/d of calcium. Subjects were randomized to 4 strata by diet (control vs higher calcium) and age (<60 vs 60 years). Main Outcome Measures.— Changes in total colonic epithelial cells and number and position of thymidine-labeled epithelial cells and changes in the ratio of sulfomucins (predominantly secreted by distal colorectal epithelial cells) to sialomucins and expression of cytokeratin AE1, 2 markers of colonic cell differentiation. Results.— During 6 and 12 months of treatment, reduction of colonic epithelial cell proliferative activity (P<.05), reduction in size of the proliferative compartment (P<.05), and restoration of acidic mucin (P<.02), cytokeratin AE1 distribution (P<.05), and nuclear size (P<.05) toward that of normal cells occurred. Control subjects showed no differences from baseline proliferative values at 6 and 12 months (P>.05). Conclusion.— Increasing the daily intake of calcium by up to 1200 mg via low-fat dairy food in subjects at risk for colonic neoplasia reduces proliferative activity of colonic epithelial cells and restores markers of normal cellular differentiation.