Diagnostic Visits Research Articles

Clinical and Economic Effects of Pertussis Outbreaks

The reported incidence of pertussis is increasing, especially among the adolescent population. Current outbreak management strategies include investigating cases, contact follow-up, diagnostic testing, and antibiotic prophylaxis and treatment. The cost of these methods is substantial and can be attributed to the mobilization within public health departments to control the outbreaks. Through an extensive review of the literature, the clinical and economic effects of pertussis outbreaks in various nonhousehold settings are discussed. The reported incidence of pertussis among adolescents and adults in the United States since the early 1980s continues to rise. The challenges of preventing and controlling pertussis outbreaks involve diagnosing pertussis in a timely, accurate, and standardized fashion and understanding the true burden of disease in different age and socioeconomic groups. The economic effects of pertussis have been demonstrated to be significant to individuals and communities, both locally and globally. Costs associated with pertussis often include diagnostic testing, hospitalization, emergency and/or medical office visits, antibiotic and symptomatic treatment, lost work days, and other reductions in productivity. In outbreak settings, increased surveillance, antibiotic prophylaxis, isolation of infected cases, and enhanced communication and education add to the economic burden of this disease. The potential opportunity to apply the use of pertussis booster vaccination to these populations, particularly among adolescents, likely would reduce the occurrence of pertussis and minimize the clinical and economic repercussions of pertussis outbreaks. In the near future, it is anticipated that evaluating the effects of a licensed acellular pertussis booster vaccine in persons > or =10 years of age will become routine in pertussis prevention and outbreak-control activities.

Collaborative learning in advanced supply systems: the KLASS pilot project

The KLASS project – Knowledge and Learning in Advanced Supply Systems – focused on the automotive and aerospace sectors. It sought to develop collaborative learning networks of suppliers. In Type 1 networks, tier one companies encouraged supplier SMEs to identify key shop floor personnel as change agents, who participated in an innovative continuous improvement learning programme. Delivery was a mix of face‐to‐face tuition and multimedia distance learning. A series of workshops, followed by in‐company diagnostic visits, enabled change agents to assess their own workplaces and to devise and implement continuous improvement programmes. Simultaneously, they worked towards accreditation. Shared learning developed across the supplier networks, benefiting operators, management, the SMEs and the tier one companies, streamlining supply and improving competitive advantage. In Type 2 networks, SME managers acquired capabilities directed towards improving their awareness of QCD performance. The KLASS approach provid...

How many sputum smears are necessary for case finding in pulmonary tuberculosis?

We reviewed the laboratory registers of 42 tuberculosis (TB) diagnostic centres in the southern region of Ethiopia to determine the value of submitting serial sputum samples for the diagnosis of pulmonary TB (PTB) and estimate the proportion of suspects that are smear positive. A total of 15,821 TB suspects submitted three smears each (47,463 smears) in 2000 with a median of 228 per centre. The smear positivity rate (two or more positive smears) was 25%, with a range of 16.8-36.4% per zone. This exceeds the international recommendations of examining 10 suspects to identify one case. A total of 4099 (26%) of the suspects had at least one positive smear with 3753 (91.6%) of the first specimens being positive. A further 303 (7.4%) were negative in the first specimen but had a positive second specimen and 42 (1%) suspects had two negative specimens followed by a positive third smear. The value of the third sputum is negligible as 99% of the cases were identified from the first and second specimens. Reducing the number of specimens to two or even one would have multiple advantages in countries where laboratories are usually over-burdened and are not easily accessible to the population. Submission of two specimens on the same day could improve compliance in submitting samples and collecting results as the number of diagnostic visits would be reduced without significant loss of sensitivity.

Children's Oral Health in the Medical Curriculum: A Collaborative Intervention at a University‐Affiliated Hospital

The purpose of this study was to 1) describe the structure of the oral health program in a university-affiliated hospital; 2) evaluate staff's knowledge and attitudes toward oral health; and 3) propose ways to strengthen the incorporation of oral health prevention for children into clinical medical education. Qualitative methods were used to evaluate the program. Structured interviews with seventeen medical center personnel were conducted, and clinic utilization reports provided ICD-9 diagnostic frequency and visits. Clinic staff, pediatric residents, dental and pediatric faculty, hospital administrators, and clinic directors were interviewed. The themes identified during these interviews were motivation, roles, operational and organizational issues, and integration into the larger medical care system. Integration of an early childhood caries prevention program into the clinical medical education curriculum can be accomplished. After implementation of the oral health program described in this paper, dental caries became the eleventh most common diagnosis seen in the clinic when previously it did not appear in the top forty. However, institutional and organizational barriers are significant. Barriers identified were 1) lack of clarity in defining leadership and roles regarding oral health, 2) time and work overload in a busy pediatric clinic, 3) a tracking system was not available to quickly determine which children needed caries prevention procedures and education, and 4) billing and medical record form changes could not be fully established prior to starting the program.

Manejo de la tos crónica en consultas de alta demanda: eficacia de un protocolo secuencial

Chronic cough is one of the main causes of medical consultation. There is not however an homogeneous attitude regarding its management. A prospective evaluation was performed of a simple therapeutic protocol based on the anatomical approach of the cough reflex. A total of 110 patients with chronic cough for longer than four weeks were studied. The exclusion criteria were: non-smoking during the last year, not to have diseases compromising the immune system and not to have received inhibitors of the angiotensing converting enzyme. A three-visit stepwise approach was performed with specific diagnostic tests ordered and a specific therapy instituted according to the clinical suspicion. At the third visit, 97% of patients were free from cough or had improved markedly. Cough causes were identified in 105 cases (95%) and the most common were: asthma (33%), postnasal dripping (29%), gastroesophageal reflux (10%), and asthma with associated gastroesophageal reflux (16%). Patients with asthma had a longer duration of tos compared with those who had postnasal dripping (p < 0.05) as the only differential feature. The diagnostic-therapeutic diagram based on the anatomic reflex of cough is useful for the management of chronic cough in a highly demanded medical office. With this protocol, the cause of cough can be identified and treated successfully in almost every patient with a small number of diagnostic tests and medical visits.

GERIATRICS IN MANAGED CARE

To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. Residents (n = 700) living in the community between September 1995 and February 1996. Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.

Multidimensional telecare strategies for rural residents with brain injury.

Rural residents with brain injury have difficulty in accessing care from qualified psychologists for consequent cognitive, emotional and behavioural symptoms. We examined high-quality videoconferencing to enhance care for persons with brain injury in three areas: cognitive assessment, psychotherapy and rural mental health training. The assessment study evaluated 52 outpatients seen for diagnostic visits over videoconferencing, and compared their experiences with those of 52 age- and diagnosis-matched controls seen in person. Persons seen via telemedicine were more likely than controls to want to repeat their experience and more satisfied than were the neuropsychologists who examined them. In the psychotherapy study, neurorehabilitation patients were seen via videoconferencing for therapy related to brain injury or stroke. Persons receiving psychotherapy were less likely than persons receiving assessment services to want to repeat their experience. In the training study, 39 rural mental health providers were trained via videoconferencing, and trainees demonstrated significant improvement on tests of knowledge about brain injury. Trainees formed a network of mental health provider referrals for persons with brain injury in a wide geographic area. Given adequate training and ongoing support, rural clinicians can treat many brain-injury adjustment issues locally, reserving specialist consultation for emergency or complex problems.

Effect of Early Referral to an Endocrinologist on Efficiency and Cost of Evaluation and Development of Treatment Plan in Patients with Thyroid Nodules

Radionuclide uptake and scan and sonogram, frequently ordered before referral to an endocrinologist, are expensive and poor predictors of thyroid nodule malignancy. We estimated costs of excessive imaging and other studies by reviewing the records of all patients (n = 70) referred to a single, consulting endocrinologist, for thyroid nodule evaluation in a 2-yr interval and subsequently, presenting only pertinent histories and results of physical examinations, thyroid function tests, and thyroid autoantibodies, to a second, reviewing endocrinologist (RE) who was blinded to diagnosis and management. Concordance in diagnosis and management between consulting endocrinologist and RE was 87.1% and 93.4%, respectively. Accuracy of diagnosis, loss of patient’s time (8.7 h, average), and cost of unnecessary testing, defined as tests not required by the RE for diagnosis and management according to published guidelines, were determined. Unnecessary testing included 153 physician’s office or diagnostic laboratory visits, 44 sets of thyroid function tests, 32 radionuclide uptake and scan, 39 thyroid sonograms, and 3 computed tomography scans. The total direct cost of unnecessary tests was estimated at $27,290 ($390/patient) in addition to costs of 30 unnecessary physician’s office visits. Only 2 of 8 surgical referrals required surgery, whereas 6 other patients required surgery, including 3 with papillary carcinoma. We conclude that early referral to an endocrinologist of patients with suspected thyroid nodules results in significant savings in cost of evaluation, patient’s time, and increased diagnostic precision. Six of the 8 patients referred for surgery before endocrine consultation had benign thyroid disease that did not require surgery. Six additional patients were referred to surgery, 3 of whom had papillary thyroid carcinoma. Early referral of patients with suspected thyroid nodules to an endocrinologist results in significant savings in both cost and patient’s time as well as increased precision of diagnosis.

Differences in Treatment of Ischemic Heart Disease at a Public and a Voluntary Hospital: Sources and Consequences

A study of hospital patients with ischemic heart disease reports that patients in a public hospital received fewer needed diagnostic tests, surgeries, and follow-up visits for their conditions than their private hospital counterparts. Factors in the hospitals' organizational environments and the patients' social backgrounds were observed to have an impact on content of treatment and to affect patient as well as provider perspectives on the quality of care. To facilitate the analysis, data were collected from four sources: direct observation of the care of each patient on rounds and at the bedside; interviews with physicians concerning the rationale for their decisions; a process-oriented chart audit assessing the appropriateness of care; and an extensive home interview with each patient three months following hospital discharge to establish further use of health services, health status, and satisfaction with care.

The Oregon Health Plan: To Cover All Diagnostic Visits

To the Editor. —This letter is written in response to a previous letter to the editor from Dr Witten 1 and a response from Dr Eddy 2 published in the February 26, 1992, issue ofThe Journal. Both Witten's letter and Eddy's response indicate a lack of understanding of this aspect of the proposed Oregon Health Plan. Witten asks, "Are the patients expected to screen their visits to the physician according to whether or not the diagnosis is covered by Medicaid?" The proposed Oregon Health Plan covers all diagnostic visits. It was our philosophy that the decision as to whether treatment should be covered could not be made until the diagnosis was known; therefore, diagnostic visits and evaluations would be covered. In the examples that Witten and Eddy cited—diaper rash, pharyngitis, and superficial wounds—the patient could be seen by the doctor and a diagnosis could be made. That diagnostic visit

The Oregon Health Plan: to cover all diagnostic visits

The Oregon Health Plan: to cover all diagnostic visits

The Oregon Health Plan: To Cover All Diagnostic Visits-Reply

In Reply —I appreciate Dr Wopat's clarification of this issue. Given that Medicaid would pay for all initial diagnostic visits, the burden on physicians of failure to pay for treatments below the line would be even less than I described in my response to Dr Witten's letter. This letter was shown to Dr Witten, who declined to reply. —Ed.

Diagnostic Testing and Return Visits for Acute Problems in Prepaid, Case-Managed Medicaid Plans Compared With Fee-for-Service

Enrollment of Medicaid recipients into capitated, case-managed systems of health care has been advocated as a means to control costs. We studied the effect of such systems on care for urinary tract infection (UTI), pelvic inflammatory disease, and vaginitis among women enrolled in Aid to Families with Dependent Children in capitated demonstration programs in Santa Barbara County, California, and Jackson County, Missouri (prepaid), compared with similar but fee-for-service (FFS) counties in Ventura County, California, and St Louis, Mo. Structured abstracts were performed on 2382 outpatient charts with one of the three conditions in 1985. The proportion of cases with UTI in which a urine culture was obtained was similar in Santa Barbara (prepaid) and Ventura (FFS), 47% vs 46%, but greater in Jackson County (prepaid) than St Louis (FFS), 58% vs 32%. The proportion of cases with return visits for a UTI was: Santa Barbara (prepaid), 40%; Ventura (FFS), 33%; Jackson (prepaid), 72%; and St Louis (FFS), 53%. The proportion of patients with pelvic inflammatory disease with cervical cultures for gonorrhea as Santa Barbara (prepaid), 81%; Ventura (FFS), 52%; Jackson (prepaid), 86%; and St Louis (FFS), 61%. The proportion of women returning for follow-up after pelvic inflammatory disease was similar across all counties at 40% and 50%. The number of office diagnostic tests performed for vaginitis was greater in both demonstration counties. These data do not demonstrate any diminution in either diagnostic testing or follow-up visits for three common ambulatory problems in a Medicaid population enrolled in a capitated, case-managed system, with some trends for more care in the demonstration sites.

Effect of extractable zinc, phosphorus, and soil ph on zinc concentrations in leaves of field‐grown corn

Abstract The variability in corn yield responses to applications of Zn fertilizer appears to be associated with several complex soil and climatic factors that affect the availability of endogenous soil Zn to the crop under specific conditions. Among the soil chemical properties that influence availability of endogenous Zn are soil pH, organic matter content, and extractable P. Over a period of several years, soil and plant analysis data were collected from 54 field experiments, field trials, and diagnostic visits to producer's fields. These data were subjected to multiple regression analysis, resulting in an equation: Znleaf = 37.14 + 1.513 Znst ‐4.04 pHst ‐ 1.791 ln(Pst/100) where Znst, pHst, and Pst were 0.1N HC1 extractable soil Zn (kg/ha), 1:1 soil‐water pH, and Bray's 1 extractable soil P (kg/ha), respectively. These factors accounted for 67% of variation in leaf Zn, which was a large portion of the variability in Znleaf considering that climatic conditions, management levels, and varietal difference...

A systems approach to patient care, curriculum, and research in family practice.

The system of data recording and retrieval which defines a family practice population of patients is described. It is organized at two levels, as a series of manual instruments or as a single instrument used as data input to a computer. Depending on resources available, it is possible to record demographic and morbidity data from the patient populations of both teaching and nonteaching practices. Data have been collected from a patient population of 88,000 in 26 practicing sites in Virginia, totaling 380,000 diagnostic and follow-up visits. Presentations are made of some of this data. The costs of this recording process in nonteaching practices, the use of such data as an educational resource for the training of primary care physicians, and the evaluations of health care delivered are discussed.