Follow-up Office Visits Research Articles

Glaucoma Management among Individuals Enrolled in a Single Comprehensive Insurance Plan

To determine the management patterns for glaucoma and suspect glaucoma in a nationally representative sample of newly treated persons. Retrospective cohort study of persons enrolled in a large managed care organization. One thousand seven hundred twelve diagnosed suspects and 3623 diagnosed glaucoma patients. Linked pharmacy and patient care data were used to examine the glaucoma management and treatment patterns in this cohort of persons insured by a single managed care organization. Rates of monitoring and treatment were calculated for the 3 study groups. Probability of monitoring (return visits, visual fields [VFs], and optic nerve head imaging or photography) and treatment (argon laser trabeculoplasty [ALT] and surgery) for newly treated persons with suspect and glaucoma diagnoses. After a median follow-up of 440 days, 83% of treated diagnosed suspects had had a billed follow-up office visit to either an optometrist or an ophthalmologist at any time during follow-up, 46% had had at least one billed VF, and 13% had had some form of optic nerve head imaging. Rates were slightly higher for those with diagnosed glaucoma (P>0.05). Surgery and ALT were performed rarely in this treated population (1%-6% at 2 years). This study suggests that a large proportion of individuals felt to require treatment for glaucoma or suspect glaucoma are falling out of care and are being monitored at rates lower than expected from recommendations of published guidelines. More research is needed to confirm these findings and to determine the reasons for loss to follow-up and low monitoring rates.

Developmental Screening/Testing Coding Fact Sheet for Primary Care Pediatricians

Developmental Screening/Testing Coding Fact Sheet for Primary Care Pediatricians

Prospective, Randomized, Controlled Clinical Trial of a Novel Matrix Hemostatic Sealant in Patients with Acute Anterior Epistaxis

Floseal, a novel hemostatic sealant composed of collagen-derived particles and topical bovine-derived thrombin, is applied as a high-viscosity gel for hemostasis. This study is a prospective, randomized, controlled clinical trial of Floseal compared with nasal packing in patients with acute anterior epistaxis. Institutional review board-approved, prospective, randomized, controlled, nonblinded, crossover clinical trial. Seventy consecutive patients presenting with acute anterior epistaxis were randomized to receive Floseal or nasal packing for control. Patients were crossed over to the other technique after two unsuccessful attempts of the first technique. Patients were seen in the clinic within 7 days for follow-up. Ten-point visual analogue scales were used to rank effectiveness (1 = ineffective, 10 = effective), physician technical ease (1 = difficult, 10 = easy), physician satisfaction (1 = unsatisfied, 10 = satisfied), patient discomfort during hemostasis (0 = none, 9 = unbearable), patient discomfort at follow-up office visit, and patient satisfaction. Additional data included need for subspecialist consultation to control bleeding, rebleeding rates within 7 days, and rebleeding at follow-up visit. Floseal (n = 35) was judged by physicians to be more effective than nasal packing (n = 35) at initial control of anterior epistaxis (9.9 vs. 7.7, P < .001). Physicians found Floseal to be easier to use (9.4 vs. 3.2, P < .001) and were more satisfied with Floseal (9.6 vs. 3.5, P < .001). Patients experienced less discomfort with Floseal than with nasal packing both at initial control (1.4 vs. 8.9, P < .001) and at follow-up visit (0.0 vs. 8.5, P < .001), and Floseal patients were more satisfied overall (9.1 vs. 2.9, P < .001). Fewer in-person otolaryngology consultations were requested for Floseal patients (8.6% vs. 31.0%, P < .05). Floseal patients experienced fewer rebleeding rates within 7 days (14% vs. 40%, P < .05). Rebleeding rates at follow-up visit were higher in the nasal packing than the Floseal group at time of packing removal (63% vs. 0%, P < .001). Eight (23%) patients were crossed over from the nasal packing group to the Floseal group when nasal packing was ineffective. One Floseal patient (3%, P < .05) was crossed over into the nasal packing group. There were no complications in either group. Floseal hemostatic sealant is a better tolerated, more effective, safe, and easy alternative to nasal packing in patients presenting with acute anterior epistaxis. Future studies may wish to evaluate Floseal's use in posterior epistaxis.

Effects of increased primary care access on process of care and health outcomes among patients with asthma who frequent emergency departments

Many asthmatic patients discharged from emergency departments do not have timely follow-up visits with a primary care physician. This study was conducted to determine the effectiveness of a health professional-based intervention in improving process of care and health outcomes among asthmatic patients discharged from emergency departments. We enrolled 125 asthmatic patients, aged 5 through 50 years, from the emergency department of a community-based hospital; 62 patients were assigned to usual care and 63 to enhanced care. Enhanced care consisted of usual care plus employment of a coordinator to make follow-up appointments with the patient's primary care physician with at least one reminder telephone call to the patient. At 6 months of follow-up, mean (+/- SD) asthma and pediatric quality-of-life scores were higher in the enhanced care group than in the usual care group (5.7 +/- 1.2 units vs. 5.0 +/- 1.3 units, P = 0.01). The enhanced care group also had a higher rate of follow-up office visits (78% [n = 44] vs. 60% [n = 33], P = 0.003), were more likely to have written action plans (46% [n = 26] vs. 25% [n = 14], P = 0.02), and had fewer asthma symptoms (1.8 +/- 1.1 units vs. 2.2 +/- 1.3 units, P = 0.09). However, these differences disappeared by 12 months of follow-up. A simple intervention wherein a health professional facilitates follow-up visits can improve the process of care and health outcomes of high-risk asthmatic patients. However, the effect of this intervention is time limited and largely wears off by 12 months.

How much variation in clinical activity is there between general practitioners? A multi-level analysis of decision-making in primary care.

There is considerable policy interest in medical practice variation (MPV). Although the extent of MPV has been quantified for secondary care, this has not been investigated adequately in general practice. Technical obstacles to such analyses have been presented by the reliance on ecological small area variation (SAV) data, the binary nature of many clinical outcomes in primary care and by diagnostic variability. The study seeks to quantify the extent of variation in clinical activity between general practitioners by addressing these problems. A survey of nearly 10 000 encounters drawn from a representative sample of general practitioners in the Waikato region of New Zealand was carried out in the period 1991-1992. Participating doctors recorded all details of clinical activity for a sample of encounters. Measures used in this analysis are the issuing of a prescription, the ordering of a laboratory test or radiology examination, and the recommendation of a future follow-up office visit at a specified date. An innovative statistical technique is adopted to assess the allocation of variance for binary outcomes within a multi-level analysis of decision-making. As expected, there was considerable variability between doctors in levels of prescribing, ordering of investigations and requests for follow up. These differences persisted after controlling for case-mix and patient and practitioner attributes. However, analysis of the components of variance suggested that less than 10% of remaining variability occurred at the practitioner level for any of the measures of clinical activity. Further analysis of a single diagnostic group--upper respiratory tract infection--marginally increased the practitioner contribution. The amount of variability in clinical activity that can definitively be linked to the practitioner in primary care is similar to that recorded in studies of the secondary sector. With primary care doctors increasingly being grouped into larger professional organisations, we can expect application of multi-level techniques to the analysis of clinical activity in primary care at different levels of organisational complexity.

When is Medical Prophylaxis Cost-effective for Recurrent Calcium Stones?

Medical management is generally recommended for recurrent calcium stones to prevent future episodes. However, in this era of extracorporeal shock wave lithotripsy and outpatient ureteroscopy it is not known whether medical prophylaxis is more cost-effective than treatment of recurrent stone episodes. The cost of medical prophylaxis was compared with the cost of clinically managing recurrent stone episodes, and the stone recurrence rate without prophylaxis (stone frequency) at which these 2 treatment approaches became cost equivalent was determined. An international cost survey was conducted in 10 countries to compare costs of medical prophylaxis and managing recurrent acute stone episodes. Costs of an acute stone episode included an emergency room visit, associated radiographic imaging to confirm diagnosis of a symptomatic stone and outpatient treatment of upper urinary tract stones that did not pass spontaneously. Costs of medical management included an initial limited metabolic evaluation, drug therapy, a followup office visit every 6 months that included a 24-hour urinalysis and radiographic imaging of the kidneys, ureters and bladder once a year. Costs of medical prophylaxis and managing an acute stone episode varied significantly from country to country. The stone frequency at which costs of these management options became equivalent ranged from 0.3 to 4 stone episodes a year. Medical management of a first stone episode is not cost-effective. Cost analysis should be individualized for specific health care plans to determine which practice patterns are most cost-effective for a particular patient with recurrent calcium stone formation.

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study

PurposeTo examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD). Subjects and methodsWe used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days. ResultsThere were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income. ConclusionAlthough these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.

Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis.

To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis. Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires. Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax. Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.

Do physician practice styles persist over time? Continuities in patterns of clinical decision-making among general practitioners.

This study seeks to determine whether there are identifiable differences in patterns of clinical decision-making among family physicians, and whether these patterns persist over time. A representative cross-sectional survey of general practice encounters in the Waikato region of New Zealand in 1979-1980 was repeated in 1991-1992. Patterns of clinical decision-making were operationalised as practitioner rates for writing a prescription, ordering a laboratory test or radiological examination and the recommendation of a future follow-up office visit at a specified date. Comparable data were available for a cohort of 50 physicians in both surveys. Multi-level techniques and a simulation exercise were used to study the patterns of decision-making over time. Raw, unadjusted correlations for the 50 family physicians between the two surveys were 0.24, 0.14 and 0.55 for rates of prescribing, investigations and follow-up, respectively. However, these correlations increased substantially, to 0.55, 0.41 and 0.70, once account was taken of case mix, data clustering and inter-practitioner variation in patient sample size. The extent of this recovery of the underlying correlations was confirmed in a parallel simulation exercise. This study confirms the existence of substantial and durable individual practice styles in primary medical care, with implications for the development and successful implementation of clinical guidelines.

Economics, health-related quality of life, and cost-effectiveness methods for the TACTICS (Treat Angina with Aggrastat ® [tirofiban] and Determine Cost of Therapy with Invasive or Conservative Strategy)–TIMI 18 trial

Concern over escalating health care costs has led to increasing focus on economics and assessment of outcome measures for expensive forms of therapy. This is being investigated in the Treat Angina With Aggrastat ® [tirofiban] and Determine Cost of Therapy with Invasive or Conservative Strategy (TACTICS)-TIMI 18 trial, a randomized trial comparing outcome of patients with unstable angina or non–Q-wave myocardial infarction treated with tirofiban and then randomized to an invasive versus a conservative strategy. Hospital and professional costs initially and over 6 months, including outpatient costs, will be assessed. Hospital costs will be determined for patients in the United States from the UB92 formulation of the hospital bill, with costs derived from charges using departmental cost to charge ratios. Professional costs will be determined by accounting for professional services and then converted to resource units using the Resource Based Relative Value Scale and then to costs using the Medicare conversion factor. Follow-up resource consumption, including medications, testing and office visits, will be carefully measured with a Patient Economic Form, and converted to costs from the Medicare fee schedule. Health-related quality of life will be assessed with a specific instrument, the Seattle Angina Questionnaire, and a general instrument, the Health Utilities Index at baseline, 1, and 6 months. The Health Utilities Index will also be used to construct a utility. By knowing utility and survival, quality-adjusted life years will be determined. These measures will permit the performance of a cost-effectiveness analysis, with the cost-effectiveness of the invasive strategy defined and the difference in cost between the invasive and conservative strategies divided by the difference in quality-adjusted life years. The economic and health-related quality of life aspects of TACTICS-TIMI 18 are an integral part of the study design and will provide a comprehensive understanding of the impact of invasive versus conservative management strategies on a broad range of outcomes after hospitalization for unstable angina or non–Q-wave myocardial infarction.

Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography.

A prospective study to determine the long-term outcome of traumatically induced vertebral artery injuries. Magnetic resonance angiography was performed at the time of cervical injury and at a follow-up office visit. To determine the long-term outcome in terms of arterial flow competency of traumatically induced vertebral artery injuries. Vertebral artery injury associated with cervical spine trauma has been well documented; however its healing or nonhealing potential has not been elucidated. During the 7-month period from July 1993 to January 1994, all patients admitted to the authors' institution with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of the cervical spine to determine the patency of their vertebral arteries. Magnetic resonance angiography was performed at the time of injury and at a follow-up office visit. Twelve of 61 patients were found to have a lack of signal flow within one of their vertebral vessels during this study period. Eighty-three percent of the patients (five of six) who were available for follow-up observation in this study did not manifest flow reconstitution of their vertebral arteries after an average 25.8-month follow-up period. According to these data, most patients with vertebral artery injuries after nonpenetrating cervical spine trauma do not reconstitute flow in the injured vertebral arteries. This lack of flow must be considered if future surgery in this region of the cervical spine is contemplated.

A model to structure student learning in ambulatory care settings.

Providing students with an explicit framework for conducting patients' follow-up visits can ease students' transition into ambulatory care settings and enhance their learning. The authors describe a model that structures and defines students' tasks for a follow-up office visit. The model gives priority to the organization of patient care issues, the efficient use of patient and preceptor time, and the student's identification of a learning agenda for each patient encounter. In a rapidly expanding managed care world where physician and practice productivity are paramount, this model has the potential to enhance standardization of learning across diverse clinical sites and to increase the cost-effectiveness of teaching medical students in ambulatory settings. The authors have introduced this model in a half-day orientation for a primary care clerkship. Initial feedback suggests that the model is useful in preparing students to function more effectively in an ambulatory care setting.

Tumescent Liposuction and Improved Postoperative Care Using Tumescent Liposuction Garments™

The tumescent technique for liposuction, using large volumes of dilute lidocaine and epinephrine infiltrated into subcutaneous fat, has improved safety by eliminating the risks of general anesthesia and the massive blood loss associated with older techniques. This article describes the results of the author's search for ways to optimize patient care after tumescent liposuction. The tumescent technique has dramatically improved postoperative comfort and accelerated recovery time. Using microcannulas and multiple incisions for cannula access, leaving the incisions open without sutures, and wearing a specially designed Tumescent Liposuction (TLG) Garment for compression, patients return to work in 1 to 2 days, and the first postoperative follow-up office visit is 5 to 6 weeks after surgery.

A Cost Analysis of Topical Drug Regimens for Dermatophyte Infections

To examine the extra cost of using higher-priced drugs as initial therapy for dermatophyte infections, because the many available effective drugs vary considerably in cost. Cost analysis from the purchaser's perspective, comparing two prototypical regimens to treat tinea pedis: one in which all patients initially receive a lower-priced drug and those with unresponsive infections receive a higher-priced drug at a follow-up office visit, and one in which all patients receive the higher-priced drug from the outset. The reference drug was miconazole, an imidazole available without a prescription, for which reported overall efficacy rates are 70% to 100%. The threshold efficacy rate (the efficacy rate of miconazole below which it is always less expensive to use a specific higher-priced drug first) and the extra cost (of beginning therapy with a higher-priced drug). Assuming the Medicare-approved charge for a follow-up visit ($21.98), it is less expensive to begin therapy with a prescription drug only if the efficacy rate of miconazole is less than 55%; this threshold efficacy rate varied from 26% (for a $0 total cost of the follow-up visit) to 79% (for an $89 total cost of the follow-up visit). If the efficacy rate of miconazole is 70%, the extra cost per patient for all patients to receive the least expensive prescription antifungal drug instead of miconazole first was $15.23 and $8.64 if total visit costs were $0 and $21.98; miconazole remained the less expensive alternative as long as the total cost of the follow-up visit was less than $50.76. For reported efficacy rates and standard costs of a follow-up office visit, using miconazole first and then treating only those patients with unresponsive infections with a higher-priced prescription drug is less expensive than treating all patients with the higher-priced drug.

Reduction in medical care cost associated with radiofrequency catheter ablation of accessory pathways

The cost of definitive therapy was compared in 25 patients who underwent radiofrequency catheter ablation of accessory pathways in 1990 and 25 patients who underwent surgical ablation of accessory pathways in 1989. In the radiofrequency group, 23 of 25 patients had a single accessory pathway and the remaining 2 patients each had 2 accessory pathways. In the surgical group, 20 patients had a single accessory pathway and 5 patients each had 2 accessory pathways. The success rate was 96% in each group. The mean duration of hospitalization was 3 ± 1 days in the radiofrequency group and 9 ± 4 days in the surgical group (p < 0.0001). All the cost data are expressed in fiscal year 1990/1991 dollar values. The total cost of therapy in the radiofrequency group was $14,919 ± $6,740 compared with $53,265 ± $12,755 in the surgical group (p < 0.0001). The cost of radiofrequency ablation consisted of a hospital charge of $7,753 ± $3,472 and physician fees of $7,166 ± $3,439. The hospital charge included charges for use of the electrophysiology laboratory, hospital stay, electrocardiograms, echocardiograms and blood studies. The cost of surgery consisted of a hospital charge of $37,708 ± $10,179 and physician fees of $15,557 ± $3,149. The hospital charge in the surgical group included the costs of a baseline electrophysiology study, in-hospital care and a follow-up office visit. In conclusion, radiofrequency catheter ablation of accessory pathways results in a dramatic reduction in the cost of definitive therapy in patients with the Wolff-Parkinson-White syndrome.

Maintenance of home hyperalimentation in patients with high-output jejunostomies.

We studied four patients with high-output end jejunostomies (greater than 3,000 mL/day) who were receiving home hyperalimentation. With knowledge of urine and stoma output, standard total parenteral nutrition fluid was infused and titrated according to individual needs, first during the hospital stay and then on follow-up office visits. Mean daily stoma output for the group was 3,556 mL/day. With oral fluid intake restricted to 1,500 mL/day, average daily stoma output dropped to 2,892 mL. The mean daily volume of nutrient fluid required to achieve stabel biochemistries and weight was 3,550 mL. Daily caloric requirements ranged from 23 kcal/kg to 44 kcal/kg, with a mean of 32.5 kcal/kg. Amino acid requirements averaged 1.6 g/kg. With 65 patient months of continuous overnight catheter infusion, there have been no serious metabolic derangements or deaths. The program of home hyperalimentation can maintain a satisfactory metabolic state in patients with high-output jejunostomies.