Freestanding Facilities Research Articles

For-Profit Versus Not-for-Profit Dialysis Care for Children With End Stage Renal Disease

Over the last 2 decades, for-profit dialysis units have become the most common providers of renal replacement therapy for adults with end stage renal disease (ESRD) and have had an increasing role in the dialysis of children. We undertook a study to determine whether dialysis facility profit status influences the choice of dialysis therapy in the pediatric population. Cross-sectional study of national data from the Health Care Financing Administration. Free-standing and hospital-based outpatient dialysis facilities in the United States. A total of 1568 children and adolescents (</=19 years of age) eligible for US Medicare ESRD benefits in 1994. The association between dialysis modality choice and the profit status of the facility. Crude associations were estimated by the OR of a patient being treated with peritoneal dialysis (PD) versus hemodialysis at nonprofit versus for-profit facilities. Adjusted associations were estimated using logistic regression analysis. In bivariate analysis, children with ESRD dialyzed at nonprofit facilities were nearly three times as likely as those at for-profit facilities to be on PD (OR: 2.9; 95% CI: 2.3,3.6). In multivariate analysis, after controlling for patient age, sex, race, cause and duration of ESRD, free-standing versus hospital-based facility, and the pediatric expertise of the facility, patients at nonprofit facilities were more than twice as likely as those dialyzed at for-profit facilities to be on PD (OR: 2.3; 95% CI: 1.6, 3.4). After taking into account the clustering of patients within facilities, the association between nonprofit status and the use of PD persisted (OR: 2.2; 95% CI: 1.5,3.2). Children with ESRD treated at nonprofit facilities are more likely to receive PD than are those treated at for-profit facilities even after controlling for other patient and facility characteristics. This finding suggests that clinical decision making for pediatrics may be influenced by the ownership of the health care facility in which the patient is treated.

Ambulatory surgery:The growth of an industry

Over a short 30 years, ambulatory surgery has grown from a few freestanding facilities to a continuously growing industry. This article gives a historical overview of that growth, while specifically documenting the impact that competition, regulation, capitation, technology, and the consumer have on nursing and a single industry.

Outpatient Laparoscopic Cholecystectomy: What Predicts the Need for Admission ?

Laparoscopic cholecystectomy (LC) is commonly performed as an outpatient (OP) procedure in selected patients, either in ambulatory surgery units associated with a hospital or in freestanding facilities. To identify factors that may preclude OPLC, a retrospective analysis of all patients who underwent LC by two surgeons from August 1996 through June 1998 was performed. A total of 126 patients were divided into three groups. Group I comprised 102 patients who underwent attempted elective OPLC. Group II comprised 20 patients who underwent LC on an emergent basis. Group III comprised 5 patients who were admitted before LC. Data were gathered regarding patient demographics, preoperative diagnoses, preoperative laboratory values, length of stay after surgery, and complications. These data were analyzed using logistic regression and univariate analysis. Age >60 and American Society of Anesthesiologists (ASA) class >2 appeared to be significant predictors of admission, but when considered together, neither was significant. The diagnosis of acute cholecystitis or biliary pancreatitis was highly predictive of admission in both groups. An ASA class >2 did predict postoperative stay of more than 12 hours. These data suggest that OPLC can be performed safely in unselected patients. However, those patients with an ASA class >2 or with a diagnosis of biliary pancreatitis or acute cholecystitis are more likely to require admission or postoperative stay over 12 hours, and these criteria should be considered relative contraindications to OPLC in free-standing facilities.

A collaborative assessment of workload and patient care needs in four rehabilitation facilities.

This article describes the process used by nurse executives at four freestanding rehabilitation facilities to implement and validate an interactive patient classification system. The research process involved defining critical indicators, measuring workloads by level of staff, and validating the number of care hours for the levels of patient classification. The database enabled the four consortium members to share their knowledge, resources, and costs of implementing a patient classification system, and it provides a benchmark of rehabilitation services. The study data are being used in making staffing decisions, preparing and defending budgets, and identifying the cost of care by disability classification.

Results of the 1988–1989 patterns of care study process survey for Hodgkin’s disease

Purpose: To document national standards of care for patients receiving radiotherapy as part of curative treatment for Hodgkin’s disease. Materials and Methods: A national survey was conducted of 61 institutions treating 275 patients with Stages I–III Hodgkin’s disease and representing six facility type strata. Pretreatment evaluation, radiotherapy treatment parameters, and use of combined modality therapy were assessed. Results: Ann Arbor stage for the 275 patients was as follows: IA, 69 (25%); IB, 7 (3%); IIA, 123 (45%); IIB, 36 (13%); IIIA 23 (8%), IIIB, 14 (5%); unknown, 3 (1%). Pretreatment evaluation included complete blood count for 93%, sedimentation rate in 29%, chest CT in 88%, abdominal CT scan in 87%, and bone marrow biopsy in 81%. Lymphangiograms were obtained in 50% of cases; laparotomy was performed in 46%. The yield of positive findings in the spleen at laparotomy was 6.5% overall. Facility differences with respect to staging were seen only for the use of gallium scans, which were more commonly used in academic centers (44% vs. 15–23% elsewhere, p < 0.001). Radiotherapy was delivered with a linear accelerator in 94% of cases. Treatment simulation was performed for 94% and individualized blocks constructed for 95% overall; however, freestanding facilities had a lower rate of performance of these procedures (78% vs. 98–99% for simulation and 88% vs. 96–99% for customized blocking, p < 0.001). The mean supradiaphragmatic dose was 36.74 Gy and the mean subdiaphragmatic dose was 33.81 Gy. Planned combined modality therapy was given in 36% of patients. The use of combined modality therapy by stage was as follows: IA, 11%; IB, 43%; IIA, 30%; IIB, 68%; IIIA, 57%; IIIB, 100%. Chemotherapy was completed prior to radiation in 80% of cases and generally consisted of ABVD (32%), an alternating regimen (25%), or MOPP (22%). Among Stage I/II patients, use of chemotherapy was associated with reduced radiation doses (mean supradiaphragmatic dose 34.53 Gy vs. 38.43 Gy and mean subdiaphragmatic dose 31.27 Gy vs. 34.51 Gy), and reduced volumes of treatment (87% vs. 28% treated to one side of the diaphragm only). Laparotomy was not associated with decreased supra- or subdiaphragmatic radiation doses or decreased volumes of treatment. Conclusions: With the exception of gallium scans, pretreatment evaluation is relatively uniform across facility strata. Increased understanding of prognostic factors in Hodgkin’s disease and greater use of planned combined modality therapy for higher risk patients appears to have contributed to a decreased use of and low yield of positive findings for laparotomy. Laparotomy was not associated with reduced radiation volumes or doses. Freestanding radiation facilities had a lower rate than other facility types for the performance of treatment simulation and customized patient blocking.

The changing structure of radiation oncology: Implications for the era of managed care

This report presents results from the facilities surveys that are useful for radiation oncology practices facing the challenges of managed care. Facilities surveys collect data from the entire census of facilities practicing megavoltage radiation therapy. Data include equipment, personnel, and patient load. The data presented show that most, but not all, facilities throughout the United States are adequately equipped in terms of highest energy treatment machine, type of treatment planning computer, simulation, and quality assurance programs. The data also present the variation in percentage of new cancer cases receiving radiation therapy and repeat patients as a percentage of new radiation therapy cases by census region. The data show trends in patient load per type of personnel for academic, hospital-based, and freestanding facilities in 1994 show that academic facilities are larger and treat more patients per treatment machine. Academic facilities used more therapists per machine than other facilities.

Outcomes and Costs After Hip Fracture and Stroke&lt;subtitle&gt;A Comparison of Rehabilitation Settings&lt;/subtitle&gt;

To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes. Inception cohort stratified by provider type and followed prospectively for 6 months. A total of 92 hospital-based units and freestanding facilities from 17 states. A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994. At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments. On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients. Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.

Treatment planning for primary breast cancer: A patterns of care study

Purpose : The 1989 Patterns of Care Study included treatment planning or early breast cancer. A Consensus Committee of radiation physicists and oncologists determined current guidelines and developed questionnaires to determined treatment planning and delivery processes used by the participating institutions (e.g., use of portal films). This article present adn analyzes the results of that survey. Methods and Materials : The survey included 449 respondents, distributed as follows: 136 (30%) from Strata I (academic facilities); 169 (38%) from Strata II (hospital based facilities); and 144 (32%) from Strata III (freestanding facilities). The treatment planning procedures surveyed included: whether individualized tissue compensators are used, whether inhomogeneity corrections are used in dose calculations, the use of computerized tomography, whether isodose distributions for external beam tangents and interstitial implants are generated, the use of lymphoscintigraphy, immobilization devices, simulations, portal films, etc. Results : The survey results demonstrated that out of 305 patients from Strata I and II institutions, 237 (78%) had simulated tangential fields. Consistent with this finding is that 76% of patients from Strata I and II institutions were immobilized, while only 51% of Strata III patients were. Moreover, only 18 out of the 449 (4%) of cases did not have any type of external beam dose distribution calculated—presumably, in these cases missing tissue compensation would be unlikely. On the other hand, 41% of the Strata II, 27% of Strata III, but only 19% of Strata I ( p < 0.0002) cases received CT. Surprisingly, 19% of the Strata I, 35% of the Strata II, and 25% of the Strata III ( p = 0.0011) patients received lymphoscintigraphy, perhaps reflecting the use of wide tangents to encompass the internal mammary nodes in these patients. In terms of optmizing treatment, 74% of Strata I, 70% of Strata II, and 78% of Strata III patients had wedges used on both tangential fields, although in 5, 12, and 14%, respectively, no beam modification of any sort was used. Furthermore, it should be noted that in 7% of the Strata I, 23% of Strata II, and 37% of Strata III cases there was no attempt to reduced the divergence of the tangential fields into the lung. On the other hand, if one considers the 135 (of 449) patients where matching of the tangential and supraclavicular fields was applicable, 41% of Strata I, 22% of Strata II and 46% of Strata III patients had those fields matched in a vertical plane, which would involve sophisticated alignment procedures. Quality control of treatment delivery was high: 97% of all surveyed received portal films at least once. The use of thermoluminescent dosimetry (TLD) to measure the dose to the contralateral breast was of little interest: only 4 of the 305 Strata I and II patients received invivo measurements. Conclusions : This national survey has established the patterns of treatment planning for early breast cancer. It shows a generally consistent approach—although a number of statistically significant variations have been identified.

Hospice inpatient care: an overview of NHO's 1995 inpatient survey results.

Hospice inpatient care is currently provided through a variety of arrangements, including freestanding facilities, dedicated units, and contracted beds, but lack of standard definitions of the various types of arrangements has led to confusion about the number and type of facilities actually in operation. This study identified a total of 97 freestanding facilities and dedicated hospice units with a total of 1,165 beds. Fifty-six percent were freestanding facilities; the balance were units located within other facilities, primarily hospitals. Forty-six percent of the units provided mainly acute hospice care, 17% provided mainly residential care, and the balance mixed acute and residential care. Seventy-seven of these facilities were operational in 1994, and these were classified into five facility types. Length of stay for the acute level of care averaged 9.7 days with a median of 6.8 days for the 36 reporting facilities. Length of stay for residential care averaged 33.2 days with a median of 30 days for the 22 reporting facilities. Bed size, total inpatient days of care, average daily census, occupancy rate, and charges are also reported by facility type.

Competition under fixed prices: effects on patient selection and service strategies by hemodialysis providers.

Dialysis services for patients with end-stage renal disease (ESRD) are delivered by predominantly private providers competing in local markets. Because prices are fixed by Medicare, providers can only compete on product quality. Using 1990 data and multiple competition measures, this study examines how competition under fixed prices influences hemodialysis providers' strategies for patient selection and service levels. It finds that provider strategies vary with competition, but competitive effects are not dominant and they differ by provider type. Providers with greater competition accept more costly patients, suggesting that competition may be contributing to changes in the Medicare ESRD population to an older and sicker patient mix. Only hospital-based facilities use richer staffing in more competitive markets. For-profit, free-standing facilities in all markets have lean staffing. Rural facilities have higher staff productivity than facilities in concentrated urban markets.

Medicare's mental health benefits: coverage, use, and expenditures.

Estimates of the proportion of persons aged 65 and older with diagnosable mental disorders, residing both in the community and in institutions, range from 13.5% to 22%. Mental health services, both inpatient and outpatient, short and long term, are necessary for the well-being of these older Americans. Mental health benefits are covered under Medicare. However, less than 3% of the $90.5 billion Medicare budget in 1988 was spent on mental health services. Of that 3%, $2.2 billion was used for Part A (hospital insurance) and $300 million for Part B (medical insurance). In contrast, in the same year, payments for mental health services represented 20% to 30% of total health expenditures made by private insurers. Differences in payments abound when comparing freestanding psychiatric facilities with both exempt and nonexempt psychiatric units in general hospitals. This article describes these differences and how they influence the use of mental health services by Medicare beneficiaries.

Review of Efficiencies and Patient Satisfaction in Australian and New Zealand Day Surgery Units: A Pilot Study

A pilot study was performed in eight Australasian day surgery facilities with a purpose of identifying common trends and differences. A prospective study was designed in which information was collected on 826 patients over a two-week period. Patients were well matched for age, anaesthetic type and mean surgical time. Three facility types were identified and results were statistically corrected for any differences that ASA status, age and surgical time may have made. Patient preoperative waiting time, recovery room times, delayed discharge time and unanticipated admission rates showed favourable outcome trends for free-standing facilities compared with hospital-integrated facilities where day patients had a shared recovery with inpatients. Similar trends were seen with patient opinions of waiting times and recovery periods. In summary, this pilot study has demonstrated the impact of different facility types on efficiencies and patient satisfaction both of which have important cost implications and relevance to those involved in continuous quality improvement processes in day surgery.

Effect of Dialyzer Reuse on Survival of Patients Treated With Hemodialysis

To evaluate the impact of dialyzer reuse on the survival of US hemodialysis patients. Nonconcurrent cohort study of 27938 patients beginning hemodialysis in the United States in 1986 and 1987. Patient survival. Dialysis in freestanding facilities reprocessing dialyzers with the combination of peracetic and acetic acids was associated with greater mortality than treatment in facilities not reprocessing dialyzers (rate ratio [RR],1.10, 95% confidence interval [CI], 1.02-1.18; P=.02) In contrast, there was no significant difference between survival in freestanding facilities reprocessing dialyzers with either formaldehyde (RR,1.03, 95% CI, 0.96-1.10; P=.45) or glutaraldehyde (RR, 1.13, 95% CI, 0.95-1.35, P=.18) and survival in freestanding facilities not reprocessing dialyzers. Among freestanding facilities reprocessing dialyzers, use of peracetic/acetic acid was associated with a higher rate of death than use of formaldehyde (RR = 1.08, 95% CI, 1.01-1.14; P=.02). There was no statistical difference between survival in hospital-based facilities reprocessing dialyzers with either peracetic/acetic acid (RR=0.95, 95% CI, 0.85-1.06; P=.40), formaldehyde (RR=1.06, 95% CI, 0.98-1.15; P=.12), or glutaraldehyde (RR=1.09, 95% CI, 0.71-1.67; P=.70) and survival in hospital-based facilities not reprocessing dialyzers. In addition, choice of sterilant was not associated with a statistically significant difference in survival among hospital-based facilities reprocessing dialyzers. Dialysis in freestanding facilities reprocessing dialyzers with peracetic/acetic acid may be associated with worse survival than dialysis in free-standing facilities not reprocessing dialyzers or in those reprocessing with formaldehyde. We were unable to determine whether these relationships arose from greater comorbidity among patients treated in facilities using peracetic/acetic acid, poor quality of dialysis procedures in these facilities, or direct toxicity of peracetic/acetic acid. These findings raise important concerns about potentially avoidable mortality among US hemodialysis patients treated in dialysis facilities reprocessing hemodialyzers.

Patterns of care survey results: Treatment planning for carcinoma of the prostate

Treatment planning has been defined differently at various institutions to encompass tasks ranging from the initial evaluation of the patient to the delivery of the treatment as well as a more narrow view, focused primarily on isodose computation. To evaluate the impact of much of the new treatment-planning technology that has become available, it is necessary to define and develop recommended guidelines for the treatment-planning process. The 1989 Patterns of Care Study (PCS) included questionnaires to access treatment planning practices currently in use for the entire census of oncology facilities in the United States. These questionnaires were developed by a consensus committee consisting of both physicists and radiation oncologists whose charge was to formulate a description of current treatment-planning practices. The description was based on the committee's experience and knowledge of the treatment-planning process considered to be widely available and in general use, as well as a review of the literature. From the description of the treatment-planning process, a set of guidelines for treatment planning was developed for prostate as well as each of the other disease sites included in the PCS. Data from the study defined the general structure, methodology, process, and tools used by each institution involved in the Patterns of Care Survey Study. National averages for all of the variables were calculated with weighted averages, with the weights reflecting the sample design and number of patients in the different types of facilities. The data were stratified according to academic, hospital, or free-standing facility and were compared with the Consensus Guidelines for Treatment Planning of the Prostate. Based on the consensus statement, the treatment-planning process was separated into the following categories: (a) Treatment-Planning Workup, (b) Treatment Plan Implementation, (c) Treatment Delivery, (d) Treatment Verification, and (e) Quality Assurance. The results from the survey were summarized for each category and compared with the consensus statement. Although there is an increasing trend toward using computed tomography (CT) information to acquire individualized patient data, volume definition and localization are often completed in the simulator without the direct use of CT information (47%). As more sophisticated beam arrangements and blocking are used, one needs to look at the full three-dimensional (3D) volume to ensure that there are no marginal misses due to blocking and beam arrangement. Improved and more widespread use of immobilization devices is also required with conformal treatments and reduced margins. The results of the survey helped to identify and establish the standard of practice for treatment planning of the prostate as well as to provide documentation for better defining a complete description of the treatment planning process. Well-documented guidelines will provide more consistent treatment of patients, which should have an impact on outcome.

Treatment planning structure and process in the united states: A “Patterns of care” study

Purpose : To conduct a study of the structure and process of treatment planning in the United States. Methods and Materials : A Patterns of Care treatment planning consensus committee developed a survey form that was used to gather data for 106 items relating to the structure and process of treatment planning. These questions were general in nature and not specific to any particular disease site. Seventy-three facilities were randomly selected for site visits from the 1321 radiation therapy facilities in the United States: 21 academic, 26 hospital, and 26 free-standing. During the site visit the facility physicist, assisted by the site-visit physicist, completed the form. Results : Twenty-nine percent of facilities have cobalt-60 machines; 25% have 4 MV linacs; 75% have photon energies in the range of 5–8 mV; and less than 10% have energies greater than 20 MV. Academic facilities led hospital and free-standing facilities by about 30 percentage points in the availability of all electron energies (88 vs. 58%, approximately, in the rage 4–13 MeV and scaling downward to about 60 vs. 30% at the highest energies). The national averages for the availability of Cs-137, Ir-192, and I-125 were 87, 73, and 44%, respectively. Computerized tomography (CT) scanning is not available or not used in 15% of hospital and free-standing facilities. Ninety-six percent of facilities have treatment planning computers; at 10% of facilities physicians do not participate in treatment planning. The estimated national averages of facilities having formal quality assurance (QA) programs for treatment planning systems, simulators, film processors, and blocking systems are 44, 79, 62, and 55%, respectively. Sixty-three percent of facilities obtain independent machine calibrations. Conclusion : This is the first patterns of treatment planning study carried out in the United States and the results reported here will establish a baseline for future studies. The present study has identified some elements that were unexpected, such as the percentage of facilities lacking formal QA programs for treatment planning systems; however, it has not established any impact of such findings. It is recommended that future studies include the availability of new technologies such as multileaf collimation, dynamic wedges, digital portal imaging, and CT simulation. With the increasing nationwide concern with the cost of health care, we must continue to monitor the implementation, use, and impact on treatment outcome of new and expensive technologies.

Creation of a Tuberculosis Directly Observed Therapy Provider Network in New York City: A New Model of Public Health

A 1990-1991 New York State Department of Health (NYSDOH) assessment of the ongoing tuberculosis (TB) epidemic in New York City (NYC) led to legislative enactment of policy recommendations to help stem the epidemic. The principal strategy entailed mobilization of community resources for TB directly observed therapy (DOT) to supplement the DOT available from the NYC Department of Health (NYCDOH). For implementation, the NYSDOH engaged a coalition of public and private health care providers in a TB DOT Provider Network. Network participants include freestanding facilities, many of which already have preexisting affiliative relationships through which DOT can be extended. The number of individuals receiving DOT in NYC has increased more than 10-fold in two years. Over 1,000 individuals have completed their anti-TB treatment while enrolled in the network.

Quality improvement in ambulatory surgery — the US perspective

Continuous evaluation of performance and outcomes leading to improvement is currently the focus of continuous quality improvement (CQI) programmes in ambulatory surgery. This can be implemented by developing clinical indicators and acceptable thresholds that are relevant to daily practice, easy to measure and can be used to initiate the analytic process. Collection of data without the ability to analyse it or develop corrective measures is futile. A cooperative effort between physicians, nurses, administrators and other personnel is essential in identifying the responsible individuals for facilitating the programme. Steps in developing a hospital-integrated and free-standing facility are provided and several examples described.

Critical decisions in 22 years of outpatient laparoscopy

More than 2400 single-incision outpatient laparoscopic operations for sterilization or diagnosis performed by the author over the past 22 years have been influenced by seven critical decisions which were made after reviewing all of the options: 1. Perform procedures on all cooperative patients in free-standing facilities, except in cases with serious medical disorders which require elaborate safeguards and the presence of an anesthesiologist. 2. Administer local anesthesia in all cases. 3. Use the Hasson cannula with blunt obturator for open abdominal entry in every case. 4. Abandon tubal coagulation for sterilization. Instead, perform mechanical tubal occlusion with the Hulka-Lexan Clip. 5. Instill low-volume filtered room air for pneumoperitoneum in place of nitrous oxide. 6. Enter the abdomen through the umbilical fossa in all obese women instead of through the lower rim of the umbilicus. 7. As preliminary steps in abdominal entry in every patient, perforate the partially incised fascia and the parietal peritoneum with a small Kelly clamp or hemostat instead of a scalpel. Each of these seven decisions has, in the author's opinion, improved the technique and safety of outpatient laparoscopy.

The Relationship of Provider Organizational Status and Erythropoietin Dosing in End Stage Renal Disease Patients

Controversy exists as to whether provider organizational characteristics such as profit status and setting are associated with the content of medical care or efficiency with which care is rendered. Following FDA approval of human recombinant erythropoietin (EPO) for use in clinical practice, Medicare approved coverage for beneficiaries in its end stage renal disease program and established a fixed payment per dose. Because cost of EPO administration varied positively with dose, providers could realize larger profit with prescription of smaller doses. We used Medicare claims data to assess EPO use by renal dialysis providers one year after FDA approval (June 1990) as a function of provider ownership (for-profit, not-for-profit, government agency) and setting (hospital-based, free-standing). Mean dose of EPO was 236 units greater (P = 0.0001) for not-for-profit freestanding facilities, 593 units greater (P = 0.0001) for government facilities, and 555 units greater for not-for-profit hospitals (P = 0.0001) than among for-profit freestanding providers. With fixed payment per dose of EPO, for-profit, freestanding providers prescribed EPO more often and administered smaller doses than not-for-profit or government providers, behavior that is consistent with profit maximization.

Underutilization of physician assistants in physical medicine and rehabilitation.

This study was undertaken to determine the utilization of physician assistants (PAs) in physical medicine and rehabilitation (PM&R). Survey questionnaires were sent to members of the American Academy of Physical Medicine and Rehabilitation, members of the American Academy of Physician Assistants, and administrators of free-standing rehabilitation facilities. One hundred thirty-seven of 1,082 physiatrists (13% of those responding) reported PAs employed in their practice settings, 83 of 549 PAs (15% of those responding) identified PM&R as their specialty, and 17 of 65 hospital administrators, (27% of those responding) reported PAs working at their facility. Seventy-nine percent (713 of 903) of physicians and 77% (50 of 65) of administrators were unaware that PA services provided in inpatient settings are reimbursed by Medicare. Eighty-four percent (108 of 129) of physiatrists employing PAs indicated that they would continue to do so even if the supply of physiatrists were adequate. PA responsibilities were concentrated in inpatient clinical areas. It is concluded that PAs are an underutilized source of health care for rehabilitation patients. Increased professional visibility and formal specialty training are recommended to enhance their contribution to the field.