Number Of Office Visits Research Articles

Healthcare Utilization in Community-Acquired Pneumonia Episodes of Care

Compare healthcare utilization and total payments for community-acquired pneumonia (CAP) episodes-of-care among 5 health plan designs spanning the continuum of managed care. Medical and prescription claims analysis of CAP episodes among enrollees of employer-sponsored health plans. Episode characteristics, healthcare utilization, and payments were compared across fee-for-service, Preferred Provider Organizations (PPO), point of service, partial capitation, and Health Maintenance Organizations as defined by the employers. Medstat Episode of Care Grouper Version 2.1.5 was employed to create episodes of CAP care. Categorical and continuous measures of patient and care characteristics across plan designs were compared by chi tests and one-way analysis-of-variance as appropriate. Total per-episode payments for provided services across plan designs were compared using a general linear model with a log-link function and gamma distribution. Greater average patient age, episode severity, number of office visits, rate of hospitalization, length of stay, and inpatient mortality overall were found within PPO episodes compared with all other plan designs. Total episode payments controlling for age, sex, disease severity, and geography were greatest among PPO episodes and attributed largely to more office visits and longer lengths of hospital stays compared with other plan types. As previously shown among other patient populations and conditions, PPO episodes of CAP are associated with greater total payments due in large part to increased resource utilization among the episodes of lowest severity.

Delayed Radionucleotide Gastric Emptying Studies Predict Morbidity in Diabetics with Symptoms of Gastroparesis

Purpose: Gastroparesis is a serious complication of diabetes mellitus (DM). However, little is known regarding the health implications of gastroparesis in diabetics. The specific aims of this study were to test the hypotheses that diabetic patients with proven gastroparesis differ from those with normal gastric emptying: 1: In the number of days spent in hospital per 1000 patient days, 2: In the prevalence of other manifestations of autonomic neuropathy and microvacular disease and 3: In blood glucose control. Methods: This was a parallel cohort study with 3 separate groups of DM patients (both Type 1 and Type 2) treated between 2000 and 2008. Group A: Gastroparesis diagnosed by both classic symptoms and a delay in gastric emptying on a radionucleotide gastric emptying study. Group B: Classic symptoms of gastroparesis but with a normal gastric emptying study. Group C: Patients without symptoms of gastroparesis (no gastric emptying study performed). We gathered data on subsequent health outcomes and resource utilization including: number of days hospitalized, number of office visits, number of ED visits, number of hospitalization and deaths in this eight-year period. We also collected data on HbA1C levels, medication use, medical history and complications of DM. Results: There were 94 subjects in each group. By univariate analysis Group A had significantly more Hospital Days per 1000 patient days than Group B. (See Table 1). Group A also had significantly more hospitalizations, office visits and ED visits. There was a trend toward more deaths per 1000 patient days in Group A compared to Group B. Compared to Group C, Group A again had significantly more days in hospital, hospitalizations, office visits and ED visits. None of these measures differed significantly between Group B and Group C with the exception of more office visits for Group B. HbA1Cs were similar in the 3 groups. Group A patients were more likely to have vascular disease (CAD, HTN, retinopathy) but not more likely to have neuropathy. On multivariate analysis, Group A maintained a significant difference vs. B and C and the differences between Groups B and C disappeared.Table 1Conclusion: In this study, a positive radionucleotide gastric emptying study for gastroparesis in diabetics was predictive of greater healthcare utilization in terms of number of hospitalizations, number of office visits, number of ED visits and number of days in hospital. Risk of death was also increased but did not reach statistical significance. We also identified a correlation between diabetic gastroparesis and CAD and HTN which has not previously been reported. These data suggest that a positive radionucleotide gastric emptying study is of clinical and prognostic significance.

Dosing and Outcomes Study of Erythropoiesis-Stimulating Therapies (DOSE)

To report the design, methodology, implementation and initial results of the Dosing and Outcomes Study of Erythropoiesis-Stimulating Therapies (DOSE) Registry, the first US patient registry to collect and report on practice patterns and outcomes associated with erythropoiesis-stimulating therapy (EST) for anaemia management in oncology patients. DOSE is a prospective ongoing registry of oncology patients treated with epoetin-alpha or darbepoetin-alpha. Patients from either community or academic centres who meet prespecified entry criteria are eligible for inclusion in the registry. Data collected include patient demographic and clinical characteristics, EST administration, haematological parameters, patient-reported outcomes and medical resource utilization. Patients are followed from EST initiation through to the end of therapy or 16 weeks, whichever is earlier. Initial results from 45 sites for 861 patients (epoetin-alpha, n = 312; darbepoetin-alpha, n = 549) showed that baseline demographic and disease characteristics were similar between the two treatment groups. Administration of EST at both weekly and > or =2-weekly intervals was observed in both groups, with similar numbers of haemoglobin determinations. However, the mean number of office visits was higher in the darbepoetin-alpha group despite more frequent administration of therapy at > or =2-weekly intervals in this group. Mean treatment duration was approximately 8 weeks for both groups. Mean post-baseline haemoglobin levels of 11-12 g/dL were achieved and maintained at all timepoints assessed with epoetin-alpha but not with darbepoetin-alpha. Both groups had similar rates of packed red blood cell transfusions. The DOSE Registry is a valuable source of data relating to anaemia management, practice patterns and outcomes in oncology patients from the perspective of actual clinical practice. Results from this registry should provide patients, clinicians and healthcare decision makers with a better understanding of the relationship between EST dosage and outcomes in the clinical setting.

Protecting Low-Income Children's Access to Care: Are Physician Visits Associated With Reduced Patient Dropout From Medicaid and the Children's Health Insurance Program?

Dropout among patients who are enrolled in Medicaid and the Children's Health Insurance Program contributes to a lack of health care access among millions of Americans. The purpose of this study was to determine which, if any, types of clinical contact with physicians are associated with reduced dropout among children who are enrolled in Medicaid and the Children's Health Insurance Program. The data are from the nationally representative Medical Expenditure Panel Survey, 1998-2002. The sample is composed of all children (n = 3043) who were reported to have Medicaid or Children's Health Insurance Program coverage throughout their first year in the survey and who did not acquire other insurance during the study period. The outcome measure is whether an individual remained enrolled in Medicaid or the Children's Health Insurance Program by the end of the following year. Exposure variables were clinical contact during an individual's first year in the survey: numbers of office visits, hospital outpatient department visits, emergency department visits, inpatient hospital stays, and dental visits. The analysis uses multivariate logistic regression to control for patient and family characteristics-most important, health status, functional status, and overall health care expenditures. Eight percent of the children in the sample had left Medicaid/the Children's Health Insurance Program by the end of the second year in the survey. More frequent contact with clinicians in an office setting was associated with a significantly lower risk for dropping out of Medicaid/the Children's Health Insurance Program among children, even controlling for demographics, health and functional status, and overall health care expenditures. After multivariate adjustment, more frequent contact in hospital outpatient departments also was associated with reduced dropout, with a borderline statistically significant odds ratio. Notably, emergency visits and inpatient stays were not associated with any significant change in the risk of Medicaid/Children's Health Insurance Program dropout. These results suggest that some but not all types of clinician visits are serving an important function in maintaining Medicaid and the Children's Health Insurance Program coverage among low-income patients. Two possible approaches to improve access to care among low-income children therefore would be (1) increased awareness among clinicians, especially in hospitals and emergency departments, regarding Medicaid/Children's Health Insurance Program retention as an issue in the ongoing care of their patients and (2) Medicaid/Children's Health Insurance Program reimbursement of clinicians and their staff for assisting patients with the public insurance renewal process.

Prevalence of Obese Patients in a Primary Care Setting*

Previous research has addressed the relationship between BMI and chronic disease in primary care; however, little has been done with regard to the association between obesity and depression in primary care. The purpose of this paper is to assess the relationship between obesity and chronic conditions including depression. Data from primary care patients seen at a university-based family medicine clinic in the southeastern United States were extracted for the time between January 1, 1999 and January 1, 2002. Data extracted included most recent height and weight, age, ethnicity, pregnancy status, number of office visits, blood pressure, cholesterol, hemoglobin A1C, current diagnoses, and medications. A total of 8197 patients were included in the analysis. Sixty-nine percent of patients seen in a 3-year period were either overweight or obese. Comparing blood pressure, cholesterol, diagnoses, and medications between BMI groups found differences in virtually all categories. Diagnoses of high cholesterol, hypertension, diabetes, and depression significantly increased for obese patients. Obese patients are over-represented in primary care, and this over-representation of obesity correlates with several diagnoses, including depression. Depression is a chronic disease that may interfere with health-related behaviors and must be addressed within the health care system.

Fungal causes of otitis externa and tympanostomy tube otorrhea

To describe the occurrence of fungal organisms in the setting of otitis externa and tympanostomy tube otorrhea, review the treatment course, timing of diagnosis, organism identified and time to resolution with fungal infections. Retrospective review. Pediatric otolaryngology clinic within a tertiary care hospital. One hundred and sixty-six patients (ages 16 days to 18 years) with fungal organisms on ear culture. Number of prior therapies, number of office visits, time to resolution and anti-fungal therapy. Ear cultures positive for fungal organisms were found in 166 patients seen between 1 January 1996 and 30 September 2003 from a total of 1242 patients undergoing ear culture. Comparing the 3-year period (1996-1998) prior to the availability of fluoroquinolone ototopical drops to the 3-year period after (1999-2001), there is a statistically significant increase in the incidence of positive fungal culture (p<0.001). Otitis media was diagnosed in 72% of these children, with otitis externa comprising 25%. Approximately 3% carried a diagnosis of both otitis externa and otitis media. Candida albicans was identified in 43% of fungal organism-positive cultures. Candida parapsilosis was found in 24% of and Aspergillus fumigatus in 13%. The remainder of the cultures yielded three other Candida and three other Aspergillus species, each at less than 5%. Time to resolution ranged from 1 week to 9 months, with a median of 3.8 weeks for symptom resolution. Patients were treated with an average of 1.7 oral antibiotics and 1.1 ototopical agent before a culture was taken. Otorrhea due to fungal organisms occurs in the setting of refractory infection and is often discovered after multiple oral and ototopical antibacterial medications. Due to the extended treatment period required to clear fungal organism, timely diagnosis with culture for bacteria and fungus is required in patients with persistent otorrhea. An increase in incidence of fungal infections of the ear was found in the period after widespread use of ofloxacin began.

Contact lens care in keratoconus

Purpose: To quantify the complexity involved in fitting contact lenses on the eyes of patients with keratoconus. Methods: The contact lens care of one randomly selected eye each of 38 keratoconus patients was retrospectively analyzed and compared to that of 38 gender and age matched controls. We evaluated the number of diagnostic contact lenses used to establish the initial contact lens order, number of ordered rigid gas permeable (RGP) contact lenses needed to complete the fit, number of office visits during the initial 4 months of care, best spectacle and RGP contact lenses corrected Log MAR visual acuities, complications encountered, and whether or not the patient was successful in contact lens wear. Results: Keratoconic eyes statistically used more diagnostic lenses, more ordered lenses, and more office visits than did normal eyes. Visual acuities improved from an average of 20/40 with spectacles to an average of 20/20 by use of RGP contact lenses in keratoconic eyes. Visions were corrected to 20/20 with both spectacles and contact lenses in control eyes. Sixty nine percent (69%) of keratoconic eyes and 95% of controls were successful in contact lens wear. Conclusions: Contact lens care of keratoconic eyes is more challenging than care of normal eyes because of the need for more diagnostic and ordered contact lenses and the use of more professional time. Keratoconic eyes may suffer more complications than normals during contact lens care, but this does not affect the success rates, and such patients benefit from enhanced visual acuity with RGP contact lenses compared to that achieved with spectacles.

Irritable bowel syndrome in Germany. A cost of illness study.

When asked, between 10% and 15% of people in the Western world report symptoms compatible with irritable bowel syndrome, and around 5% seek medical advice for these complaints. This should incur considerable costs. The present study was designed to give a cost estimate for the treatment of patients with irritable bowel syndrome paid for by German statutory health insurance. Fifty doctors working in private practice were randomly selected to each carry out personal interviews on four irritable bowel syndrome patients chosen from their own records (total 200 patients). Using a structured questionnaire, information regarding diagnostic procedures, drugs and other therapies, hospitalization and days off work were obtained from the case records. To calculate the total direct costs of the illness, all single cost elements such as physician services, medication and hospitalization were included. The number of office visits was nine per patient per year; nearly one-third of employed patients missed work for irritable bowel syndrome, and one out of 15 patients was hospitalized for this condition. Several technical procedures were ordered, mostly laboratory tests. Nearly all patients had at least one drug prescription for irritable bowel syndrome during the year of the survey, with a mean of 3.5 prescriptions per patient. The largest pharmacological groups were antispasmodics (29.2%) and prokinetics (8.9%). Total direct costs for one irritable bowel syndrome patient per year amounted to 1548 DEM (791.48 [OV0556]), comprising roughly 25% for physician visits and tests, 50% for drugs and 25% for hospitalization. Including indirect costs for sick leave, total costs were 1946 DEM (994.97 [OV0556]) per patient per year. The costs incurred by irritable bowel syndrome are considerable.

Evaluating the Impact of an Educational Program on Practice Patterns of Canadian Family Physicians Interested in Depression Treatment.

BACKGROUND: Depression is frequently unrecognized and undertreated. Therefore, there is a need to increase the knowledge and skills of primary care physicians regarding the diagnosis and treatment of depression. The aim of this study was to provide, and evaluate the impact of, a brief educational program with a number of practice tools and resources in order to improve family physicians' knowledge, diagnosis, and treatment of depression. METHODS: Two educational programs (general and enhanced) were delivered to family physicians interested in depression treatment. The enhanced program focused on more practical clinical issues such as use of diagnostic and symptom assessment tools, recommended dosing of citalopram, how to initiate and discontinue treatment, and relapse prevention. Physicians' knowledge of depression was assessed pretraining and posttraining. Chart audits were conducted for 6 months. Primary endpoints were recognition of depression and pharmacologic management (initial dose, maximum dose, length of treatment, adverse events, and concomitant psychotropic drugs). Secondary endpoints were patient satisfaction with treatment, compliance, withdrawal from the study, treatment outcome, use of adjunctive psychotherapy, and number of office visits. RESULTS: There was a global increase in physicians' knowledge of depression in the short term. Physicians in the enhanced group were more likely to use a symptom-based diagnostic checklist, record the diagnosis of depression, and prescribe the recommended initial dose of citalopram, and they referred less frequently for adjunctive psychotherapy. No difference between educational intervention groups was found in patient satisfaction, compliance, and treatment outcome. CONCLUSIONS: A well-designed brief, simple, and low-cost educational program can increase family physicians' knowledge of depression, improve their diagnostic skills, and optimize their treatment of depression.

Complexity of contact lens fitting after refractive surgery

PURPOSE: To quantify and describe the complexity of contact lens correction on corneas altered by refractive surgery. DESIGN: A case-control study involving postrefractive surgery patients and controls from one multidisciplinary contact lens practice. METHODS: The contact lens care of one randomly selected eye of 30 postrefractive surgery patients (15 postincisional and 15 postlamellar refractive surgery cases) was retrospectively analyzed and compared with that of 30 age-and-gender matched nonrefractive surgery controls. We quantified the complexity by the number of diagnostic lenses used to establish the initial lens order, the number of ordered lenses required to complete the fit, and the number of office visits during the first 4 months of lens care. Final contact lens optical powers, corrected visual acuities, complications, and lens success/failure were also studied. The nonparametric Mann-Whitney U test was used for statistical analysis. RESULTS: Postrefractive surgery eyes utilized statistically more diagnostic lenses ( P = .048), ordered lenses ( P = .008), and office visits ( P < .0001). There were no statistical differences in the number of office visits, number of diagnostic contact lenses used, and number of ordered contact lenses between the postincisional and postlamellar refractive surgery patients. Although final contact lens optical powers were not significantly different ( P = .06) between the two groups, contact lens corrected LogMAR acuities were statistically worse ( P = .013) in the postrefractive surgery eyes than in the control group. Contact lens failures occurred in four postrefractive surgery eyes, while no eyes in the control group failed to tolerate contact lenses. CONCLUSIONS: Corneas altered by either incisional or lamellar refractive surgery techniques are more challenging to fit with contact lenses than nonsurgically altered eyes, requiring more lenses and chair time, while resulting in slightly poorer contact lens corrected visions and more failures.

Randomized comparison of efficacy and acceptability of medical versus surgical abortion

Objective: To compare the clinical efficacy, patient acceptance, and provider resources needed to provide medical and surgical abortion in women with pregnancies up to 49 days gestation.Methods: Women with no pretreatment preference for method of abortion were randomized to medical abortion (group 1: methotrexate 50 mg orally, followed 5–6 days later by misoprostol 800 μg vaginally; the misoprostol dose was repeated if the abortion did not occur) or surgical abortion under local anesthesia using manual vacuum aspiration (group 2). The time spent by clinical staff for all interactions with participants were recorded prospectively.Results: Enrollment of 50 subjects took 24 months. Twenty-three of 25 women (92%, 95% CI 81, 100%) in group 1 and 24 of 25 women (96%, 95% CI 88%, 100%) in group 2 had complete abortions (P = 0.9). The complete abortion rate by study day 15 was 20 of 24 (83%, 95% CI 68, 98%), and 24 of 25 (96%, 95% CI 88%, 100%) for groups 1 and 2, respectively (P = 0.2). Only 63% of women randomized to medical abortion would choose that option again, compared with 92% of women who had a surgical abortion (P = 0.03). Surgical abortion is 3–13% more expensive to provide (from a personnel standpoint) than medical abortion using methotrexate and misoprostol.Conclusions: In women who did not have a preference between medical and surgical abortion, the side effect profile and patient acceptability of medical abortion are inferior to surgical abortion. Medical abortion, even with an increase in the number of office visits, seems to be slightly less costly than surgical abortion.

Current follow-up strategies after potentially curative resection of extremity sarcomas

The follow-up of patients after potentially curative resection of extremity sarcomas has significant clinical and fiscal implications. However, the ideal postoperative surveillance regimen for these uncommon neoplasms remains ill-defined. This study was designed to determine the current follow-up practices of a large, diverse group of physicians who care for sarcoma patients. The 1592 members of the Society of Surgical Oncology (SSO) were surveyed regarding their follow-up practices with a detailed questionnaire mailed in 1997. Information regarding frequency of follow-up testing was requested for extremity sarcoma patients treated for cure based on 4 vignettes: low grade lesion </= 5 cm and > 5 cm and high grade lesion </= 5 cm and > 5 cm. Respondents were asked to indicate the number of office visits, laboratory tests and imaging studies performed annually during the first 5 years and the 10th year after surgery. Forty-five percent (716 of 1592) completed the survey. Of the 343 respondents who performed sarcoma surgery, 318 (93%) also provided long term postoperative follow-up for their patients. Ninety-four percent of respondents (295 of 318) were trained in general surgery and 5% (15 of 318) completed orthopedic residencies. Ninety-one percent (291 of 318) were also fellowship trained (80% in surgical oncology). Sixty-three percent (201 of 318) were in academic practice. Routine office visits and chest X-ray (CXR) were the most frequently performed items for each of the years. The frequency of office visits and CXR increased with tumor size and grade and decreased with postoperative year. Complete blood count and liver function tests were the most commonly ordered blood tests, but many respondents did not order any blood tests routinely. Imaging studies of the extremities were performed on the majority of patients with large (> 5 cm) low grade lesions and on both large and small high grade lesions during the first postoperative year. Postoperative sarcoma surveillance strategies utilized by members of the SSO rely most heavily on office visits and CXR. Tumor grade, tumor size, and postoperative year affect surveillance intensity.

Chronic back pain: does bed rest help?

If your patients with uncomplicated back pain get relief with bed rest and pain relievers yet you are told that bed rest doesn't help, you are not alone in your belief. When researchers from the University of Washington surveyed several thousand physicians about back pain management, most believed in the utility of prolonged bed rest along with muscle relaxants and narcotics.1,2 Despite a plethora of research intended to guide physicians in their management of back pain, physicians still hold strong non-evidence based beliefs dating back to the 19th century. Uncomplicated back pain is common—the fifth most frequent reason patients visit their doctor, accounting for nearly 3% of all office visits.3 By uncomplicated we are referring to back pain that does not radiate below the knee in an otherwise healthy person between the ages of 20 and 55. Of course, primary care physicians treat only a small proportion of uncomplicated back pain; many patients go to orthopedists, chiropractors, physical therapists, and massage specialists. In fact, when studies have looked at outcomes of uncomplicated back pain, 95% of patients recover in 6 months (most within 30 days) regardless of health care provider or intervention. The specialty of the provider, however, was strongly linked to the number of visits, the cost of care, and patient satisfaction. Orthopedists had the fewest number of office visits, the greatest costs associated with care, and the least patient satisfaction. Chiropractors had the lowest cost per visit (although total care was equal to primary care physicians) and the greatest patient satisfaction. Orthopedists and chiropractors were far more likely to order tests and radiographs than primary care providers. The cost of care for uncomplicated back pain for orthopedists was $756 compared to $783 for chiropractors and $508 for primary care physicians.4. There is strong evidence that prolonged bed rest does not improve outcome (pain, disability, days missed from work, or functional ability). One randomized controlled trial5 comparing bed rest, exercise, and routine care showed that bed rest was associated strongly associated with three negative outcomes (more days off from work, intensity of pain, and disability). The next question is, if bed rest does not help, is there benefit to active exercise/physical therapy? The answer is less strong, but 14 of 18 controlled studies do report that active exercise can improve outcomes.6 Further, research suggests that specially tailored active exercise may result in fewer episodes of back pain in the future.7 Is there a role for imaging studies? Not in uncomplicated back pain, so say the studies and expert consensus panels.8 What about TENS units, ultrasound, massage, and cosset use to treat back pain? The one randomized controlled trial that looked at these treatment modalities found that those with more intensive contact with a provider resulted in the greatest satisfaction but that there were no significant differences in objective outcome measures.9 So although some patients may need to temporarily modify their activity during the acute phase of back pain, most should be encouraged to avoid bed rest and resume normal activity as soon as possible. For those so motivated, an active exercise program appears to improve outcomes and speed recovery.

Use of physician and acute care services by persons with and without Alzheimer's disease: a population-based comparison.

To estimate differences in use of acute care services between persons with and without Alzheimer's disease (AD). Population-based historical cohort study. All Rochester, Minnesota, residents with AD onset between January 1, 1980, and December 31, 1984 (n = 301), plus one age- and sex-matched nondemented control per case, were identified with a retrospective review of community-based medical records. Cases and controls were followed in their medical records for number of acute care encounters in the year before January 1 of the index year (year of onset for AD case and their matched control) and in the 4 years following December 31 of the index year. Encounters included clinician visits (office or nursing home), emergency room (ER) visits, hospitalizations (inpatient and outpatient), and inpatient days. Multivariate regression analyses were adjusted for age, sex, pre-index level of illness, and follow-up time. In the pre-index period, cases and controls were similar with respect to level of illness, number of office visits, ER visits, and hospitalizations. In the year before AD onset, 17 cases (7%) had a clinician visit in the nursing home compared with no controls. In the 4 years after the index year, mean length of follow-up was 3.4 years for both cases and controls. The numbers of ER visits, hospitalizations, and inpatient days were similar for cases and controls. Sixty-four percent of AD cases had a clinician visit in a nursing home versus 1% of controls. Controls experienced more office visits than cases (median = 16 vs 10, P < .001). The onset of AD is not associated with greater use of acute care services. However, neither is the high use of nursing home care offset by fewer ER or hospital encounters.

Outpatient management of diabetes mellitus in five Arizona Medicare managed care plans.

We report findings on the outpatient management of diabetes mellitus in Medicare beneficiaries enrolled in five Arizona Medicare-managed care plans. These findings are the baseline of an ongoing collaboration between the Health Services Advisory Group, Inc., Arizona's Peer Review Organization (PRO), and the five plans whose object is improved care of diabetes patients. The purpose of the study was to determine congruity between quality indicators identified by the five plans and the care actually received by diabetes patients enrolled in the five plans. The five plans agreed on a common set of quality indicators, including 10 services and 10 measures of patient status. Each plan has identified its diabetic population, 75 of whom are randomly selected each quarter by the PRO for chart review and inclusion in the study. The findings in this report cover two quarters of data. Data from chart review were examined to determine the extent to which actual practice reflected the indicators. The mean patient age was 71.8, and for most patients onset occurred between 55 and 69 years of age. About 25% had a positive family history, and we estimate the annual incidence of diabetes in this population to be about 1.1%. Mean hemoglobin A1c (HbA1c) was 8.9 +/- 2.1%; 46% were hypertensive; 42% continued to smoke cigarettes; 36% had retinopathy; 20% had proteinuria; and only 22% were on some kind of exercise program. Thirty-two percent were hospitalized during the 1-year baseline period, and the average number of outpatient visits per patient was 11.1 +/- 7.4. When care provided to diabetes patients enrolled in the plans was compared with the 10 quality standards identified by the plans themselves, only two of these standards was attained in more than 60% of patients: blood pressure, 98.7%; and foot examination, 62.7%. Two standards were achieved less than one-third of the time: urine dipstick, 10.4%, and appropriate use of angiotensin-converting enzyme (ACE) inhibitors, 31.25%. The others were all between 40 and 55%. Of the 10 service standards, about one-third received 1-4, one-third received 5-6, and one-third received 7-10. Only 5% of patients received 9 or 10 services. Outpatient management of diabetes patients in managed-care plans is similar to that in fee-for-service. When compared with fee-for-service or another HMO, a higher proportion of Arizona-managed care patients had HbA1c, and a much lower proportion had a dipstick test for urine protein. Values for other variables were usually within 10 percentage points of each other. Regardless of payment scheme, diabetes care is characterized by inconsistencies, omissions, and a lower than desirable level of services. Although few patients received most of the indicator services, diabetes patients are nevertheless high utilizers of medical care, both in and out of the hospital. The hospitalization rate is twice that of Arizona Medicare beneficiaries as a whole, and the number of office visits is three or four times that reported in other studies. Further, it seems that many visits are required to achieve even these modest service levels. Had the average number of visits been six or less, HbA1c rates, for example, would have fallen to less than one-third in three of the five plans. We believe that these data are conservative because it is likely that some and perhaps most of these indicators are underreported. It should be emphasized that these are baseline data whose purpose is to provide a basis against which subsequent improvements many be measured.

A combination of norethindrone acetate and leuprolide acetate blocks the gonadotrophin-releasing hormone agonistic response and minimizes cyst formation during ovarian stimulation

A protocol utilizing both leuprolide acetate (LA) and norethindrone acetate (NETA) in subjects undergoing ovarian suppression prior to follicle aspiration proved more effective than LA alone in reducing the incidence of ovarian cyst formation without affecting clinical outcome. Patients (n = 105) undergoing ovarian stimulation followed by follicle aspiration and in-vitro fertilization (IVF) were prospectively randomized and studied. Study measures included ovarian suppression days, days of human menopausal gonadotrophin (HMG) stimulation, serum oestradiol concentrations, number of cycles developing de novo cysts (>15 mm), number of induced flare responses (day 8 oestradiol >=50 pg/ml), number of office visits, total dose exogenous gonadotrophins, number oocytes retrieved, and clinical pregnancy and delivery rates per retrieval. Patients undergoing IVF received either LA alone (n = 58; controls) or LA and NETA (n = 47; study group) for the first 8 days of their cycle. Results comparing NETA/LA versus LA demonstrated: serum oestradiol 20.7 +/- 3.9 versus 57.3 +/- 9.4 pg/ml respectively on day 8 of ovarian suppression (P P < 0.01); and only three individuals (6.4%) using NETA/LA developed ovarian cysts >15 mm compared to 15 (25.9%) controls (P < 0.01). No differences were observed for days of stimulation, peak oestradiol attained, total dosage of exogenous gonadotrophins, or number of aspirated oocytes. Neither were there differences in the clinical pregnancy (26.8 versus 22.6%) nor in delivery rates (19.5 versus 20. 8%). We conclude that the addition of NETA to LA enhances ovarian suppression and lessens ovarian cyst formation, thereby significantly decreasing the overall cost per cycle.

Screening Mammography Use: The Importance of a Population Perspective

Mammography has been shown to be effective in decreasing breast cancer mortality. However, not all women receive recommended screening. The purpose of this study was to measure the effect of systemic health care delivery factors and patient demographic factors on the use of mammography among a population of women with insurance coverage for screening mammography. We studied 8,805 women, 50 to 74 years of age, who were members of a health maintenance organization in Michigan during 1992. Data were obtained from computerized patient registration and billing systems. Estimated household income was based on zip code and 1990 U.S. Census information. During the study period, 47% of the entire study population received a mammogram. Among the 4,628 women who did not receive a mammogram, 2,358 (51%) did not have any primary care visits in 1992, or did not have a visit at a time when they were due for mammography. Among women with at least one visit during 1992, 60% received a mammogram. Analysis of this group revealed that Caucasian race, married status, and higher estimated household income were associated with 3%-5% higher mammography rates (in absolute terms); seeing a gynecologist and attending a primary care clinic where mammography was available on site were associated with 10%-11% higher rates; and not having at least one of their primary care visits at a time when due for screening was associated with a 33.5% lower mammography rate. These differences persisted after adjusting for other variables. In this population, factors surrounding health care delivery, such as having an office visit when due for screening, the number of office visits, and having been seen by a gynecologist, had a greater association with mammography use than did demographic factors. A population-based perspective that includes developing outreach strategies for women overdue for screening, who have not visited their health care provider, is as important as further improvements in office-based strategies to increase breast cancer screening.

Physicians' utilization of health care.

To describe how physicians attend to their own health care needs. Rhode Island. A random sample of Blue Cross/Blue Shield providers. The 306 respondents (67% of 458) primarily (92%) had MD or DO degrees. The nonphysician providers were chiropractors, dentists, optometrists, and podiatrists. A mailed survey provided data describing the respondents' medical conditions and utilization of formal and informal care during a three-year period. Questions asked about provider visits, physical examinations, preventive and diagnostic tests, and medication use. The respondents indicated whether services had been initiated by themselves or by another physician. The physicians' overall use of formal health services was low; their number of office visits was a fourth of the national average. Two-thirds of the respondents reported having a primary care physician, and one-third had sought informal care. The respondents' use of preventive services was high. During the three-year period, 82% of the women physicians had received a Pap test, and 81% of the women physicians over the age of 40 years had received mammography. Cholesterol levels were checked for more than two-thirds of all the respondents. Medical examinations and laboratory tests tended to be ordered by another physician, although self-prescribing was not uncommon. Furthermore, 61% of the respondents had self-prescribed at least one medication. Physicians' care-seeking behavior covers a broad spectrum, ranging from self-care, to informal consultation, to formal treatment by another physician. Physicians appear to be low users of formal services overall, but high users of preventive care.

Health perceptions of primary care patients and the influence on health care utilization.

This prospective study was conducted to determine the influence of primary care patients' health perceptions on their utilization of health care services. Patients' health perceptions were measured using the RAND Corporation's General Health Perceptions Questionnaire. Physicians provided scores of how they thought the patients perceived their health and of actual physical and emotional health. Utilization data (number of office visits, number of telephone calls to the physician, and ambulatory charges) were evaluated for a 12-month period after completion of the questionnaire. Of 208 patients, 62 (30%) patients with health perceptions scores less than 50 had greater degrees of anxiety (P less than .001), depression (P less than .001), health-related worry (P less than .001), and felt less able to resist illness (P less than .001) than patients with higher health perception scores. Analysis of covariance was used to control for differences in physical health among groups of patients with varying health perceptions. These analyses revealed that patients with low health perceptions made more office visits (P = .002), more telephone calls to the physician (P = .01), and had more office charges (P = .05) than patients with higher scores. Physicians accurately predicted the patients' health perceptions in 49% of the cases. In 37%, they thought patients would score their health perceptions higher than they did; in 14% they thought patients would score their health perceptions lower. Health perceptions are an important factor contributing to the use of health care by primary care patients, regardless of the patient's actual physical health. Persons with low health perceptions account for approximately 5% of office visits, a clinically important fraction, especially when compared to the 9% of office visits for hypertension, the most common disease treated in the medical office.