Number Of Patient Visits Research Articles

A Review of Learner Impact on Faculty Productivity

A Review of Learner Impact on Faculty Productivity

The long-term financial impact of electronic health record implementation.

To examine the financial impact of electronic health record (EHR) implementation on ambulatory practices. We tracked the practice productivity (ie, number of patient visits) and reimbursement of 30 ambulatory practices for 2 years after EHR implementation and compared each practice to their pre-EHR implementation baseline. Reimbursements significantly increased after EHR implementation even though practice productivity (ie, the number of patient visits) decreased over the 2-year observation period. We saw no evidence of upcoding or increased reimbursement rates to explain the increased revenues. Instead, they were associated with an increase in ancillary office procedures (eg, drawing blood, immunizations, wound care, ultrasounds). The bottom line result-that EHR implementation is associated with increased revenues-is reassuring and offers a basis for further EHR investment. While the productivity losses are consistent with field reports, they also reflect a type of efficiency-the practices are receiving more reimbursement for fewer seeing patients. For the practices still seeing fewer patients after 2 years, the solution likely involves advancing their EHR functionality to include analytics. Although they may still see fewer patients, with EHR analytics, they can focus on seeing the right patients. Practice reimbursements increased after EHR implementation, but there was a long-term decrease in the number of patient visits seen in this ambulatory practice context.

Association Between Local Area Unemployment Rates and Use of Veterans Affairs Outpatient Health Services

Prior research indicates that federal spending on Medicare, Medicaid, and other government health programs accelerated during the Great Recession. To examine whether local unemployment was associated with utilization of Veterans Affairs Health Care System (VA) primary care, specialty care, and mental health services during 2004-2012. We analyzed utilization of VA health services at the clinic level using fixed-effects negative binomial models. We stratified analyses by veterans' copayment status (exempt and nonexempt) and age (under 65 and 65+) to account for differences in VA utilization because of Medicare eligibility. A total of 11,041,855 veterans assigned to 892 clinics identified in the VA Primary Care Management Module, representing nearly all veterans receiving primary care from VA, were included. Clinic-level utilization was calculated quarterly as the total number of visits for patients assigned to a clinic. Local area unemployment rates were defined as quarterly unemployment rates within VA geographical planning sectors. Higher local unemployment was associated with greater use of VA care in all categories among veterans exempt from copayments. The association between local unemployment and utilization differed by age group among veterans subject to copayments. Higher local unemployment was associated with lower use of primary and specialty care among Medicare-eligible veterans aged 65+, but greater use of primary care among veterans under age 65. Our findings highlight the importance of the state of the economy in interpreting and forecasting demand for government health programs including VA, particularly during periods focused on deficit reduction.

Private Practice of Prosthodontists in the United States: Results from the 2008 & 2011 Surveys of Prosthodontists

The purpose of this article is to review data and results from past surveys of prosthodontists sponsored and conducted by the American College of Prosthodontists. Surveys were conducted in 2002, 2005, 2008, and 2011. Selected survey results are examined for prosthodontists in private practice. Results from past surveys of prosthodontists were statistically examined and used to estimate several characteristics of the current population of practicing prosthodontists. The selected characteristics included age, gender, number of patient visits, hours in the practice, employment of staff, referral sources, and financial conditions (e.g., gross receipts, expenses in the practice, and net income of prosthodontists). While the most recent survey was conducted in 2011, the results reported by respondents are for the previous year, 2010. The average age of a private practicing prosthodontist in 2010 reached 53 years; 26 years since graduation from dental school and 20 years since completion of residency; an average of 13 years in their current practice. Sixty percent were in solo practice. The mean number of hours per week in the practice was 35 hours, and practicing prosthodontists treated an average of 35 patient visits per week. The patient was the single largest source of referrals, while general practitioners were a close second. The largest percentage of time spent treating patients was for fixed prosthodontics (21%), which declined from a mean of 24.1% in 2007. The mean amount of gross billings in 2010 was $721,970, which was a decline from 2007. Average total practice expenses were $538,230, and the mean net earnings of prosthodontists in private practice were $238,010. Changes have occurred since the last survey of prosthodontists in 2008 (with results for the year 2007). The prosthodontist private practice industry, not unlike dentistry as a whole, has undergone economic challenges that have affected the private practice of prosthodontists.

Utilization of Medication Bags To Improve the Medication Reconciliation Process and Identify Medication Errors in a Heart Failure Clinic

Introduction: The Heart Success Clinic at CMC-Northeast Medical Center in Concord, North Carolina is a transitional outpatient clinic designed to follow primary heart failure patients after hospital discharge. The goal of the clinic is to reduce readmission rates and improve heart failure management. The team consists of a Nurse Practitioner, Pharmacist, and 3 Nurse Navigators. Our program intensively manages heart failure patients, focusing on disease education, medication management, and dietary instruction. Medication related problems have been shown to increase the likelihood for readmission to the hospital, increase health care costs, increase patient costs, and increase the risk for patient harm. Medication errors may go undetected without thorough evaluation of prescrition bottles and medication lists. Hypothesis: Providing a bag for patients to bring their prescription and nonprescription medication bottles to clinic visits should improve the medication reconciliation process and help identify medication related errors. A bag that is durable, easy to clean, and simple to transport should improve the long-term success in encouring patients to bring all medications to clinic visits. Methods: The Heart Success Clinic opened in May 2012. After 4 months of service, the clinic obtained soft-sided medication cooler bags which were provided to patients in October 2012. Each patient received a bag during their first clinic visit. Nurse Practitioner and Pharmacist provider notes were used to compare baseline rates of medication errors and compliance with bringing medications to clinic visits for 4 months prior to and after initiation of the medication bag program. Results: Prior to initiating the use of medication bags, patients brought medication bottles to 40% of new visits and 39% of follow up visits. Post initiation of medication bag program, patients brought in medication bottles for 54% of new visits and 57% of follow up visits. Prior to medication bags, 84 medication errors were identified. After medication bag initiation, 158 medication errors were identified, representing a 91% increase in detection of medication errors. The number of patient visits were similar before and after initiation of the medication bag program. The number of identified medication errors tripled in patients using the medication bags. The majority of medication errors identified were related to cardiac medications. Patients continued to bring medication bags to subsequent visits without a drop-off in utilization. The majority of patients were seen for 4 clinic visits before they were transitioned back to their primary care physician or cardiologist for long-term follow up care. Conclusions: The utilization of medication bags significantly improved the medication reconciliation process and increased the identification of clinically significant medication errors in a primary heart failure population.

Prevalence of nonmusculoskeletal versus musculoskeletal cases in a chiropractic student clinic

Objective : We sought to identify the percentage of nonmusculoskeletal and musculoskeletal conditions treated by interns in the National University of Health Sciences (NUHS) Student Clinic compared to chiropractic and allopathic health care professionals. Methods : The information gathered was taken from the charts of patients treated in the fall trimester, dated September 12, 2011 through December 9, 2011. The data collected included ICD-9 codes for the conditions treated, the number of patient visits, age, and gender, and was evaluated using Microsoft Excel. Results : Over half of the 113 eligible patients were women with a mean patient age of 28 years, an average of three treated diagnoses, and a mean of seven treatments. Those treated only for musculoskeletal conditions totaled 52% of the patients; 48% of the patients were treated for nonmusculoskeletal conditions, or musculoskeletal plus nonmusculoskeletal conditions. Conclusion : The NUHS Student Clinic interns are treating a greater percentage of nonmusculoskeletal conditions and a lesser percentage of musculoskeletal conditions than practicing chiropractic physicians. The student interns also treat a lesser percentage of nonmusculoskeletal and a greater percentage of musculoskeletal conditions than allopathic practitioners. This comparison would suggest that NUHS is nearing its institutional goal of training its student interns as primary care practitioners.

Prevalence of nonmusculoskeletal versus musculoskeletal cases in a chiropractic student clinic.

Objective : We sought to identify the percentage of nonmusculoskeletal and musculoskeletal conditions treated by interns in the National University of Health Sciences (NUHS) Student Clinic compared to chiropractic and allopathic health care professionals. Methods : The information gathered was taken from the charts of patients treated in the fall trimester, dated September 12, 2011 through December 9, 2011. The data collected included ICD-9 codes for the conditions treated, the number of patient visits, age, and gender, and was evaluated using Microsoft Excel. Results : Over half of the 113 eligible patients were women with a mean patient age of 28 years, an average of three treated diagnoses, and a mean of seven treatments. Those treated only for musculoskeletal conditions totaled 52% of the patients; 48% of the patients were treated for nonmusculoskeletal conditions, or musculoskeletal plus nonmusculoskeletal conditions. Conclusion : The NUHS Student Clinic interns are treating a greater percentage of nonmusculoskeletal conditions and a lesser percentage of musculoskeletal conditions than practicing chiropractic physicians. The student interns also treat a lesser percentage of nonmusculoskeletal and a greater percentage of musculoskeletal conditions than allopathic practitioners. This comparison would suggest that NUHS is nearing its institutional goal of training its student interns as primary care practitioners.

Systematic review on self-ligating vs. conventional brackets: initial pain, number of visits, treatment time

Meta-analysis of differences between conventional and self-ligating brackets concerning pain during tooth movement, number of patient visits, total treatment duration, and ligation times. Online search in Medline, Embase, and Central focused on randomized clinical trials and controlled clinical studies published between 1996 and 2012. Four studies on pain met our inclusion criteria, two on the number of appointments, two on overall treatment time but none on ligation times. Pain levels did not differ significantly between patients treated with conventional or self-ligating brackets after 4 h, 24 h, 3 and 7 days. The number of appointments and total treatment times revealed no significant differences between self-ligating and conventional brackets. The lack of significant overall effects apparent in this meta-analysis contradicts evidence-based statements on the advantages of self-ligating brackets over conventional ones regarding discomfort during initial orthodontic therapy, number of appointments, and total treatment time. Due to the limited number of studies included, further randomized controlled clinical trials are required to deliver more data and to substantiate evidence-based conclusions on differences between the two bracket types considering orthodontic pain, number of visits, treatment, and ligation times.

Impact of erythropoiesis-stimulating agents on red blood cell transfusion in Korea

Erythropoiesis-stimulating agents (ESAs) have been shown to reduce the need for red blood cell (RBC) transfusions and to improve quality of life for cancer patients with anaemia. However, increased risks of mortality and disease progression have been reported when using ESAs with excessive target haemoglobin levels. In 2007, the United States Food and Drug Administration and Korea Food and Drug Administration issued regulatory alerts for using ESAs in cancer patients. This retrospective study was performed to evaluate changes in ESA prescribing patterns between 2006 and 2010 and the impact on RBC transfusions in patients with solid tumours. The Seoul National University Hospital (SNUH) in Korea. This study includes adult patients with solid tumours who were diagnosed and treated in the SNUH from January 2006 to December 2010. The exclusion criterion was concomitant chronic renal failure. The patients' Hb levels and prescription data for ESAs and RBC transfusions were statistically analysed. The number of inpatient and outpatient solid-tumour patients was also analysed as a baseline. Main outcome measure Prescription data on ESAs and RBC transfusion. After adjusting for the number of patient visits, the monthly mean ESA doses dispensed decreased by an average of 1,192 mcg per quarter over the last 5 years, and the number of RBC transfusions ordered increased by 3.77 instances per quarter. After correcting for the number of patients, the mean doses of ESA dispensed each month decreased by 3,190 mcg per quarter, and the number of RBC transfusions ordered increased by 9.51 instances per quarter. During the last 5 years, the number of ESA doses dispensed at SNUH decreased and the number of RBC transfusions at SNUH increased, independent of the number of patients. The reduction in ESA use was thought to be due to the release of the safety alert letter in 2007. However, this study did not analyse other risk factors that may have influenced the number of RBC transfusions (e.g. metastatic cancer, comorbidities, surgery). Still, the results of this study suggest that the decreased ESA doses were relevant to the increased RBC transfusions.

Breast and Cervical Cancer Screening Patterns among American Indian Women at IHS Clinics in Montana and Wyoming

We investigated factors associated with primary and secondary breast and cervical cancer screening among American Indian (AI) women receiving care from the Indian Health Service (IHS) in Montana and Wyoming. Rates of primary screening (i.e., screening without evidence of a prior abnormal) and secondary screening during a three-year period (2004-2006) were determined in an age- and clinic-stratified random sample of 1,094 women at six IHS units through medical record review. Three-year mammography prevalence rates among AI women aged ≥45 years were 37.7% (95% confidence interval [CI] 34.1, 41.3) for primary and 58.7% (95% CI 43.9, 73.5) for secondary screening. Among women aged ≥18 years, three-year Pap test prevalence rates were 37.8% (95% CI 34.9, 40.6) for primary and 53.2% (95% CI 46.0, 60.4) for secondary screening. Primary mammography screening was positively associated with number of visits and receiving care at an IHS hospital (both p<0.001). Primary Pap test screening was inversely associated with age and positively associated with the number of patient visits (both p<0.001). Secondary mammography screening was inversely associated with driving distance to an IHS facility (p=0.035). Our results are consistent with other surveys among AI women, which report that Healthy People 2010 goals for breast (90%) and cervical (70%) cancer screening have not been met. Improvements in breast and cervical cancer screening among AI women attending IHS facilities are needed.

Evaluation of record linkage between a large healthcare provider and the Utah Population Database

Electronically linked datasets have become an important part of clinical research. Information from multiple sources can be used to identify comorbid conditions and patient outcomes, measure use of healthcare services, and enrich demographic and clinical variables of interest. Innovative approaches for creating research infrastructure beyond a traditional data system are necessary. Records from a large healthcare system's enterprise data warehouse (EDW) were linked to a statewide population database, and a master subject index was created. The authors evaluate the linkage, along with the impact of missing information in EDW records and the coverage of the population database. The makeup of the EDW and population database provides a subset of cancer records that exist in both resources, which allows a cancer-specific evaluation of the linkage. About 3.4 million records (60.8%) in the EDW were linked to the population database with a minimum accuracy of 96.3%. It was estimated that approximately 24.8% of target records were absent from the population database, which enabled the effect of the amount and type of information missing from a record on the linkage to be estimated. However, 99% of the records from the oncology data mart linked; they had fewer missing fields and this correlated positively with the number of patient visits. A general-purpose research infrastructure was created which allows disease-specific cohorts to be identified. The usefulness of creating an index between institutions is that it allows each institution to maintain control and confidentiality of their own information.

Private Practice of Prosthodontists: Current Conditions of Practice in the United States

The purpose of this article is to examine data and results from the 2008 Survey of Prosthodontists. Survey results are used to examine current trends and characteristics of prosthodontists in private practice. Characteristics of prosthodontists and conditions of private practice are based on surveys conducted in 2002, 2005, and 2008 sponsored by the American College of Prosthodontists. Survey results are used to estimate several characteristics including age, gender, number of patient visits, hours in the practice, employment of staff, referral sources, and financial conditions (gross receipts, expenses of the practice, and net income of prosthodontists). The average age of a private-practicing prosthodontist reached 51 years in 2007; 12.3 is the number of years in the current practice; and most prosthodontists (71%) are solo private practitioners. The average amount of time per week by prosthodontists in the practice averaged 36.1 hours, and prosthodontists treated an average of 44.1 patient visits per week. The largest source of patient referrals is the patient themselves. The largest percentage of a prosthodontist's treatment time is spent rendering procedures in fixed prosthodontics, but this percentage has declined since 2001. In 2007, the average gross billings of a practicing prosthodontist reached $805,675; average total practice expenses were $518,255; the mean net earnings of practitioners were $268,930. In 2007, prosthodontists in private practice paid out about $1.4 billion in practice expenses to provide $2.2 billion dollars in prosthodontic care. Based on survey results from 2007 and the previous 6 years, specialization in prosthodontic care continues to be an economically attractive and productive healthcare profession in the United States.

St. Kizito Clinic Primary Health Care Centre

This case is useful for introducing the dynamics of not-for-profit marketing and organizational structuring. It reinforces the view of marketing as the range of activities involved in continuing to meet customer needs while generating value in return irrespective of the context--consumer, business-to-business, or nonprofit. It also demonstrates how charitable organizations could be funded as nonprofits but grow into revenue-generating organizations. St. Kizito Clinic in Nigeria had grown in the number of patient visits, number of services provided, and number of staff members since its inception 15 years earlier. The scope and quality of services were comparable to those provided by a number of competing secondary institutions. The clinic's location had evolved from a slum in a rural area to a slum in an urban area, leading to an increasing number of visits from the more affluent members of the surrounding communities. Medical Director Chiara Mezzalira, MD, faced the challenge of balancing the clinic’s mission, which had as its primary audience the poor, the needy, and the underprivileged members of the society with environmental pressures wealthier clients presented. She was also mindful of the pressures from the clinic’s Italian founder, the Association of Volunteers in International Services, to institutionalize proper management and accounting systems and reduce its financial dependence on the organization.

Insights and Trends in Diabetes Education

The purpose of this study is to describe current diabetes education practice and specific interventions and responsibilities of diabetes educators in the United States. The 2008 National Practice Survey (NPS) instrument consisted of 53 items addressing diabetes education program structure, processes and interventions, outcomes and quality improvement activities, and the chronic care model. The survey was hosted online for American Association of Diabetes Educators (AADE) members. Participants totaled 2447 members, constituting a 25% return rate. Data from the 2008 NPS were analyzed and compared with results from previous surveys. Nearly two-thirds of respondents in 2008 provided diabetes education in a single location, most commonly in a clinical outpatient/managed care setting (39%). Most programs provided comprehensive services. Managers noted that 42% of their programs were either cost/revenue neutral or profitable. Programs varied in types of services, number of patient visits, team member functions, time spent on services, and instructional methods used. At least 50% of managers said their programs report outcome data, and 88% participate in quality/performance improvement activities. Nearly two-thirds of respondents were unfamiliar with the AADE-adopted chronic care model. Many 2008 NPS results concur with those obtained in 2005 through 2007. Areas of variability among programs suggest a need for standardized interventions and practice guidelines. Educators are encouraged to report outcomes to elucidate the contributions of their programs to patient care. AADE can use the results and comparative data obtained from the 2008 survey when developing practice, research, and advocacy activities.

Consultation Request Patterns, Patient Characteristics, and Utilization of Services within a Veterans Affairs Medical Center Chiropractic Clinic

A retrospective review of completed chiropractic consultations in 2006 (N = 354) was carried out to investigate consultation request patterns, patient characteristics, and the utilization of chiropractic services within the Department of Veterans Affairs of Western New York Health Care System. Primary care was the main source of patients with variation in the volume of consultation requests among providers. The average chiropractic patient was a 55-year-old male with low back pain who was overweight or obese with 27.43% service-connected disability. Post-traumatic stress disorder was diagnosed in 16.44%. The mean number of patient visits was minimized by following outcome-based practice parameters. Management consisted mainly of spinal manipulative therapy and mobilization techniques. Veteran chiropractic patients differed demographically from those in the general public who are predominantly female and younger. The implications of these differences on clinical outcomes and chiropractic clinical education are unclear and serve as the stimulus for additional research.

Prosthodontists in Private Practice: Current and Future Conditions of Practice in the United States (Part I)

The purpose of this study was to use data from surveys of prosthodontists to examine the current conditions and characteristics of prosthodontists in private practice in the United States. Characteristics of prosthodontists and conditions of practice are based on the 2002 Survey of Prosthodontists and the 2005 Survey of Prosthodontists. Both surveys were conducted by the American College of Prosthodontists. Several characteristics of private practice/practitioners are estimated including age, gender, number of patient visits, hours in the practice, employment of staff, and financial conditions (gross receipts, expenses of the practice, and net income of prosthodontists) In 2004, the average age of private practitioners was 50 years. Years since graduation from dental school averaged 23.4 years, and years since completion of residency was 18.3 years. Prosthodontists spent an average of 35.7 hours per week in the office and 29.5 hours treating patients. In 2004, the average gross revenue per owner of a private practice reached $782,130, and mean net income was $258,490. The largest percentage of prosthodontist time was spent providing six procedures including fixed prosthodontics, implant services, complete dentures, operative care, diagnosis, and partial dentures. The United States spends about $1.8 billion on prosthodontic services provided by prosthodontists in private practice. Prosthodontists spend $1.1 billion dollars in expenses and treat an estimated 1.1 million patients per year.

Determining Factors in the Prescription of Moxifloxacin in Exacerbations of Chronic Bronchitis in??the Primary-Care Setting

To describe the characteristics of patients and exacerbations that may determine the choice of an antibacterial in exacerbations of chronic bronchitis (ECB). This was a multicentre, observational study in ECB. A group of 225 primary-care practitioners were randomly selected to include 1007 patients. A logistic regression model was used to identify the characteristics of the physicians, patients and exacerbations associated with the choice of an antibacterial. The mean age of the patients was 67.6 years (+/- SD 11) and 72.1% were male. In 91.4% of patients, the exacerbation was type I or II according to Anthonisen's classification. Most exacerbations (68.2%) were treated with moxifloxacin while only 31.8% were treated with other antibacterials. The more experienced practitioners (those with the longest professional careers and those who had higher numbers of patient-visits for chronic bronchitis) prescribed moxifloxacin more frequently (per each year of experience: OR 1.05; 95% CI 1.02, 1.07; per each additional patient-visit per week: OR 1.02; 95% CI 1.003, 1.04). The probability of receiving moxifloxacin increased with the severity of baseline dyspnoea (OR 1.94; 95% CI 1.27, 2.96) and decreased in smokers (OR 0.54; 95% CI 0.36, 0.81) and in patients receiving oral corticosteroids (OR 0.61; 95% CI 0.41, 0.90). Prescription of moxifloxacin in primary care is significantly associated with more years of physician practice and with a higher severity of disease. The use of oral corticosteroids in exacerbations is commonly associated with other antibacterials (non-quinolones), either to improve antibacterial efficacy or because of doubtful bacterial aetiology, thus the preference for a narrow-spectrum antibacterial combined with an anti-inflammatory drug.

National Trends in Statin Use by Coronary Heart Disease Risk Category

BackgroundOnly limited research tracks United States trends in the use of statins recorded during outpatient visits, particularly use by patients at moderate to high cardiovascular risk.Methods and FindingsData collected between 1992 and 2002 in two federally administered surveys provided national estimates of statin use among ambulatory patients, stratified by coronary heart disease risk based on risk factor counting and clinical diagnoses. Statin use grew from 47% of all lipid-lowering medications in 1992 to 87% in 2002, with atorvastatin being the leading medication in 2002. Statin use by patients with hyperlipidemia, as recorded by the number of patient visits, increased significantly from 9% of patient visits in 1992 to 49% in 2000 but then declined to 36% in 2002. Absolute increases in the rate of statin use were greatest for high-risk patients, from 4% of patient visits in 1992 to 19% in 2002. Use among moderate-risk patients increased from 2% of patient visits in 1992 to 14% in 1999 but showed no continued growth subsequently. In 2002, 1 y after the release of the Adult Treatment Panel III recommendations, treatment gaps in statin use were detected for more than 50% of outpatient visits by moderate- and high-risk patients with reported hyperlipidemia. Lower statin use was independently associated with younger patient age, female gender, African American race (versus non-Hispanic white), and non-cardiologist care.ConclusionDespite notable improvements in the past decade, clinical practice fails to institute recommended statin therapy during many ambulatory visits of patients at moderate-to-high cardiovascular risk. Innovative approaches are needed to promote appropriate, more aggressive statin use for eligible patients.

Do clinical grant payment practices in phase 3 clinical trials influence subsequent clinical investigator prescribing behavior?

The advancement of science requires the cooperation of clinical investigators. Recent discourse, which attempts to relate pharmaceutical company grant payments to clinical investigators to subsequent preferential prescribing behavior, erodes the physician/patient relationship and may lead to an inadequate number of investigators. This study was designed to determine why the level of grant payments to Phase 3 clinical investigators differs for comparable levels of work and whether these differences are related to subsequent prescribing behavior of either the study drug or other drugs from the same sponsoring company. From a database of 100,000 investigator contracts, 2,108 U.S. physicians participating in Phase 3 trials at 2,897 clinical sites for new drugs launched in 1999-2000 were randomly selected in 10 outpatient indications. The relative grant amounts (RGAs) paid to the investigators were compared with their subsequent prescribing of the study drug and other sponsor company drugs for a period of six months after study drug introduction. The RGA is the payment percentile represented by the absolute cost per patient grant paid to any specific investigator compared with other similar studies, including such considerations as the number of patient visits, the number and types of medical procedures performed, the investigator's geographic location, and whether the study was conducted at the investigator's office or hospital. Linear regression correlations were calculated between study, investigator, and drug characteristics with the RGA, and the correlation between the RGA and subsequent prescribing behavior of the study drug and other drugs from the sponsor company at three and six months after study drug product launch. Five variables were statistically significantly related to the RGA received by an investigator: compound therapeutic novelty, the number of similar studies being conducted at same time, investigator clinical research experience, and the inverse of drug class prescription volume. Most significantly, investigators' post-study prescribing behavior was not related to RGA. Drug development and market forces explain the RGA, but RGA is not related to subsequent sponsor or study drug prescribing.

Clinical deterioration in pediatric asthma patients living near the world trade center after 9/11/01

Rationale Residents of Manhattan were exposed to inhaled substances after the collapse of the World Trade Center. Exposure may lead to an increase in asthma severity, with residential distance from the disaster site (Ground Zero) predictive of the degree of change. Methods We retrospectively reviewed the charts of 205 established asthma patients from a community health center in lower Manhattan's Chinatown. Clinical data were obtained for the year before and the year after September 11, 2001. Measurements included: number of patient visits, asthma medication prescriptions, oral corticosteroid prescriptions, weekly doses of rescue inhaler, and peak expiratory flow rates (PEFR). Residential zip codes were used to compare the asthma severity of patients living within and beyond a 5 mile radius of Ground Zero. Results After 9/11, all patients had significantly more asthma-related clinic visits (mean 3.79 pre-9/11 versus 4.69 post-9/11, p=0.002), and received significantly more prescriptions for asthma medications (mean 2.05 pre-9/11 versus 2.33 post-9/11, p=0.018). No significant differences in oral steroid or rescue inhaler use were noted. Those living within 5 miles had significantly more clinic visits post 9/11 (3.95 pre-9/11 versus 5.10 post-9/11, p=0.013); the increase in clinic visits for patients living greater than 5 miles from Ground Zero was not significant. Mean percent predicted PEFRs declined solely for those patients living within 5 miles of Ground Zero during the three months following 9/11. Conclusions Asthma severity worsened after 9/11/01 in pediatric asthmatics living near Ground Zero. Residential proximity was predictive of the degree of decline.