Office-based Physician Practices Research Articles

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population.

Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Cluster Analysis of Primary Care Physician Phenotypes for Electronic Health Record Use: Retrospective Cohort Study.

BackgroundElectronic health records (EHRs) have become ubiquitous in US office-based physician practices. However, the different ways in which users engage with EHRs remain poorly characterized.ObjectiveThe aim of this study is to explore EHR use phenotypes among ambulatory care physicians.MethodsIn this retrospective cohort analysis, we applied affinity propagation, an unsupervised clustering machine learning technique, to identify EHR user types among primary care physicians.ResultsWe identified 4 distinct phenotype clusters generalized across internal medicine, family medicine, and pediatrics specialties. Total EHR use varied for physicians in 2 clusters with above-average ratios of work outside of scheduled hours. This finding suggested that one cluster of physicians may have worked outside of scheduled hours out of necessity, whereas the other preferred ad hoc work hours. The two remaining clusters represented physicians with below-average EHR time and physicians who spend the largest proportion of their EHR time on documentation.ConclusionsThese findings demonstrate the utility of cluster analysis for exploring EHR use phenotypes and may offer opportunities for interventions to improve interface design to better support users’ needs.

Does Vertical Integration Improve Access to Surgical Care for Medicaid Beneficiaries?

Vertical integration is increasingly common among surgical specialties in the US; however, the effect of vertical integration on access to care for low-income populations remains poorly understood. We explored the characteristics of surgical practices associated with vertical integration and the effect of integration on surgical access for Medicaid populations. Using a survey of US office-based physician practices, we examined characteristics of 15 surgical subspecialties from 2007 to 2017, including provider sex and specialty, practice payer mix, surgical volume, and county socioeconomic status. Using multivariable logistic regression and time-series analysis, we evaluated practice and provider characteristics associated with vertical integration-our primary outcome-and practice Medicaid acceptance rates-our secondary outcome. Our analysis included 84,795 unique surgical practices (303,903 practice-years). The rate of vertical integration during the 10-year period was 18.0%, with 72.1% of surgical practices never integrating. Practices that integrated were more likely to accept Medicaid patients than practices that did not (81.0% vs 60.8%, p < 0.001). Accepting Medicaid increased the likelihood of vertical integration relative to practices that did not (odds ratio [OR] 4.20, 95% CI 3.93 to 4.49). Practices that integrated were more likely to accept Medicaid in the future (OR 2.61, 95% CI 2.40 to 2.83), even after adjusting for previous Medicaid acceptance and hospital and time fixed effects. Surgical practices caring for the underinsured are more likely to join larger health care systems, driven by market characteristics. Vertical integration is associated with future increased rates of Medicaid acceptance among practices, allowing for increased access to surgical care for vulnerable, low-income patients. The potential benefit of increased surgical access for low-income beneficiaries from vertical integration must be balanced with the potential for increased prices.

Electronic health record use-diffusion patterns and eSharing of health information among US office-based physician practices

BackgroundThe use of some computerized capabilities (CCs) that support eligibility for meaningful use incentive has lagged despite an increase in Electronic Health Record adoption. PurposeThis study described the use-pattern of CC among office-based physician practices by applying the Use-Diffusion model (UD); to identify CCs that support the Stage 1 core objectives for meaningful use, and to predict their effect on eSharing of health information. MethodsData from the United States 2013 National Ambulatory Medical Care Survey was used, and four use-patterns based on the variety and frequency of CC use were identified. Logistic regression was used to assess factors related to the use of a low variety of CC, and factors predictive of eSharing of health information. ResultsThe unweighted sample of 2444 physician practices reported at least one computerized capability. The unweighted proportion of each UD group was 53%, 20%, 15% and 12% representing the intense, non-specialized, specialized, and limited groups respectively. Only 5.3% in the specialized and 8.9% in the limited UD groups reported the ability to provide electronic access to patients in 2013. Provision of email/internet patient consult and having an increasing number of CCs were predictive of eSharing of health information. ConclusionsThe use-diffusion model can describe office-based physician practices’ use-pattern of EHR capabilities, and the characteristics that differentiate the groups. Solo and specialty practices may lag in their readiness to meet the Stage 1 meaningful use objectives, both in the variety of capabilities and the frequency of use to qualify for incentive payments.

Does Insurance Coverage Affect Use of Tests and Treatments for Working Age Individuals With Carpal Tunnel Syndrome in the United States? Analysis of the National Ambulatory Medical Care Survey (2005-2014)

ObjectiveCarpal tunnel syndrome (CTS) is frequently seen as a work-related disorder. Few studies have examined the treatment of CTS by insurance coverage, and none have used a large, population-based dataset. This study examined the extent to which the use of CTS tests and treatments varied for those on workers’ compensation insurance (WCI) vs private insurance and Medicaid, controlling for patient and provider characteristics. DesignAnalysis of 10 years of data (2005-2014) from the National Ambulatory Medical Care Survey. SettingUnited States office-based physician practices. ParticipantsAdults 18-64 years who had a physician visit for CTS (N=23,236,449). InterventionsNot applicable. Main Outcome MeasuresWe examined use of 2 diagnostic tests, imaging and electromyography, and 7 treatments: casting, splinting, occupational therapy (OT), physical therapy (PT), carpal tunnel release surgery, steroid injections, and nonsteroidal anti-inflammatory drug (NSAID). ResultsIndividuals who sought care for CTS were more likely to be covered by private insurance (56.9%) than WCI (9.8%) or Medicaid (6.5%). The most commonly prescribed treatment for all types of insurance coverage was splints, followed by NSAID prescription, and OT or PT therapies. Steroid injections (1.2%) and CTS surgery (4.5%) were used significantly less than other treatment types. Patients on WCI were less likely to receive diagnostic tests, and more likely to receive OT or PT than those on other types of insurance coverage. ConclusionPatients with CTS who seek ambulatory care are most likely to be covered by private insurance. Insurance coverage appears to play a role in treatment and diagnostic choices for CTS.

Adoption of Electronic Dental Records: Examining the Influence of Practice Characteristics on Adoption in One State.

Compared with medicine, less research has focused on adoption rates and factors contributing to the adoption of electronic dental records (EDRs) and certified electronic health records (EHRs) in the field of dentistry. We ran two multivariate models on EDR adoption and certification-capable EHR adoption to determine environmental and organizational factors associated with adoption. We conducted telephone survey of a 10-item questionnaire using disproportionate stratified sampling procedure of 149 dental clinics in Tennessee in 2017 measuring adoption of dental information technology (IT) (EDRs and certification-capable EHRs) and practice characteristics, including region, rurality, specialty, and practice size. We used binomial logistic regression models to determine associations of adoption with predictor variables. A total of 77% of surveyed dental clinics in Tennessee had adopted some type of EDR system. When the definitions of certification capable were applied, the adoption rates in dental clinics dropped to 58%. A binomial logistic regression model for the effects of rurality, specialization, and practice size on the likelihood that a clinic would adopt an EHR product was statistically significant (chi-square (3) = 12.41, p = 0.0061). Of the three predictor variables, specialization and practice size were significant: Odds of adopting an EHR is 67% lower for specialists than for general dentists; and clinics with two or more practicing dentists were associated with a much greater likelihood of adopting an EHR-capable system (adjusted odds ratio = 3.09, p = 0.009). Findings from this study indicate moderate to high levels of overall dental IT adoption. However, adoption rates in dental clinics do remain lower than those observed in office-based physician practices in medicine. Specialization and practice size were significant predictors of EHR-capable system adoption. Efforts to increase EHR adoption in dentistry should be mindful of potential disparities in smaller practices and between dental specialties and generalists.

High rate of systemic corticosteroid prescription among outpatient visits for psoriasis: A population-based epidemiological study using the Korean National Health Insurance database.

The use of systemic corticosteroids (SC) for the treatment of psoriasis is not recommended according to textbooks and guidelines. In clinical practise, however, many physicians frequently prescribe SC for patients with psoriasis. To determine the magnitude of SC prescription for outpatients with psoriasis in Korea and identify factors associated with the use of SC, we used the 2010-2014 nationwide claims data of the Health Insurance Review and Assessment Service of Korea. In frequency analysis for the full scale of prescribed SC, oral methylprednisolone was the most frequently prescribed SC, followed by dexamethasone and betamethasone injections. The prescription rate of SC was 26.4% in outpatient visit episodes for psoriasis. The prescription rate of SC was higher in older patients, Medical Aid recipients, patients who visited office-based physician practices and hospitals, and patients living in non-metropolitan areas. In multiple logistic regression analyses, the older age group and smaller health-care institutions were more associated with the SC prescription. In conclusion, SC were widely prescribed for patients with psoriasis in Korea despite the current guidelines. Both patients' individual and institutional characteristics were associated with the SC prescription.

The Influence of the Degree of Rurality on EMR Adoption, by Physician Specialty.

To explore the influence of varying degrees of remoteness on practice-level electronic medical record (EMR) adoption, including whether the effect differs across practice specialty. Survey data on over 270,000 office-based physician practices (representing over 1,250,000 providers) collected by SK&A information services during 2012. This study examined differences in EMR adoption by practices located across the nine-category rural-urban continuum. Logistic regressions and associated marginal effects are used to assess how much a move up or down the rural-urban continuum code impacts the likelihood of EMR adoption, after controlling for characteristics likely to affect EMR adoption such as practice size and specialty. Overall practice-level EMR adoption rates generally increase with the degree of rurality and range from 47 percent in the most urban counties to over 60 percent in the most rural. Moving from the most urban county to the most rural corresponded to a 7 percent increase in the likelihood of EMR adoption (p<.01). EMR adoption rates do vary significantly across nonmetropolitan counties, and they generally increase as a practice becomes more rural. From a policy perspective, this suggests that urban practices may in fact be the lowest hanging remaining fruit for increasing EMR adoption rates.

Determinants of Physicians’ Acceptance of New Medicaid Patients

Medicaid plays a significant role in the healthcare of millions of U.S. families and individuals, and office-based physician practices are an important part of the national health care delivery system. Yet access to these providers has been and continues to be a challenge for Medicaid beneficiaries. Exacerbating the issue is the recent expansion of insurance coverage under the Affordable Care Act. This study explores this national conundrum from the physicians’ perspective. The impact of practice characteristics, compensation and performance measures are examined on physicians’ propensity to accept new Medicaid patients. This study draws upon data from the 2008 Health Tracking Physician Survey restricted-use file and is the first to provide for a comprehensive look at the determinants of physician acceptance. The approach is rooted in the economic theory of control, agency theory. The most significant factors found to be associated with diminished physician propensity for Medicaid access include: no present participation, having an ownership interest in the practice, operating as a one- or two-physician sized practice, operating as a primary care physician, low relative geographic physician reimbursement, lacking supportive clinical information technology and gender. Knowing what determinants are associated with physicians’ decision may provide opportunities for public policy solutions.

Rural EMR adoption rates overtake those in urban areas.

To assess rural-urban differences in electronic medical record (EMR) adoption among office-based physician practices in the United States. Survey data on over 270 000 office-based physician sites (representing over 1 280 000 physicians) in the United States from 2012 was used to assess differences in EMR adoption rates among practices in rural and urban areas. Logistic regression tests for differences in the determinants of EMR adoption by geography, and a nonlinear decomposition is used to quantify how much of the rural-urban gap is due to differences in measureable characteristics (such as type of practice or affiliation with a health system). Overall EMR adoption rates were significantly higher for practices in rural areas (56%) vs those in urban areas (49%) in 2012 (P < 0.001). Twenty-nine states had statistically significantly different adoption rates between rural and urban areas, with only two states demonstrating higher rates in urban areas. EMR adoption continues to be higher for primary care practices when compared to specialists (51% vs 49%, P < 0.001), and state-level rural-urban differences in adoption are more pronounced for specialists. The decomposition technique finds that only 14% of the rural-urban gap can be explained by differences in measurable characteristics between practices. At the national level, rates of EMR adoption are higher for rural practices than for their urban counterparts, reversing earlier trends. This suggests that outreach efforts, namely the Regional Extension Centers created by the Office of the National Coordinator, have been particularly effective in increasing EMR adoption in rural areas.

Impact of Compensation, Performance Measures and Other Organizational Characteristics on Physicians’ Acceptance of New Medicaid Patients

Medicaid plays a vital role in the U.S. health care system and the importance of office-based physician practices to the care of Americans served cannot be overstated. Despite increases in program enrollment, a number of sources report that the proportion of U.S. office-based physicians willing to accept new Medicaid patients is decreasing. This discovery is significant. This managerial accounting study utilizes a national survey of practicing physicians to explore this conundrum from the physicians’ perspective. Specifically, the impact of organizational-related determinants including (1) practice characteristics, (2) compensation and (3) performance measures is examined on physicians’ propensity to accept new Medicaid patients. With an empirical analysis using the cumulative odds ordinal logit model, this study breaks new ground in several significant venues. Only a limited number of studies have yet examined physician practice characteristics relative to physician acceptance of Medicaid, but these were far more limited in scope. In addition, this study offers a first look at how financial and non-financial incentives collectively impact patients’ access to Medicaid. Finally, it is important to point out that this study provides for a comprehensive look at understanding what organizational characteristics help to determine the probability of physician acceptance of new Medicaid patients.The most significant factors found to be associated with diminished propensity for Medicaid access include: operating as a primary care doctor, physician ownership in the practice, practice size, low relative geographic reimbursement, supportive clinical IT and gender. Knowing what factors are associated with physicians’ decisions should provide opportunities for potential public policy solutions.

A Case of Intention Tremor Induced by the Combination of Aripiprazole and Lamotrigine

To the Editor: In patients with chronic disabling psychiatric conditions in whom many therapeutic interventions have been implemented, augmentation and combination therapies are commonly used to improve the outcome. The number of visits during which a psychotropic medication was prescribed increased from 32.73 million to 45.64 million in less than 10 years in office-based physician practices in the United States.1 Here, we report a case of intention tremor induced by a combination of aripiprazole and lamotrigine. Case report. Ms A was a 60-year-old white woman with a 6-year history of DSM-IV major depressive disorder and generalized anxiety disorder and no history of psychiatric hospitalizations. Her past medical and surgical history was significant for type 2 diabetes mellitus, above-knee amputation, hysterectomy, and arthritis. Her family history was negative for psychiatric disorders. She denied smoking, drinking alcohol, or using illegal drugs. Multiple medications were tried before Ms A became stable on treatment with lamotrigine 300 mg/d for several years. Although the patient was stable, there was room for improvement in her symptoms, and in February 2011, aripiprazole 5 mg/d was added as an augmenting agent. The patient's symptoms improved, and she became socially active, volunteering at the local hospital and spending time with her friends. However, 2 months after starting aripiprazole treatment, the patient developed a disabling intention tremor in her hands, head, and jaw. Lamotrigine was tapered off slowly with no deterioration of her mood and complete resolution of her tremor. Moreover, she reported maintaining an active social life at 3-, 6-, and 12-month follow-up. Our patient was prescribed both lamotrigine and aripiprazole for major depression, and she had a therapeutic response, but we noted an interesting adverse effect that can be attributed only to the concomitant prescription of these medications. Aripiprazole, like other atypical antipsychotics, displays antagonistic action at serotonin-2A (5-HT2A) receptors. However, it differs from other antipsychotics in that it is a partial agonist at dopamine-2 receptors and 5-HT1A receptors.2 Both cytochrome P450 (CYP) 3A4 and the polymorphic enzyme CYP2D6 are involved in the metabolism of aripiprazole to its main metabolite dehydroaripiprazole.3 On the other hand, lamotrigine is metabolized predominantly by glucuronic acid conjugation, mainly by UDP-glucuronosyltransferase 1A4 with the inactive 2-N-glucuronide conjugate as the major metabolite.4 Literature suggests that lamotrigine increases the concentration to dose ratios of aripiprazole by 51%.5 According to the Naranjo Adverse Drug Reactions Probability Scale, the intention tremor reaction reported in this case can be classified as a “probable” association between the combination of aripiprazole and lamotrigine and the side effect.6 The onset of the clinical adverse effect is consistent with the administration of the drugs together, and the effect was not present when either drug alone was given to the patient. To our knowledge, this is the first report of a clinical interaction of aripiprazole and lamotrigine that resulted in intention tremor. We anticipate that many more such cases will surface as combination treatment becomes a norm in the treatment of psychiatric illnesses. Clinicians should be vigilant against this problem and should be ready to adjust treatment with discontinuation of either medication if faced with such an adverse effect in their patients.

Length of Office Visits for Gastrointestinal Disease: Impact of Physician Specialty

Physician-visit length is an important determinant of patient satisfaction and outcomes. Our objective was to compare visit length for gastrointestinal disorders between gastroenterologists and primary-care providers (PCPs). From the National Ambulatory Medical Care Survey, visits to office-based physician practices between 1993 and 2004 were identified and multivariate regression was used to identify predictors of visit duration. There were 3135, 3391, and 3964 office visits associated with gastrointestinal disease, corresponding to 71, 140, and 180 million visits nationwide in 1993-1996, 1997-2000, and 2001-2004 respectively. Visit duration to all physicians increased from 17.3 minutes in 1993-1996 to 20.2 minutes in 2001-2004. Among gastroenterologists, visit length remained constant, from 21.0 minutes in 1993-1996 to 22.3 minutes in 2001-2004. On multivariate regression, age >50 years (1.8 minutes), new-patient encounters (7.4 minutes), and visits in 1997-2000 (2.7 minutes) and 2001-2004 (3.4 minutes) were associated with longer visit length. Encounters with gastroenterologists (3.3 minutes) were associated with longer visit duration than those with PCPs. The greatest adjusted difference in visit length between the two was seen for visits associated with constipation (5.7 minutes favoring gastroenterologists) and irritable bowel syndrome (2.4 minutes). There has been an overall increase in length of physician visits associated with gastrointestinal disease. Both patient and provider factors predict visit length.

Association between use of rapid antigen detection tests and adherence to antibiotics in suspected streptococcal pharyngitis

Objective. Few studies have analysed adherence to antibiotic treatment in pharyngitis. The aim of this study was to evaluate the association of rapid antigen detection tests (RADT) and treatment adherence among patients 18 years of age or over with pharyngitis treated with different antibiotic regimens. Design. Prospective study from 2003 to 2008. Setting. Office-based physician practices. Intervention. The adherence of patients prior to the use of RADTs – no test was available until mid-2006 – was compared with the adherence associated with the use of RADTs. Subjects. Patients with suspected streptococcal pharyngitis. Main outcome measures. Patient adherence was assessed by electronic monitoring. The adherence outcomes considered were antibiotic-taking adherence, correct dosing, and good timing adherence during at least 80% of the antibiotic course. Results. A total of 196 patients were recruited. The percentage of container openings was 77.9%±17.7%, being significantly higher for patients in whom the RADTs were performed compared with those in whom this test was not undertaken (80.1% vs. 70.8% for thrice-daily antibiotic regimens and 88.1% vs. 76.5% for twice-daily regimens; p < 0.01). The other variables of adherence were also better among patients undergoing RADT in both those who took at least 80% of the pills (71.3% vs. 42.2%; p < 0.001) as well as those with good timing adherence (52.5% vs. 32.8%; p < 0.01). Furthermore, correct dosing was always greater when the patient had undergone an RADT. Conclusion. Adherence to antibiotic treatment is higher when an RADT is carried out at the consultation prior to administration of antibiotic treatment.

Primary care physician office visits for depression by older Americans

Background: Older patients mostly receive depression care from primary care physicians, but it is not known whether depression treatment is primarily received from family/general practice physicians or internal medicine physicians and whether the type of depression treatment offered varies between these types of primary care physicians. Objective: To assess what proportion of visits for depression are to family/general practice physicians or to internal medicine physicians and whether the type of depression treatment offered varies by primary care physician specialty. Design: Data from the 2000 and 2001 National Ambulatory Medical Care Surveys, a nationally representative survey of visits to office-based practices using clustered sampling, were used. Participants: Office-based physician practices in the United States. Results: There were an estimated 9.8 million visits made to office-based providers by older patients for depression in 2001 to 2002, of which 64% were to primary care physicians. Visits to primary care providers were evenly split between Internists and family/general practice physicians. There was no significant difference in the rate of antidepressant prescribing between visits to Internists versus family/general practice (55.9% vs 48.0%;P=.42). Mental health counseling or psychotherapy was offered more often during visits to family/general practice physicians than to Internists (39.4% vs 14.0%;P=.07). Conclusions: Visits for depression by elderly patients continue to take place in primary care settings to both family/general practice physicians and Internists. Interventions aimed at improving depression care in primary care should focus on both types of primary care physicians and emphasize improving rates of diagnosis and referral for counseling or psychotherapy as a viable treatment option.

Datapoints: Trends in ADHD and Stimulant Use Among Adults: 1995-2002

1497 T dramatic rise in the number of children given a diagnosis of attention-deficit hyperactivity disorder (ADHD) and a prescription for stimulant pharmacotherapy for its treatment has been well established (1). Follow-up studies have documented the persistence of ADHD into adulthood, with estimates that oneto two-thirds of individuals who were given a diagnosis in childhood continue to manifest symptoms into adulthood. We used data from the National Ambulatory Medical Care Survey (NAMCS) to evaluate whether there has been an increase among adults in the number of office visits in which a diagnosis of ADHD was recorded. The NAMCS is an ongoing annual survey of a representative sample of U.S. office-based physician practices. We extracted all records with a recorded diagnosis of ADHD for patients aged 20 years or older for the years 1995 through 2002. We combined the data into two-year intervals to enhance sample size and derived annualized mean visits (1). Unweighted sample sizes for visits in which a diagnosis of ADHD was recorded were 99 in 1995–1996, 64 in 1997–1998, 106 in 1999–2000, and 142 in 2001–2002. As shown in Figure 1, over this time frame weighted national estimates of the number of these annualized office-based physician visits increased 2.5-fold (p<.05), from 583,000 in 1995–1996 (95 percent confidence interval [CI]=329,000 to 837,000), to 1,462,000 in 2001–2002 (CI=994,000 to 1,930,000). After adjustment for population growth, the rate per year of officebased visits per 1,000 U.S. population aged 20 years or older that resulted in a diagnosis of ADHD Trends in ADHD and Stimulant Use Among Adults: 1995–2002

Changes in isotretinoin prescribing before and after implementation of the System to Manage Accutane Related Teratogenicity™ (SMART™) risk management program

To assess changes in isotretinoin prescribing following the implementation of the System to Manage Accutane Related Teratogenicity (SMART) risk management program. Using nationally representative commercial data resources on prescription drug dispensing patterns, surveys of office-based physician practices, and a large, claims database from a pharmacy benefits manager (PBM), we examined the total number of isotretinoin prescriptions (new and refill), prescriber speciality, and patient characteristics (age, gender, severity of acne indication) in the year before (April 2001-March 2002) and the year following (April 2002-March 2003) implementation of the SMART program. In the 12-months prior to SMART, 1 508 000 prescriptions were dispensed for isotretinoin, declining approximately 23% to 1 160 000 prescriptions in the year following SMART. There was little or no change in prescriber specialty, severity of acne, and patient age and gender. SMART may have lead to a decrease in isotretinoin prescriptions. Further research is needed to determine whether the reduced number of isotretinoin prescriptions reflects appropriate use or inhibited use resulting in loss of access to the product's benefits.

Prevalence of nutrition and exercise counseling for patients with hypertension. United States, 1999 to 2000.

To evaluate the prevalence of nutrition and exercise counseling for patients with hypertension. Cross-sectional survey data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 1999 and 2000. Office-based physician practices and hospital outpatient departments. Patients age 18 or older with a diagnosis of hypertension. In 1999 and 2000, over 137 million patient encounters had a diagnosis of hypertension. Nutrition and exercise counseling were provided at 35% and 26% of visits, respectively. Patients older than 74 received the least nutrition (28%) and exercise (18%) counseling. Asians and Hispanics were more likely to undergo any lifestyle counseling, while non-Hispanic whites received the least exercise and nutrition counseling. Patients with 2 cardiovascular comorbidities were counseled for diet (53%) and exercise (32%) more than those with 1 (44% and 31%) or none (30% and 23%; P</=.001 and P</=.001). The encounters in the NAMCS had higher rates of counseling than those in the NHAMCS. There were no significant differences in counseling rates with respect to gender, geographic region, severity of hypertension, or physician specialty. While there were significant differences in counseling rates with respect to age, race, comorbidity, and survey cohort, counseling for therapeutic lifestyle changes for patients with hypertension was uniformly suboptimal. Physicians need to recognize the importance of nonpharmacologic treatment in hypertension.

Physician referrals to physical therapy for the treatment of musculoskeletal conditions

Freburger JK, Holmes GM, Carey TS. Physician referrals to physical therapy for the treatment of musculoskeletal conditions. Arch Phys Med Rehabil 2003;84:1839–49. Objectives To identify factors associated with orthopedic surgeons’ and primary care physicians’ referrals to physical therapy (PT) for musculoskeletal conditions. Design Cross-sectional analysis of National Ambulatory Medical Care Survey data. Setting US office-based physician practices. Participants Visits to primary care physicians (N=4911) or orthopedic surgeons (N=4201) for musculoskeletal conditions. Interventions Not applicable. Main outcome measure Whether a PT referral was made. Results After controlling for diagnosis, illness severity, and PT supply, insurance status and physician characteristics remained strong predictors of PT referral. Primary care visits covered by Medicaid or a managed care plan were less likely to result in PT referral than were visits covered by private insurance or a nonmanaged care plan. Orthopedic surgeon visits covered by workers’ compensation or managed care were more likely to result in PT referral than were visits not covered by workers’ compensation or not covered by managed care. Osteopathic primary care visits were more likely than allopathic primary care visits to result in PT referral. Given identical visit characteristics, orthopedic surgeon visits were more likely than primary care visits to result in PT referral. Conclusions Significant differences exist in orthopedic surgeons’ and primary care physicians’ referrals to PT, both within and across specialties. Variation in PT referral may be indicative of problems with access and/or inappropriate referral.

Datapoints: trends in combined pharmacotherapy with stimulants for children.

Back to table of contents Previous article Next article ColumnsFull AccessDatapoints: Trends in Combined Pharmacotherapy With Stimulants for ChildrenVinod S. Bhatara, M.D., M.S.H.S., Michael Feil, M.S., M.B.A., Kimberly Hoagwood, Ph.D., Benedetto Vitiello, M.D., and Bonnie Zima, M.D., M.P.H.Vinod S. BhataraSearch for more papers by this author, M.D., M.S.H.S., Michael FeilSearch for more papers by this author, M.S., M.B.A., Kimberly HoagwoodSearch for more papers by this author, Ph.D., Benedetto VitielloSearch for more papers by this author, M.D., and Bonnie ZimaSearch for more papers by this author, M.D., M.P.H.Published Online:1 Mar 2002https://doi.org/10.1176/appi.ps.53.3.244AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Use of stimulants in the treatment of children in the United States increased steadily between 1989 and 1996 (1,2), but little is known about how this trend is related to combination pharmacotherapy in which stimulants are used with other psychotropic agents.Stimulants may be prescribed alone or with other medications for the treatment of attention-deficit hyperactivity disorder (ADHD). There are indications that combined psychopharmacotherapy with stimulants is on the rise (3). It has been estimated from data from the National Ambulatory Medical Care Survey (NAMCS), an annual survey of a representative sample of U.S. office-based physician practices (4), that a stimulant is prescribed during 83 percent of physician office visits for the treatment of ADHD; in 10 percent of these visits, additional psychotropic medications are prescribed (2). Because these data were pooled across eight years, however, trends in such combined pharmacotherapy cannot be determined.To explore whether combined pharmacotherapy with stimulants is increasing, we examined NAMCS prescription data for the periods 1993-1994, 1995-1996, and 1997-1998. We combined the data from pairs of consecutive surveys to obtain larger samples. Sample sizes for all visits in which a stimulant was prescribed were 231 (weighted, 4,810,000) for 1993-1994, 228 (weighted, 4,530,000) for 1995-1996, and 203 (weighted, 4,980,000) for 1997-1998.As described elsewhere (1), we examined 11 categories of psychotropic medications prescribed for patients under age 18. We determined the frequency of outpatient visits that included a prescription for a stimulant and determined the proportion of these visits that involved concurrent prescription of any other psychotropic agent.Among pediatric office visits between 1993 and 1998, 1.46 percent to 1.66 percent, or nearly two million visits a year, involved prescription of a stimulant. As Figure 1 shows, of these visits, the proportion that included a concomitant prescription for any other psychotropic agent increased fivefold during the study period, from 4.78 for 1993-1994, to 10.79 for 1995-1996, to 24.70 for 1997-1998. The most commonly prescribed concomitant psychotropic medications were clonidine and various antidepressants.Our results should be interpreted cautiously, because the sample was small and because NAMCS data do not provide estimates of patients' actual drug use, and thus use may have been overestimated because of noncompliance. Despite these limitations, our findings suggest that definitive safety and efficacy data are needed to support common forms of combined psychopharmacotherapy among youths.Dr. Bhatara and Dr. Zima are affiliated with the Health Services Research Center of the University of California, Los Angeles. Dr. Bhatara is also affiliated with the department of psychiatry at the University of South Dakota in Vermillion. Mr. Feil is with the U.S. Department of Agriculture. Dr. Hoagwood and Dr. Vitiello are with the National Institute of Mental Health. Send correspondence to Dr. Bhatara at 2601 W. Nicole Drive, Sioux Falls, South Dakota 57105 (e-mail, [email protected]). Harold A. Pincus, M.D., and Terri L. Tanielian, M.A., are editors of this column.Figure 1. Proportion of pediatric office-based visits during which both a stimulant and another psychotropic drug were prescribed, as a percentage of all visits during which a stimulant was prescribedaa For 1993-1994, 95% confidence interval=172−7.24; for 1995-1996, CI=6.62−14.96; for 1997-1998, CI=17.72−31.68