Percentage Of Visits Research Articles

Trends in the use of neurotoxins and dermal fillers by US physicians

Demand for minimally invasive cosmetic procedures have led to an increased market of available products for facial rejuvenation.To characterize trends in the usage of aesthetic products, specifically the use of botulinum toxins and dermal fillers, by United States physicians.Data from the National Ambulatory Medical Care Survey was analyzed from 1993 to 2010 to evaluate the use of dermal fillers and neurotoxins in the United States outpatient setting. The types of physician specialties administering these products and their preferences in products were characterized.There were an estimated 100,000 annual cosmetic visits at which a dermal filler was administered from 1993 to 2010. From 2002 to 2010, there were 140,000 annual cosmetic visits for a dermal filler and 440,000 visits for a neurotoxin. While collagen was the most common filler used over the entire study period, its use declined eight percent annually. Hyaluronic acid fillers were preferred from 2002 to 2010, followed by calcium hydroxylapatite filler, representing 50 percent and 16.1 percent of visits, respectively. The leading neurotoxin was onabotulinumtoxin A, used at 87.1 percent of visits. Dermatologists were the leading specialty for the cosmetic use of both dermal fillers and neurotoxins.Providers' preference for cosmetic products appears to be influenced by their familiarity with them, with products that first came to market, such as the neurotoxin onabotulinumtoxin A and the hyaluronic acid fillers being used most frequently from 2002 to 2010.

G591 Using multilingual patient education videos to support a prompt and safe discharge from the emergency department

Context The Paediatric Emergency Department at The Royal London Hospital. The project involved a team of doctors and nurses of all grades. Problem Paediatric gastroenteritis is one of the most common presentations to in the emergency department (ED) at the Royal London Hospital, accounting for more than six percent of visits. Gastroenteritis is easy to diagnose and the vast majority of these children could be safely managed at home. The challenge with managing these children is twofold. Firstly, identifying seriously unwell children who need urgent treatment. Secondly, educating families about safe and effective management of gastroenteritis at home. Before our intervention, children who present with diarrhoea and/or vomiting are seen by an assessment nurse and a junior doctor or general practitioner, spending over two and half hours in the emergency department. Assessment of problem and analysis of its causes We quantified the scale of the problem by undertaking a retrospective audit of the care children received when they presented with gastroenteritis. Ninety percent of children who presented had a very mild illness that could have been managed safely at home. We supplemented the quantitative data with informal conversations with colleagues. There was a widespread view that many parents presented to hospital due to anxiety and/or uncertainty about how to manage their child’s illness at home. We extracted data from the electronic medical records of 580 children presenting with diarrhoea and/or vomiting. The concordance between a final diagnosis of viral gastroenteritis and the parents reporting diarrhoea or vomiting at reception was 97% and 90% respectively. Such a high concordance between symptoms and diagnosis reassures us that the assessment nurse could accurately diagnose gastroenteritis. We calculated the relative risk of serious illness depending on the presence of 16 easy to illicit clinical symptoms and signs. Based on these findings we have designed a pathway that the triage nurse will use to discharge patients. We have retrospectively tested the efficacy and safety of this new pathway. Our research suggests that half of these patients could be safely discharged by the assessment nurses using our simple protocol. Intervention We designed a criteria based discharge pathway, allowing nurses to safely discharge patients from triage without waiting to see a doctor. The discharge pathway is supported by a multilingual patient and parent education video that can be viewed in the department and on the trust website. Strategy for change After designing the discharge pathway we presented it at departmental meetings and teaching sessions in order to get feedback. Once the pathway was approved we identified’champions’ who have supported its implementation and have helped to train staff. Measurement of improvement We designed a dashboard providing a visual display of the four key performance indicators: number of cases of diarrhoea and vomiting, percentage of cases discharged on the pathway, mean duration of stay in the emergency department and reattendance rate. Effects of changes 42 children have been safely discharged on the new pathway. Anecdotal feedback has been very positive. It is too early to measure the impact of the new pathway on mean duration of stay in the emergency department and reattendance rate. Lessons learnt It takes time to embed new pathways into routine care and engage stakeholders. It has been very important to build a team of people to champion the new pathway. Message for others This has been a really exciting project and was enthusiastically received by staff. It represents an innovative way of managing simple paediatric presentations and has the potential to deliver a better service to children and their parents and, we hope, a longer term effect as we are educating parents and giving them a resource they can refer back to. Please declare any conflicts of interest The video was funded by the Barts and The London Charity.

Statewide Initiative to Embed Consumer Health Librarians in Public Libraries: A Case Study

In 2004 a collaborative, statewide outreach project in Delaware was undertaken where consumer health librarians were embedded in public libraries. In order to explore the effect of the embedded librarians on the quality of health information provision, unobtrusive reference visits were made to half of the public libraries in the state. The query “Do vaccines cause autism?” was posed to library staff; resources provided were recorded. In 67 percent of visits, public library staff provided authoritative health information resources. It appears the embedded librarians had a positive residual effect on the provision of authoritative health resources for addressing an ambiguous query.

Receipt of Systemic Corticosteroids during Asthma Visits to US Emergency Departments, 2007–2009

Background. National Asthma Education and Prevention Program recommended emergency department (ED) asthma treatment includes both providing systemic corticosteroids in the ED and a steroid prescription at discharge. Objective. To examine the prevalence of three types of substandard ED asthma care–providing a discharge prescription only, providing corticosteroids in the ED only, and providing neither— and how care varies with exacerbation severity. Methods. We used the National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED) (2007, 2008, and 2009) to identify ED asthma visits (International Classification of Diseases-9th Revision Clinical Modification (ICD-9-CM codes 493.xx)) for patients aged 1 to <65 years. The primary outcome was the percent of visits receiving each type of substandard care, both overall and by exacerbation severity. Multinomial logistic regressions with predictive margins were used to obtain estimates adjusted for patient, visit, and hospital characteristics. Results. For 27.1% (confidence interval (CI): 24.0–30.2%) of visits, patients received corticosteroids both in the ED and as a discharge prescription. A discharge prescription only was provided for 12.3% of visits (CI: 10.2–14.6%), corticosteroids were provided in the ED only for 18.2% (CI: 15.6–21.2%), and no corticosteroids were provided for 42.4% (CI: 38.8–46.2%). Even among visits by patients with abnormal overall respiratory status (fast respiratory rates, pulse oximetry values <97%, or both), only 32.3% (CI: 27.8–36.8) were provided corticosteroids both in the ED and as a prescription, while the remainder received some type of substandard care. Adjusted and unadjusted results were similar. Conclusions. Substandard ED asthma care is common, even among visits by patients with more severe asthma exacerbations.

Depression as a Predictor of Weight Regain Among Successful Weight Losers in the Diabetes Prevention Program

OBJECTIVETo determine whether depression symptoms or antidepressant medication use predicts weight regain in overweight individuals with impaired glucose tolerance (IGT) who are successful with initial weight loss.RESEARCH DESIGN AND METHODSA total of 1,442 participants who successfully lost at least 3% of their baseline body weight after 12 months of participation in the randomized controlled Diabetes Prevention Program (DPP) continued in their assigned treatment group (metformin, intensive lifestyle, or placebo) and were followed into the Diabetes Prevention Program Outcome Study (DPPOS). Weight regain was defined as a return to baseline DPP body weight. Participant weight and antidepressant medication use were assessed every 6 months. Depression symptoms (Beck Depression Inventory [BDI] score ≥11) were assessed every 12 months.RESULTSOnly 2.7% of the overall cohort had moderate to severe depression symptoms at baseline; most of the participants with BDI score ≥11 had only mild symptoms during the period of observation. In unadjusted analyses, both depression symptoms (hazard ratio 1.31 [95% CI 1.03–1.67], P = 0.03) and antidepressant medication use at either the previous visit (1.72 [1.37–2.15], P < 0.0001) or cumulatively as percent of visits (1.005 [1.002–1.008], P = 0.0003) were predictors of subsequent weight regain. After adjustment for multiple covariates, antidepressant use remained a significant predictor of weight regain (P < 0.0001 for the previous study visit; P = 0.0005 for the cumulative measure), while depression symptoms did not.CONCLUSIONSIn individuals with IGT who do not have severe depression and who initially lose weight, antidepressant use may increase the risk of weight regain.

Psychiatric-Related Emergency Department Visits Among Children With an Autism Spectrum Disorder

This study aimed to examine the prevalence and characteristics of psychiatry-related emergency department (ED) visits among children with an autism spectrum disorder (ASD), including the specific reason for visit, as well as the influence of insurance type. Data used for this cross-sectional, observational study were obtained from the 2008 National Emergency Department Sample, the largest all-payer ED database in the United States. Psychiatry-related visits to the ED among children with ASD were identified using International Classification of Diseases, Ninth Revision, billing codes. A total of 3,974,332 visits (unweighted) were present for youth 3-17 years, of which 13,191 involved a child with ASD. Thirteen percent of visits among children with ASD were due to a psychiatric problem, as compared with 2% of all visits by youths without ASD. Results from the multivariate analyses revealed that the likelihood for a psychiatric ED visit was increased 9-fold (odds ratio [OR], 9.13; 95% confidence interval [CI], 8.61-9.70) among pediatric ASD visits, compared with non-ASD visits. Children with ASD who were covered by private insurance, compared with those with medical assistance, were at even greater risk for a psychiatric ED visit (OR, 1.58; 95% CI, 1.53-1.63). Visits among children with ASD were more likely to be due to externalizing (OR, 1.62; 95% CI, 1.44-1.83) and psychotic (OR, 1.93; 95% CI, 1.58-2.35) disorders compared with visits among non-ASD children. This study highlights the need for improving community-based psychiatric systems of care for youths with ASD to divert psychiatry-related ED visits, particularly for those children with private insurance.

Pregnancy during Operation Iraqi Freedom/Operation Enduring Freedom

The purpose of this study was to evaluate pregnancy during war-time deployment. A retrospective review of gynecology visits was evaluated at Camp Doha, Kuwait, from August 2003 through April 2004. Of the 1,737 visits, 77 demonstrated a positive pregnancy test. These charts were evaluated for factors that may lead to important information for future deployments. The average age of the female soldier with a positive pregnancy test in theater was 27 +/- 7 years. The primary presenting complaint was amenorrhea. Ninety-two percent had an ultrasound. Fifty-four percent of visits were active duty, followed by Reserve, National Guard, and civilian government employees. Ninety-two percent were administratively redeployed. Seventy-seven percent of the soldiers became pregnant in country. Twenty-three percent arrived in country pregnant. Given the number of pregnancies before and during deployment, current screening procedures as well as new concepts in prevention need to be addressed.

Pattern of Drug Prescription and Utilization among Bam Residents during the First Six Months after the 2003 Bam Earthquake

It is important to identify what kinds of drugs are required by disaster-affected populations so that appropriate donations are allocated. On 26 December 2003, an earthquake with an amplitude of 6.3 on the Richter scale struck southeastern Iran, decimating the city of Bam. In this study, the most frequently utilized and prescribed drugs for Bam outpatients during the first six months after the Bam Earthquake were investigated. In this descriptive, cross-sectional study, the data were collected randomly from 3,000 prescriptions of Bam outpatients who were examined by general practitioners from Emergency Medical Assistance Teams in 12 healthcare centers during the first six months after the Bam Earthquake. The data were analyzed for: (1) patient sex; (2) number of drugs/prescriptions; (3) drug category; (4) drug name (generic or brand); (5) route of administration; (6) percent of visits where the most frequent drug categories were prescribed; and (7) the 25 most frequently prescribed drugs, using World Health Organization (WHO) indicators of drug use in health facilities. Male patients represented 47.4% and females 52.6% of the total number of outpatients. The mean number of drugs/prescriptions was 3.5 per outpatient. Oral administration was the most frequent method of administration (81.7%), followed by injections (10.9%). Respiratory drugs were the most frequently used drugs (14.2%), followed by analgesics/non-steroidal anti-inflammatory drugs (NSAIDs) (11.3%), antibacterials (11.2%), gastrointestinal (GI) drugs (9.6%), and central nervous system drugs (7%). Penicillins (6.8%), cold preparations (8%), and systemic anti-acids (ranitidine and omeprazole) were among the 25 most frequently used drugs by outpatients and inhabitants of Bam during the first six months after the Bam Earthquake. Respiratory, analgesic, antibacterial, GI, and psychiatric medications were among the most commonly prescribed pharmaceuticals after the catastrophic Bam Earthquake. The results of this study may help to predict the needs of patients during future disasters and prevent unnecessary donations of medicine.

Medical Support for Emergency Relief Workers After Typhoon Sudal in Yap, Micronesia

On 09 April 2004, Typhoon Sudal struck the Island of Yap in the Federated States of Micronesia (FSM). Over 90% of homes, public utilities, and public property were damaged or destroyed. Nearly 10% of the population was displaced to shelters, and the majority of the population was without drinking water or power. United States disaster workers were deployed to Yap for three months to assist in the recovery and relief efforts. The objective of this study was to evaluate the acute healthcare needs of the US disaster relief population serving in a remote setting with limited medical resources. A retrospective chart review of all disaster relief workers presenting to an emergency clinic in Yap during the disaster relief effort from April 2004-July 2004 was performed. Investigators extracted demographic data, chief complaints, medical histories, medical management, disposition, and outcome data from the clinic charts. Together, the 60 disaster workers present on Yap during the relief effort made 163 patient contacts in the disaster emergency clinic. A total of 92% of patient contacts were for minor medical complaints or minor trauma, 13% were for upper-respiratory infections, 9% were for gastrointestinal illness, and 9% were for dermatological problems. Eight percent of visits were for serious medical problems or trauma. Life-threatening illnesses or injuries did not occur. Disaster relief workers on Yap frequently utilized the disaster relief clinic. In general, disaster workers remained healthy during the relief effort in Yap, and most injuries and illnesses were minor. On-site medical providers resulted in rapid care and stabilization, and after treatment, disaster workers were able to return to duty.

Trends in provider capitation, 1996–2000

We examine the extent to which the health care services delivered by physicians and hospitals in public and private health plans are capitated, and how this changed from 1996 to 2000. The data are from the 1996 to 2000 years of the nationally representative Medical Expenditure Panel Survey (MEPS). Information on whether health care use was covered by capitated arrangements was obtained from billing offices of physicians and hospitals. We compare changes in the percentage of office-based physician visits, hospital outpatient department (OPD) visits, hospital emergency department (ED) visits, and hospital inpatient stays that are covered by capitation arrangements. We also compare differences by health insurance coverage and socio-demographic characteristics. We use standard two-tail tests of significance, accounting for the complex survey design of the MEPS. We find that only 15 percent of visits to office-based physicians were capitated in 1996, declining to 13 percent in 2000. Even among HMO enrollees, visits covered by a provider capitation arrangement represented a minority of all office visits, declining to 25 percent for Private HMO enrollees and 15 percent for Medicaid HMO enrollees in 2000. Even smaller proportions of hospital services were capitated. Conclusions: Capitation remains relatively rare even among public and private HMO enrollees.

Time Burden of Blood Transfusion.

Background:Patients necessarily receive transfusions of packed red blood cells (PRBCs) in the course of ameliorating symptoms of anemia from a variety of causes, including chemotherapy-induced anemia, anemia of chronic disease, myelodysplastic syndrome, and chronic renal failure. Blood product availability is often at a critically low level in many regions throughout the US. Blood product administration is not without risk including: transfusion reaction and infection. In addition, routine blood transfusions require substantial time and resources from the healthcare practitioners, and the patients and their families. In the event of a transfusion reaction, even greater resources are expended. This study was designed to describe and quantify the time required for PRBC transfusion visits, the various events that take place during the visit, to describe PRBC transfusion reaction incidence in this population, and estimate providers' labor and costs in providing PRBC transfusions.Methods:The study protocol was approved by the IRB of the INOVA Health System of Northern Virginia. Records of patients receiving PRBCs for any reason were retrospectively selected by working backwards from May 1, 2005 until 85 patient records were obtained. Data elements included:•Primary diagnosis•Number of PRBC units administered•Adverse transfusion-related event(s)•Procedures performed to treat the adverse events•Transfusion visit time durationsTrained nurse data collectors reviewed transfusion and medical records of the selected patients. Adverse events were characterized according to whether the record either documented a reaction or information suggesting a reaction (e.g., furosemide or additional steroids administered during the visit).Results:Average patient age was 67.2 years and 79% were males. Most common diagnoses were Myelodysplastic Syndrome (MDS) (59%) and chemotherapy-induced anemia (22%). Most (65%) patients received no pre-medication. Seventy-eight percent of patients received 2 units of PRBCs. The blood was not filtered 81% of the time. Mean time to infuse the first and second units was 100.8 and 99.3 minutes, respectively. Mean time between the end of the first unit and initiation of the second unit was 21.3 minutes. Mean total time per patient from the start of the first unit to the completion of however much was transfused (1 or 2 units) was 190.8 minutes. Five percent of visits had documented reactions, and another 6% had evidence suggestive of a reaction, for a total visit-based incidence of 11%.Conclusions:PRBC transfusions in this predominately MDS population consumed substantial time for both the staff and patient. The above data does not include the time required for blood draw, type and cross, patient identification, insurance verification (all of which are substantial time commitments). There is also associated staff time for billing for the procedure. Additional time/motion analysis is ongoing to further document the total time burden involved. Adverse reactions requiring intervention occurred in approximately 1 in 10 patients. Transfusions have previously been shown to not be without risk. We have now shown them to be associated with a significant time burden. In the future, the use of non-transfusion alternatives should be investigated and encouraged.

Developing a Quality Measure for Clinical Inertia in Diabetes Care

To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control. Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999. Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined. Increases in antiglycemic medications occurred at only 9.8 percent of visits despite 39 percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p < .001). Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.

Influence of psychotherapy attendance on buprenorphine treatment outcome

We evaluated the influence of psychotherapy attendance on treatment outcome in 90 dually (cocaine and heroin) dependent outpatients who completed 70 days of a controlled clinical trial of sublingual buprenorphine (16 mg, 8 mg, or 2 mg daily, or 16 mg every other day) plus weekly individual standardized interpersonal cognitive psychotherapy. Treatment outcome was evaluated by quantitative urine benzoylecgonine (BZE) and morphine levels (log-transformed), performed three times per week. Repeated-measures linear regression was used to assess the effects of psychotherapy attendance (percent of visits kept), medication group, and study week on urine drug metabolite levels. Mean psychotherapy attendance was 71% of scheduled visits. Higher psychotherapy attendance was associated with lower urine BZE levels, and this association grew more pronounced as the study progressed ( p = 0.04). The inverse relationship between psychotherapy attendance and urine morphine levels varied by medication group, being most pronounced for subjects receiving 16 mg every other day ( p = 0.02). These results suggest that psychotherapy can improve the outcome of buprenorphine maintenance treatment for patients with dual (cocaine and opioid) dependence.

Does patient-centered care improve provision of preventive services?

While patient-centered care (PCC) is desirable for many reasons, its relationship to treatment outcomes is controversial. We evaluated the relationship between PCC and the provision of preventive services. We obtained facility-level estimates of how well each VA hospital provided PCC from the 1999 ambulatory Veterans Satisfaction Survey. PCC delivery was measured by the average percentage of responses per facility indicating satisfactory performance from items in 8 PCC domains: access, incorporating patient preferences, patient education, emotional support, visit coordination, overall coordination of care, continuity, and courtesy. Additional predictors included patient population and facility characteristics. Our outcome was a previously validated hospital-level benchmarking score describing facility-level performance across 12 U.S. Preventive Services Task Force-recommended interventions, using the 1999 Veterans Health Survey. Facility-level delivery of preventive services ranged from an overall mean of 90% compliance for influenza vaccinations to 18% for screening for seat belt use. Mean overall PCC scores ranged from excellent (>90% for the continuity of care and courtesy of care PCC domains) to modest (<70% for patient education). Correlates of better preventive service delivery included how often patients were able to discuss their concerns with their provider, the percent of visits at which patients saw their usual provider, and the percent of patients receiving >90% of care from a VA hospital. Improved communication between patients and providers, and continuity of care are associated with increased provision of preventive services, while other aspects of PCC are not strongly related to delivery of preventive services.

Adverse drug events in two emergency departments in Naples, Italy: an observational study

The aims of this study, conducted in the emergency departments of two hospitals of Naples (Italy), which differ in type of catchment area and in the number of daily visits, were to determine: (1) the percent of emergency department visits due to adverse drug events (ADEs); (2) the percent of visits requiring hospitalisation due to acute ADEs; (3) the drugs implicated in ADEs; and (4) the types of ADEs and their frequency. We studied all emergency department visits at the A. Cardarelli and Incurabili hospitals between 8.00 a.m. and 8.00 p.m. (prospectively), and between 8.00 p.m. and 8.00 a.m. (retrospectively) for two 10-day periods. When possible, a form was completed for each subject. Patients were asked if they had taken a drug (name, dosage and reason for its use) in the previous 2 weeks. Of the 2442 emergency visits considered, 34 (1.3%) were drug related. Of the 480 patients who were subsequently hospitalised 17 (3.6%) had an ADE. The number increased to 34 (8.9%) in the 379 patients who took drugs in the 2 previous weeks. Non-steroidal anti-inflammatory drugs accounted for 26.5% of cases, antibiotics 23.6%, and antihypertensive agents 17.7%. The most frequent ADEs were gastrointestinal diseases (diarrhea, vomiting and haemorrhagic gastritis) and cutaneous rash (erythema, dermatitis). This study shows that ADEs account for a large percent of hospital admissions and confirms that drug-induced disorders is a notable public health problem.

Mental illness and length of inpatient stay for medicaid recipients with AIDS.

To examine the associations between comorbid mental illness and length of hospital stays (LOS) among Medicaid beneficiaries with AIDS. DATA SOURCE AND COLLECTION/STUDY SETTING: Merged 1992-1998 Medicaid claims and AIDS surveillance data obtained from the State of New Jersey for adults with >or=1 inpatient stay after an AIDS diagnosis from 1992 to 1996. Observational study of 6,247 AIDS patients with 24,975 inpatient visits. Severe mental illness (SMI) and other less severe mental illness (OMI) diagnoses at visits were ascertained from ICD-9 Codes. About 4 percent of visits had an SMI diagnosis; 5 percent had an OMI diagnosis; 43 percent did not have a mental illness diagnosis, but were patients who had been identified as having an SMI or OMI history; and 48 percent were from patients with no identified history of mental illness. The overall mean hospital LOS was 12.7 days. After adjusting for measures of HIV disease severity and health care access in multivariate models, patients presenting with primary and secondary severe mental illness (SMI) diagnoses had approximately 32 percent and approximately 11 percent longer LOS, respectively, than did similar patients without a mental illness history (p<0.001 for each). But in these adjusted models of length of stay: (1) diagnosis of OMI was not related to LOS, and (2) in the absence of a mental illness diagnosed at the visit, an identified history of either SMI or OMI was also not related to LOS. In adjusted models of time to readmission for a new visit, current diagnosis of SMI or OMI and in the absences of a current diagnosis, history of SMI or OMI all tended to be associated with quicker readmission. This study finds greater (adjusted) LOS for AIDS patients diagnosed with severe mental illness (but not for those diagnosed with less severe mental comorbidity) at a visit. The effect of acute severe mental illness on hospitalization time may be comparable to that of an acute AIDS opportunistic illness. While previous research raises concerns that mental illness increases LOS by interfering with treatment of HIV conditions, the associations here may simply indicate that extra time is needed to treat severe mental illnesses or arrange for discharge of afflicted patients.

Characteristics of primary care visits for individuals with severe mental illness in a national sample

Individuals with severe mental illness (SMI) are at risk for inadequate general medical and preventive care, but little is known about their visits for primary care. We performed a cross-sectional analysis of primary care physician visits from the National Ambulatory Medical Care Survey (NAMCS) 1993–1998 and compared visit characteristics for patients with and without SMI. SMI was defined from ICD-9 diagnoses and medications. Primary care visits for patients with SMI were more likely to be return visits, were longer, and were more likely to have scheduled follow-up than for patients without SMI. Obesity, diabetes, and smoking were reported approximately twice as frequently in visits for patients with SMI compared to patients without SMI. The percent of visits with preventive counseling and counseling targeted at chronic medical conditions was similar for both groups. Likely appropriate to their complex needs, patients with SMI using primary care tend to have more return visits, longer time with the physician and are more often scheduled for follow-up care; their preventive counseling appears similar to non-SMI visits.

New strains of bacteria and exacerbations of chronic obstructive pulmonary disease.

The role of bacterial pathogens in acute exacerbations of chronic obstructive pulmonary disease is controversial. In older studies, the rates of isolation of bacterial pathogens from sputum were the same during acute exacerbations and during stable disease. However, these studies did not differentiate among strains within a bacterial species and therefore could not detect changes in strains over time. We hypothesized that the acquisition of a new strain of a pathogenic bacterial species is associated with exacerbation of chronic obstructive pulmonary disease. We conducted a prospective study in which clinical information and sputum samples for culture were collected monthly and during exacerbations from 81 outpatients with chronic obstructive pulmonary disease. Molecular typing of sputum isolates of nonencapsulated Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, and Pseudomonas aeruginosa was performed. Over a period of 56 months, the 81 patients made a total of 1975 clinic visits, 374 of which were made during exacerbations (mean, 2.1 per patient per year). On the basis of molecular typing, an exacerbation was diagnosed at 33.0 percent of the clinic visits that involved isolation of a new strain of a bacterial pathogen, as compared with 15.4 percent of visits at which no new strain was isolated (P<0.001; relative risk of an exacerbation, 2.15; 95 percent confidence interval, 1.83 to 2.53). Isolation of a new strain of H. influenzae, M. catarrhalis, or S. pneumoniae was associated with a significantly increased risk of an exacerbation. The association between an exacerbation and the isolation of a new strain of a bacterial pathogen supports the causative role of bacteria in exacerbations of chronic obstructive pulmonary disease.

Narrowing the gap in treatment of depression.

Although effective treatments for depression exist, under or non-treatment of depression is common. Efforts were made in the early 1990s to improve recognition and treatment of depression, with many of those efforts targeted at groups most vulnerable to under-treatment. The purpose of this study is to assess treatment rates in 1993-1994 and 1996-1997. Using nationally representative surveys of office-based practice covering the years 1993, 1994, 1996, and 1997, we obtained estimates of visits by adults in which depression was diagnosed and a prescription for antidepressant medication and/or psychotherapy was provided or ordered. The proportion of physician office visits in which a depression diagnosis was recorded did not change from 1993-1994 (3.48 percent) to 1996-1997 (3.40 percent). However, the rate of antidepressant prescription or psychotherapy rose from 74.2 percent of visits with a depression diagnosis in 1993-1994 to 82.3 percent of these visits in 1996-1997. Significantly lower rates of treatment for depression during office visits made by African American patients, elderly patients, and patients on Medicaid occurred in 1993-1994, but were not evident in 1996-1997, reflecting improved rates of depression treatment in these populations. Although rates of diagnosis of depression during office visits have not increased, treatment rates for depression are improving among those who are diagnosed, including groups of people who historically were less likely to be offered treatment. Additional efforts to improve recognition and diagnosis of depression in ambulatory medical practice and to improve dissemination of treatment are needed.

Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO: a preliminary study.

Somatization is a common, costly problem with great morbidity, but there has been no effective screening method to identify these patients and target them for treatment. We tested a hypothesis that we could identify high utilizing somatizing patients from a management information system (MIS) by total number of visits and what we termed "somatization potential," the percentage of visits for which ICD-9 primary diagnosis codes represented disorders in the musculoskeletal, nervous, or gastrointestinal systems or ill-defined complaints. We identified 883 high users from the MIS of a large staff model HMO as those having six or more visits during the year studied (65th percentile). A physician rater, without knowledge of hypotheses and predictors, then reviewed the medical records of these patients and identified somatizing patients (n = 122) and nonsomatizing patients (n = 761). In two-thirds of the population (the derivation set), we used logistic regression to refine our hypothesis and identify predictors of somatization available from the MIS: demographic data, all medical encounters, and primary diagnoses made by usual care physicians (ICD-9 codes). We then tested our prediction model in the remaining one-third of the population (the validation set) to validate its usefulness. The derivation set contained the following significant correlates of somatization: gender, total number of visits, and percent of visits with somatization potential. The c-statistic, equivalent to the area under the ROC curve, was 0.90. In the validation set, the explanatory power was less with a still impressive c-statistic of 0.78. A predicted probability of 0.04 identified almost all somatizers, whereas a predicted probability of 0.40 identified about half of all somatizers but produced few false positives. We have developed and validated a prediction model from the MIS that helps to distinguish chronic somatizing patients from other high utilizing patients. Our method requires corroboration but carries the promise of providing clinicians and health plan directors with an inexpensive, simple approach for identifying the common somatizing patient and, in turn, targeting them for treatment. The screener does not require clinicians' time.