Private Practice Providers Research Articles

Utilization of In-Hospital Orthopaedic Spine Consultations: Evaluating the Impact of Health Care Policy

Access to specialty and private practice providers has been a divisive policy issue over the last decade, complicated by the conflict between a reduction in government-funded health care reimbursement and the need for health care providers to sustain a financially sound practice. This study evaluates the orthopedic spine consult service at an academic tertiary care center at 2 separate time points over a 5-year period to better understand the impact of decreasing orthopedic reimbursement rates and the increasing prevalence of federally supported medical insurance on the access to specialty care. In total 500 patients in 2017 and 480 patients in 2021 were included for the final analysis. A higher percentage of consults in 2021 came from the emergency department (74.0% versus 60.4%, P < 0.001); however, the emergency department saw fewer spinal cord injuries (11.9% versus 21.4%, P < 0.001), and the spinal cord injuries were less severe (3.1% versus 6.2% Association Impairment Scale A or B, P = 0.034). A smaller percentage of patients in 2021 went on to receive orthopedic spine surgery following consultation (35.2% versus 43.8%, P = 0.007), and those receiving surgery had an operation performed farther out from the initial consultation (4.73 versus 4.09 days, P < 0.001). Additionally, fewer patients with Medicare insurance (23.5% versus 30.8%) and more patients with Medicaid insurance (20.2% versus 12.4%) were seen in 2021 compared with 2017 (P = 0.003). Overall, this study found an increased proportion of Medicaid patients seen by the spine consult service but a decrease in the acuity of consults. Measures to improve access to health insurance under the Affordable Care Act have revealed the complexity of this issue in health care. This study’s findings have demonstrated that while more patients did have insurance coverage following the Affordable Care Act, they still face a barrier to accessing outpatient orthopedic spine providers.

ACR Presidential Address: Rheumatologists-Folks You Can Trust.

ACR Presidential Address: Rheumatologists-Folks You Can Trust.

The socioeconomic effect of COVID-19 on pediatric ophthalmologists: data from the first 12 months

PurposeTo investigate the socioeconomic effect on pediatric ophthalmologists (POs) of the first year of the COVID-19 pandemic and to assess the association of practice type with financial impact.MethodsAn email follow-up survey of all AAPOS active members (POs) in April 2021, was used in conjunction with two prior surveys. The majority of US states were represented, and respondents were categorized as academic/university (AU), hospital employee (H), or one of three types of private practice: multispecialty ophthalmology practice (MSP), pediatric ophthalmology/strabismus group (PG), or solo practice (SP).ResultsThe cumulative results during this one-year period revealed 1,533,203 examinations not performed, of which 498,291 were Medicaid. Over 65,000 surgeries were not performed. The average salary loss per PO was $57,188. The total loss of revenue for the pediatric ophthalmology sector was over $303,788,000. Practice groups making at least 75% of their prior year revenue were as follows: H, 81%; AU, 64%; MSP, 52%; PG, 50%; SP, 40%. Salary reduction in each group was as follows: H, 4.2%; AU, 15.4%; MSP, 17.2%; PG, 23.1%; SP, 40.9%. The average loss per practice was $290,151. More than 95% of private practice POs received funds from the Paycheck Protection Program.ConclusionsAt the one-year mark of the pandemic, patient care had been severely disrupted, with subsequent financial consequences. Private practice providers (and especially solo practices) were disproportionally negatively affected.

Preoperative Evaluation of Otosclerosis: A National Survey of Otologists.

Describe practice patterns in preoperative assessment for stapedectomy. Survey. Tertiary referral center. Active members of the American Neurotologic Society and American Otologic Society. Survey. Percent of respondents performing preoperative testing with acoustic reflexes (ARs), electrocochleography, vestibular evoked myogenic potentials, and computed tomography (CT). Further analysis of those not ordering routine CT to determine whether imaging would be ordered for previous ear surgery, vestibular complaints, childhood hearing loss, AR inconsistent with otosclerosis, possible advanced otosclerosis, or atypical complaints, including autophony. Further subgroup analysis based on years in practice and practice setting (private versus academic). Most respondents (56.5%) had practiced more than 15 years and worked in academic settings (69.4%). Rates of routine use of preoperative AR, vestibular evoked myogenic potential, and electrocochleography were 80, 4.7, and 0%, respectively. There were no significant differences based on time in practice or practice settings. For CT, 35.3% reported routine use with a statistically significant difference between academic and private practice respondents (42.4% versus 19.2%, p = 0.040). For CT contingent on specific clinical factors, only AR inconsistent with otosclerosis showed a statistically significant difference between academic and private practice providers (85.3% versus 57.1%, p = 0.020). Most otologists routinely obtain AR before stapedectomy. Academic providers more commonly order CT routinely and for AR inconsistent with otosclerosis. Most respondents not ordering routine CT ordered imaging in specific clinical scenarios. Overall, there is a high level of consistency in preoperative testing regardless of practice setting or time in practice.

Online marketing practices of vasectomy reversal providers in the United States

ABSTRACT Introduction Vasectomy reversal (VR) is rarely covered by insurance, creating a market similar to cosmetic surgery with direct marketing to patients. While cost is an immediate concern for patients, surgeon training and experience are essential for a successful outcome. Patients considering VR are likely to seek information online regarding providers and the nature of the procedure. Objective In this study, we reviewed the characteristics of providers marketing VR online, as well as the comprehensiveness of their website content. Additionally, we sought to determine differences in VR practice patterns between academic and private practices. Methods We identified VR practices operating within the top 50 populous metropolitan areas in the USA. Practice websites were reviewed to obtain information such as educational background of providers, use of operating microscope, ability to perform vasoepididymostomy (VE), surgical volume, and out-of-pocket cost. Based on the information available from practice websites, providers were assigned a non-validated “REVERSAL score” out of 12, based on 8 domains (Risks disclosure; provider's Educational background; ability to perform VE; Expense disclosure; success Rate disclosure; Surgical volume disclosure; disclosure of Alternatives to VR; and Level of magnification used for VR) (Table). Descriptive statistics were used to compare the results between academic and private practices. Results 107 providers were identified (29 academic and 78 private). All but 2 were male, and similarly all but 2 had Doctor of Medicine (M.D.) degree. Review of practice websites allowed us to obtain complete information (REVERSAL score of 12) on only one provider (academic), with the majority (66%) of providers achieving REVERSAL score of ≤6. Providers with formal fellowship training in andrology, microsurgery, and/or infertility achieved higher REVERSAL scores compared to those without (6.9 ± 2.4 vs. 4.8 ± 2.4, p < 0.01). Academic providers were more likely to have completed pertinent fellowship training compared to private practice providers (97% vs. 44%, p < 0.05). Only 14% of academic providers disclosed procedure cost online, compared to 40% of private practice providers (p < 0.05). There was a trend toward increased use of online advertisements by private practice providers (22% vs. 10%, p = 0.07), and increased reference to literature success rates by academic providers (59% vs. 41%, p = 0.10). Among the 35 providers who disclosed pricing online, mean cost of VR was $5,990 ± 1,935. There was a non-significant trend toward increased cost with academic practices compared to private practices ($7,337 ± 1,103 vs. $5,765 ± 1,964, p = 0.09). There was significant reduction in cost when comparing non-urologists vs. urologists ($3,584 ± 1,554 vs. $6,591 ± 1,518, p < 0.01), and when comparing providers without pertinent fellowship training to those with ($5,405 ± 2,000 vs. $6,769 ± 1,590, p < 0.05). Conclusions There is significant lack of transparency in publicly available information from VR practices, both academic and private. Practices should implement measures to improve the dissemination of information to the general public, so that patients may more easily compare various providers. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Coloplast, AMS).

ONLINE MARKETING PATTERNS OF VASECTOMY REVERSAL PRACTICES

Vasectomy reversal (VR) is rarely covered by insurance, and is associated with high direct and indirect costs to the patient. We sought to determine the ease with which patients can compare the characteristics of various academic and private VR practices, using an online search engine. Additionally, we sought to determine differences in VR practice patterns between academic and private practices. We identified VR practices operating within the top 50 populous metropolitan areas in the USA. Practice websites were reviewed to obtain information such as educational background of providers, use of operating microscope, ability to perform vasoepididymostomy (VE), surgical volume, and out-of-pocket cost. Based on the information available from practice websites, providers were assigned a non-validated “REVERSAL score” out of 12, based on 8 domains (Risks disclosure; provider’s Educational background; ability to perform VE; Expense disclosure; success Rate disclosure; Surgical volume disclosure; disclosure of Alternatives to VR; and Level of magnification used for VR). Descriptive statistics were used to compare the results between academic and private practices. 107 providers were identified (29 academic and 78 private). All but 2 were male, and similarly all but 2 had Doctor of Medicine (M.D.) degrees. Review of practice websites allowed us to obtain complete information (REVERSAL score of 12) on only one provider (academic), with the majority (66%) of providers achieving REVERSAL score of ≤6. Providers with formal fellowship training in andrology, microsurgery, and/or infertility achieved higher REVERSAL scores compared to those without (6.9 ± 2.4 vs. 4.8 ± 2.4, p < 0.01). Academic providers were more likely to have completed pertinent fellowship training compared to private practice providers (97% vs. 44%, p < 0.05). Only 14% of academic providers disclosed procedure cost online, compared to 40% of private practice providers (p < 0.05). There was a trend toward increased use of online advertisements by private practice providers (22% vs. 10%, p = 0.07), and increased reference to literature success rates by academic providers (59% vs. 41%, p = 0.10). Among the 35 providers who disclosed pricing online, mean cost of VR was $5990 ± 1935. There was a non-significant trend toward increased cost with academic practices compared to private practices ($7337 ± 1103 vs. $5765 ± 1964, p = 0.09). There was significant reduction in cost when comparing non-urologists vs. urologists ($3584 ± 1554 vs. $6591 ± 1518, p < 0.01), and when comparing providers without pertinent fellowship training to those with ($5405 ± 2000 vs. $6769 ± 1590, p < 0.05). There is significant lack of transparency in publicly available information from VR practices, both academic and private. Practices should implement measures to improve the dissemination of information to the general public, so that patients may more easily compare various providers.

Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

ObjectiveTo determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices. Materials and MethodsWe identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results. ResultsOf the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6. ConclusionThere is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

Mental Health Practitioners' Immediate Practical Response During the COVID-19 Pandemic: Observational Questionnaire Study.

BackgroundThe COVID-19 pandemic has been associated with increased psychological distress, signaling the need for increased mental health services in the context of stay-at-home policies.ObjectiveThis study aims to characterize how mental health practitioners have changed their practices during the pandemic. The authors hypothesize that mental health practitioners would increase tele–mental health services and that certain provider types would be better able to adapt to tele–mental health than others.MethodsThe study surveyed 903 practitioners, primarily psychologists/doctoral-level (Psych/DL) providers, social workers/master’s-level (SW/ML) providers, and neuropsychologists employed in academic medical centers or private practices. Differences among providers were examined using Bonferroni-adjusted chi-square tests and one-way Bonferroni-adjusted analyses of covariance.ResultsThe majority of the 903 mental health practitioners surveyed rapidly adjusted their practices, predominantly by shifting to tele–mental health appointments (n=729, 80.82%). Whereas 80.44% (n=625) were not using tele–mental health in December 2019, only 22.07% (n=188) were not by late March or early April 2020. Only 2.11% (n=19) reported no COVID-19–related practice adjustments. Two-thirds (596/888, 67.10%) reported providing additional therapeutic services specifically to treat COVID-19–related concerns. Neuropsychologists were less likely and Psych/DL providers and SW/ML providers were more likely than expected to transition to tele–mental health (P<.001). Trainees saw fewer patients (P=.01) and worked remotely more than licensed practitioners (P=.03). Despite lower rates of information technology service access (P<.001), private practice providers reported less difficulty implementing tele–mental health than providers in other settings (P<.001). Overall, the majority (530/889, 59.62%) were interested in continuing to provide tele–mental health services in the future.ConclusionsThe vast majority of mental health providers in this study made practice adjustments in response to COVID-19, predominantly by rapidly transitioning to tele–mental health services. Although the majority reported providing additional therapeutic services specifically to treat COVID-19–related concerns, only a small subset endorsed offering such services to medical providers. This has implications for future practical directions, as frontline workers may begin to seek mental health treatment related to the pandemic. Despite differences in tele–mental health uptake based on provider characteristics, the majority were interested in continuing to provide such services in the future. This may help to expand clinical services to those in need via tele–mental health beyond the COVID-19 pandemic.

Exploring strategies used by physiotherapy private practices in hosting student clinical placements

Introduction: Private practice clinical education experiences are important for workforce readiness of physiotherapy graduates, however there are limited opportunities to experience this setting during training. Furthermore, private practice is considered a valuable source of placements for education providers where shortages occur. Exploring the strategies used by physiotherapy private practice providers when hosting students may provide insight into how students can be integrated into practice whilst minimising disruption to staff, clients and service delivery. Methods: A qualitative study with a general inductive thematic analytical approach was undertaken. Semi-structured interviews of ten physiotherapy private practice placement providers responsible for student placement provision were used to explore the strategies used to successfully integrate students into private practice settings. Results: Four key themes emerged following data analysis; developing systems, student service provision, finding other ways to educate, and seeking support from the education provider. Conclusion: This study is the first to explore the perspective of private practice placement providers regarding how students are successfully integrated into private practice settings where learning and service delivery can be maximised. Areas for further research are outlined.

Prenatal intent and postpartum receipt of long-acting reversible contraception among women receiving medication-assisted treatment for opioid use disorder

BackgroundMany women with opioid use disorder (OUD) do not use highly effective postpartum contraception such as long-acting reversible contraception (LARC). We evaluated factors associated with prenatal intent and postpartum receipt of LARC among women receiving medication-assisted treatment (MAT) for OUD. Study designThis was a retrospective cohort study of 791 pregnant women with OUD on MAT who delivered at an academic institution without immediate postpartum LARC services between 2009 and 2012. LARC intent was defined as a documented plan for postpartum LARC during pregnancy and LARC receipt was defined as documentation of LARC placement by 8 weeks postpartum. We organized contraceptive methods into five categories: LARC, female sterilization, short-acting methods, barrier methods and no documented method. Multivariable logistic regression identified characteristics predictive of prenatal LARC intent and postpartum LARC receipt. ResultsAmong 791 pregnant women with OUD on MAT, 275 (34.8%) intended to use postpartum LARC and only 237 (29.9%) attended the postpartum visit. Among 275 women with prenatal LARC intent, 124 (45.1%) attended their postpartum visit and 50 (18.2%) received a postpartum LARC. Prenatal contraceptive counseling (OR 6.67; 95% CI 3.21, 13.89) was positively associated with LARC intent. Conversely, older age (OR 0.95; 95% CI 0.91, 0.98) and private practice provider (OR 0.48; 95% CI 0.32, 0.72) were negatively associated with LARC intent. Although parity was not predictive of LARC intent, primiparous patients (CI 0.49; 95% CI 0.26, 0.97) were less likely to receive postpartum LARC. ConclusionsDiscrepancies exist between prenatal intent and postpartum receipt of LARC among pregnant women with OUD on MAT. Immediate postpartum LARC services may reduce LARC access barriers. ImplicationsDespite prenatal interest in using LARC, most pregnant women with OUD on MAT did not receive postpartum LARC. The provision of immediate postpartum LARC services may reduce barriers to postpartum LARC receipt such as poor attendance at the postpartum visit.

Preserving fertility for adolescent and young adult cancer survivors: A community model.

109 Background: Loss of fertility is a significant late effect of cancer treatment for those patients diagnosed during their reproductive years. This loss is a source of considerable distress for patients who have not yet started or completed building their families. Fertility preservation counseling to discuss reproductive concerns regardless of treatment phase can ease this burden. However, due to access- and health-related barriers, approximately half of oncologists report having never referred a patient for a fertility consultation, and as many as 60% of cancer survivors do not recall receiving this information from their healthcare team at time of diagnosis. Methods: The Moncrief Cancer Institute (MCI) Fertility Preservation Program synchronizes services between oncology care providers and fertility specialists. This model is designed to remove discomfort associated with discussing options while enhancing access to care by arranging physician and patient education opportunities specific to fertility preservation and the treatment options available, patient care coordination for fertility preservation treatment, and financial assistance for fertility preservation treatment for underinsured and uninsured adolescent and young adult cancer patients. Results: Referrals for fertility counseling have been provided from 5 institutions through an established referral network comprised of non-profit organizations, local hospitals, and private practice providers. MCI partners with 2 reproductive specialty care groups who offer treatment at reduced rates, which MCI further subsidizes based on financial need. No patients are turned away for inability to pay. The institutions that MCI has targeted for education and partnerships support an environment that meet the distinct needs of adolescent and young adult patients with cancer. Conclusions: Program impact is evaluated by the number of patients and providers receiving education, and the number of patients receiving care coordination and/or financial support for fertility preservation treatment. In the fight against cancer, MCI is assisting patients to protect their future families through fertility preservation education and care coordination.

Health care provider perspectives on tuberculosis care for foreign-born populations in New York City.

Tuberculosis (TB) in foreign-born patients is a key determinant of TB epidemiology in low-burden settings. In New York City (NYC), foreign-born TB populations are heterogeneous and face diverse challenges in accessing care. To characterize barriers and facilitators to health care services and identify potential mechanisms to improve TB care for foreign-born patients in NYC. Semi-structured interviews with health care providers identified through the NYC TB registry and snowball sampling. Transcripts were analyzed using a modified grounded theory approach. Fourteen providers from private practice (21%), community clinic (36%), and hospitals (43%) were interviewed. Barriers clustered into thematic areas: interrelated social and economic issues that impact TB care and treatment (documentation status, poverty, mental/behavioral health issues), challenges of fragmented health system (care continuity, costs), latent tuberculous infection, and relative lack of resources and significant barriers for clinic and private practice providers. Health care providers' deep commitment to foreign-born TB patients was evidenced by their attitudes and actions. Improving access to TB care for foreign-born patients in NYC requires strategies that address specific social, economic and structural barriers. Improving linkages between private providers and public health initiatives is a key challenge. Health care providers' commitment to foreign-born communities is a significant resource.

Screening and evaluation of hepatitis C virus infection in pregnant women on opioid maintenance therapy: A retrospective cohort study

ABSTRACTBackground: The purpose of this study was to describe the delivery of prenatal care services to women with opioid use disorder (OUD) on opioid maintenance therapy at high risk for hepatitis C virus (HCV) infection. Methods: We conducted a retrospective cohort evaluation of 791 pregnant women with OUD from 2009 to 2012. HCV screening was defined as documentation of (a) an anti-HCV antibody test or (b) a provider discussion regarding a known HCV diagnosis during pregnancy. Multivariate logistic regression was used to identify predictors of HCV screening during pregnancy. Results: Among 791 pregnant women with OUD, 611 (77.2%) were screened for HCV infection and 369/611 (60.4%) were HCV positive. In multivariable analysis, patients who were married (odds ratio [OR] = 0.52; 95% confidence interval [CI] = 0.29, 0.91), used buprenorphine (OR = 0.45; 95% CI = 0.28, 0.71), and were cared for by private practice providers (OR = 0.29; 95% CI = 0.19, 0.45) were significantly less likely to be screened. In contrast, patients who used benzodiazepines (OR = 1.72; 95% CI = 1.02, 2.92), intravenous (IV) opioids (OR = 6.15; 95% CI = 3.96, 9.56), had legal problems (OR = 2.23; 95% CI = 1.12, 4.45), had children not in their custody (OR = 1.81; 95% CI = 1.01, 3.24), and who had a partner with substance abuse history (OR = 2.38; 95% CI = 1.23, 4.59) were significantly more likely to be screened. Of 369 HCV-positive patients, a new diagnosis of HCV was made during pregnancy for 108 (29.3%) patients. Only 94 (25.5%) had HCV viral load testing, 61 (16.5%) had HCV genotype testing, and 38 (10.4%) received an immunization for hepatitis A. Although 285 (77.2%) patients were referred to hepatology, only 71 (24.9%) attended the consultation. Finally, only 6 (1.6%) patients received HCV treatment 1 year following delivery. Conclusions: Prenatal care approaches to HCV infection remain inconsistent, and the majority of patients diagnosed with HCV infection during pregnancy do not receive treatment after delivery.

Practice Patterns of Endoscopic Ultrasound (EUS) With Fine Needle Aspiration in Pancreatic Mass Lesions

Introduction: To investigate current practice patterns with regards to fine needle aspiration (FNA) of pancreatic mass lesions in the United States. Methods: A 13-question online survey was sent to members of the American Society for Gastrointestinal Endoscopy (ASGE) within the United States. Categorical data were analyzed using Fisher’s exact tests. Results: A total of 298 responses were received of which 118(46.8%) were in academic setting and 119( 47.2%) were in community practice. Seventy-one percent of respondents performed at least 100 EUS procedures in the past year and another 18% performed between 50 and 100 procedures. Seventy-nine percent performed both EUS and ERCP. Interestingly, 54.5% used primarily 22 g needle as compared to 44% who preferred 25 g needle. Not surprisingly, academic practitioners had an on-site cytopathologist available 84% of the time, compared to 76% for community and 36% for independent practitioners (p value <0.05). Most of the practioners consider using stylet during the FNA procedures (80% vs 20%) irrespective of their practice setting. Eleven percent of academic practitioners regularly performed >6 passes per pancreatic mass lesion, compared to 3% for community and 36% for independent practitioners (p <0.05). Eighty-two percent of academic practitioners had no minimum size of pancreatic mass lesion in which they considered performing FNA, compared to 74% for community practice (p 0.33). Providers who perform high volume of EUS procedures are more likely to consider repeating EUS/FNA, if the initial procedure was non-diagnostic (75% vs 96%), (p <0.05). There is a trend towards performing higher volume of EUS procedures resulting in less likelihood of evaluating the superior mesenteric artery (SMA) for pancreatic cancer involvement with EUS. Similarly, academic practioners are less likely to evaluate the SMA involvement as compared to private practice providers. Conclusion: Among members of ASGE who responded to our online survey, there was only a slight variation in practice patterns between the academic and community practice providers. Despite evidence that 25 g needles are as efficacious as 22 g needles, respondents still primarily use 22 g needles, perhaps due to comfort with an established modality. This also explains why the majority of practitioners use a stylet during FNA. Finally, academic practitioners and the providers with high volume of EUS procedures were less likely to evaluate the SMA during EUS than their peers, perhaps due to the availability of radiology services for accurate tumor staging and thus making evaluation of the SMA with EUS at times unnecessary.

Radiation Oncology Practices Owned by Private Companies? Does Corporate Medicine Work in Radiation Oncology?

• Radiation oncology practised in public hospitals or private practice. • Adelaide Radiotherapy Centre is sole private practice provider of services in South Australia. • Corporate medicine not involved in radiation oncology. • Adelaide Radiotherapy Centre bought out by private company in 2008. • Rationale, benefits and disadvantages discussed.

The Integration of Advanced Trainees into Radiation Oncology Private Practice

Adelaide Radiotherapy Centre is the private practice provider of radiation oncology services in South Australia. In 2004, it decided to have advanced trainees integrated into the practice. The purpose of this study is to - 1. Ascertain whether this has been a benefit for the trainees. 2. Decide whether the practice should continue with advanced training. 3. Decide methods to improve the training for trainees.

Does Pre-hospital Telephone Communication with a Clinician Result in More Appropriate Medication Administration by Parents during Childhood Asthma Exacerbations?

Background. The National Heart, Lung and Blood Institute asthma guidelines recommend that parents communicate with a clinician during childhood asthma exacerbations when symptoms worsen or do not improve with initial therapy. This study tested the hypothesis that communication by parents with a clinician before an Emergency Department visit was associated with more appropriate medication administration for children with asthma exacerbations. Methods. This was a retrospective cohort study using data gathered from parents of children presenting with an asthma exacerbation to the emergency department. The communicating cohort included parents who communicated by telephone with a clinician during the exacerbation and the non-communicating cohort included parents who did not. Multivariate logistic regression models were used to test three hypotheses; communication with a clinician is associated with (1) administration of short-acting β-agonists (SABAs), (2) increased dosing frequency of SABAs, and (3) administration of an oral corticosteroid. Results. A total of 199 subjects were enrolled, with 104 (52.3%) in the communicating and 95 (47.7%) in the non-communicating cohort. There was an association between communication and provider practice type, with children who received routine care from a private practice provider more likely to communicate with the clinician than children in hospital-based clinics or community health centers (Adjusted OR 1.9, 95% CI 1.0–3.7). Impoverished children and children insured by Medicaid were less likely to communicate with a clinician (controlling for provider type). Parents who communicated with a clinician were more likely to administer a SABA (adjusted OR 3.6, 95% CI 1.3–9.4) and an oral corticosteroid (adjusted OR 3.3, 95% CI 1.3–8.4) but were not more likely to administer a SABA with increased dosing frequency (adjusted OR 0.9, 95% CI 0.5–1.6). Conclusions. Parents of children with asthma exacerbations who communicated with clinicians were more likely to administer SABAs and an oral corticosteroid before bringing their child to an emergency department. Frequency of SABA dosing was not associated with communication. Clinicians providing telephone advice to parents need to provide explicit instructions about medication administration, emphasizing the frequency with which SABAs should be administered.

Predictors of episiotomy use at first spontaneous vaginal delivery

Objective: To identify factors associated with the use of episiotomy at spontaneous vaginal delivery. Methods: We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nulliparas at Brigham & Women’s Hospital between December 1, 1994 and July 31, 1995. The association of demographic variables and obstetric factors with the rate of episiotomy use were examined. Adjusted odds ratios (OR) and confidence intervals (CI) were estimated from multiple logistic regression analysis. Results: The overall rate of episiotomy was 40.6% (640 of 1576). Midwives performed episiotomies at a lower rate (21.4%) than faculty (33.3%) and private providers (55.6%) ( P = .001). After controlling for confounding factors with logistic regression, private practice provider was the strongest predictor of episiotomy use (OR, 4.1; 95% CI, 3.1, 5.4) followed by faculty provider (OR, 1.7; 95% CI, 1.1, 2.5), prolonged second stage of labor (OR, 1.8; 95% CI, 1.2, 2.7), fetal macrosomia (OR, 1.6; 95% CI, 1.1, 2.5), and epidural analgesia (OR 1.4, 95% CI, 1.1, 1.8). Conclusion: The strongest factor associated with episiotomy at delivery was the category of obstetric provider. Obstetric and demographic factors evaluated did not readily explain this association.

Challenges to Private Provider Participation in Immunization Registries

Background For immunization registries to be effective, all providers (both private and public) of childhood vaccines must be willing to participate. The purpose of this study was to identify and fully understand the (1) benefits of the North Carolina Immunization Registry (NCIR), (2) barriers to participation by private practice physicians, and (3) potential incentives to address the barriers identified. Methods We conducted a statewide series of 13 focus groups (6 with pediatricians, 5 with family physicians, and 2 with office managers). Participants represented the full range of nonpublic practice settings (e.g., solo, small, and large group practices, HMOs, and university clinics). Many participants questioned the need for an immunization registry and wanted evidence that it is a cost-effective intervention. We compared our findings with those found in other All Kids Count (AKC) sites. Results The benefits of the NCIR commonly identified included having access to a complete and accurate history of a child’s immunizations, thus eliminating the need for phone calls to other practices for immunization records and eliminating the need to document immunization information in multiple sites, thus automatically producing immunization forms for daycare, school, etc., and decreasing missed immunization opportunities. Barriers to participation included the following: the staff time needed to submit and obtain data, direct and indirect costs to practices (e.g., computer software, hardware, upgrades, data entry time), accuracy of data, liability for errors, and access to and security of data. Conclusions Physicians must be convinced that the NCIR will be simple and inexpensive to use, flexible, and easy to integrate into their existing office systems. Public health officials should not underestimate the effort that will be required to achieve full participation by private-practice providers.