Regional Variation In Utilization Research Articles

Time trends and regional variation in utilization of antidiabetic medicines in China, 2015-2022.

To assess the use of non-insulin antidiabetic medicines in China. We analysed the national procurement data for 29 non-insulin antidiabetic medicines from nine subgroups in China from 2015 to 2022. We estimated the number of defined daily doses (DDDs) procured per year in seven regions of China for nine subgroups and adjusted the data by the number of patients with diabetes. For each subgroup, the regional ratio was calculated by comparing the procurement per patient in each region with the procurement nationwide. The regional disparity was the difference between the highest and lowest regional ratios. We compared the medication patterns across regions. Nationally, between 2015 and 2022, the number of DDDs per patient increased from 14.45 to 47.37. The two most commonly used categories were sulphonylurea and biguanides, which increased from 7.04 to 15.39 (119%) and 3.28 to 11.11 (239%) DDDs per patient, respectively. The procurement of new drugs (dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter type 2 inhibitors and glucagon-like peptide-1 receptor agonists) increased quickly and had >5000% relative changes. Particularly for sodium-glucose cotransporter type 2 inhibitors, it increased from 0.08 to 5.03 DDDs (6662%). The southwest region had the highest relative change (319%), while the southern region had the lowest (118%). Biguanide and thiazolidinediones had the lowest (1.19) and highest level (2.21) of regional disparity in 2022, respectively. The procurement of non-insulin antidiabetic medicines in China has increased a lot from 2015 to 2022. In terms of DDDs per patient, sulphonylurea ranked first, followed by metformin. The procurement of new drugs increased greatly. A large regional disparity existed in medicine usage and patterns.

Nationwide Analysis of Sacroiliac Joint Fusion Trends: Regional Variations in Utilization and Population Characteristics.

Retrospective cohort analysis. This study evaluates utilization and demographic trends for sacroiliac joint (SIJ) fusions across the United States (US). Patients who underwent SIJ fusion from 2010-2021 were identified within the PearlDiver national database using International Classification of Disease (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Indications for trauma, malignancy, or infection were excluded. Demographic, clinical, and procedure characteristics were recorded along with annual utilization rates. Annual percent change (APC) was calculated to identify increasing or decreasing utilization from prior years. Negative binomial regression was performed to project subsequent utilization for 2022-2028. Chi-squared analysis followed by post-hoc comparisons were used to compare differences in diagnostic indications and clinical features associated with SIJ fusion across regions. Bonferroni adjustments were applied to P-values for pairwise analyses. Overall, 18032 patients (69.8% female, mean age = 51.0 + 13.4years) underwent SIJ fusion between 2010 and 2021. Annual utilization increased by 33.5% on average. The South comprised the largest proportion of cases (48.9%). Projections for 2022-2028 predict continued growth in procedures, with an overall increase of 1100% from 1350 cases in 2021 to 16195 by end of 2028. Spondyloarthropathy-induced sacroilitis was the most prevalent diagnostic indication nationwide (51%). Of patients undergoing SIJ fusion, 18% had a prior lumbar fusion, and only 45% received a preoperative diagnostic SIJ injection. As SIJ fusion is increasingly utilized to treat refractory SIJ-based pain, establishing evidence-based guidelines, improving diagnostic strategies, and defining indications are imperative to support growing applications within clinical practice.

Degree of regional variation and effects of health insurance-related factors on the utilization of 24 diverse healthcare services - a cross-sectional study

BackgroundRegional variation in healthcare utilization could reflect unequal access to care, which may lead to detrimental consequences to quality of care and costs. The aims of this study were to a) describe the degree of regional variation in utilization of 24 diverse healthcare services in eligible populations in Switzerland, and b) identify potential drivers, especially health insurance-related factors, and explore the consistency of their effects across the services.MethodsWe conducted a cross-sectional study using health insurance claims data for the year of 2014. The studied 24 healthcare services were predominantly outpatient services, ranging from screening to secondary prevention. For each service, a target population was identified based on applicable clinical recommendations, and outcome variable was the use of the service. Possible influencing factors included patients’ socio-demographics, health insurance-related and clinical characteristics. For each service, we performed a comprehensive methodological approach including small area variation analysis, spatial autocorrelation analysis, and multilevel multivariable modelling using 106 mobilité spaciale regions as the higher level. We further calculated the median odds ratio in model residuals to assess the unexplained regional variation.ResultsUnadjusted utilization rates varied considerably across the 24 healthcare services, ranging from 3.5% (osteoporosis screening) to 76.1% (recommended thyroid disease screening sequence). The effects of health insurance-related characteristics were mostly consistent. A higher annual deductible level was mostly associated with lower utilization. Supplementary insurance, supplementary hospital insurance and having chosen a managed care model were associated with higher utilization of most services. Managed care models showed a tendency towards more recommended care. After adjusting for multiple influencing factors, the unexplained regional variation was generally small across the 24 services, with all MORs below 1.5.ConclusionsThe observed utilization rates seemed suboptimal for many of the selected services. For all of them, the unexplained regional variation was relatively small. Our findings confirmed the importance and consistency of effects of health insurance-related factors, indicating that healthcare utilization might be further optimized through adjustment of insurance scheme designs. Our comprehensive approach aids in the identification of regional variation and influencing factors of healthcare services use in Switzerland as well as comparable settings worldwide.

Regional Variation in Utilization of Hepatitis C-Positive Organs for Heart Transplantation in the United States

Purpose With increasing organs available in light of the national opioid epidemic and the availability of direct acting-antiviral (DAA) therapy for Hepatitis C virus (HCV), HCV antibody (Ab)+ organs serve as an important potential supply to the donor pool. We sought to examine trends over time in the utilization of HCV Ab+ organs both nationally and regionally. Methods We queried the United Network for Organ Sharing registry data in the DAA era between January 2012 and March 2018 for adults ≥18 years who had undergone heart transplantation with a HCV Ab+ donor as well as donor recovery data. Results The incidence of HCV Ab+ deceased donors have increased from 4.6% in 2012 to 8.7 in 2018 (p Conclusion Over the last two years, with the availability of DAA therapy, there has been increased nationwide recovery and utilization of HCV Ab+ donor hearts that is accompanied by significant regional variability. Adopting standardized protocols across UNOS regions and transplant centers may increase utilization of these donors more effectively and potentially lead to better outcomes.

Regional Variation in Utilization and Outcomes of Liver Allografts From Donors With High Body Mass Index and Graft Macrosteatosis: A Role for Liver Biopsy.

Obesity, defined as a high body mass index (hBMI) of 30 kg/m or greater, is a growing epidemic worldwide and is associated with multiple comorbidities. High BMI individuals account for an increasing portion of potential liver donors. Here we evaluate trends in the utilization and outcomes of hBMI donors on a national and regional level and the potential role of liver biopsy in donor evaluation. United Network for Organ Sharing Standard Transplant Analysis and Research database was evaluated for deceased donor liver transplants between 2006 and 2016 across 11 Organ Procurement and Transplantation Network regions. High BMI donors were compared with lower BMI counterparts and evaluated for biopsy rates, utilization rates and allograft outcomes. Univariate and multivariable analyses were performed. Seventy-seven thousand fifty potential donors were identified and 60 200 transplants were evaluated. Utilization rates for hBMI donors were 66.1% versus 78.1% for lower BMI donors (P < 0.001). Pretransplant biopsy was performed more frequently in hBMI donors (52.1% vs 33.1%, P < 0.001) and macrosteatosis of 30% or greater was identified more often (21.1% vs 12.2%, P < 0.001). Biopsy performance increased utilization rate of hBMI donors in 7 of 11 Organ Procurement and Transplantation Network regions. region 6 showed the highest rate of biopsy performance, high rate of hBMI donor utilization, and highest 5-year estimated graft survival rates of all regions. High BMI donors have not previously been associated with worse graft survival in multivariable analyses; however, they are used much less frequently. Liver biopsy may increase the utilization rate of hBMI donors and improve donor selection. Further evaluation of regions with high rates of utilization and good outcomes is warranted.

MP50-09 REGIONAL VARIATION IN UTILIZATION OF URETEROSCOPY OVER SHOCKWAVE LITHOTRIPSY IN CALIFORNIA

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II1 Apr 2018MP50-09 REGIONAL VARIATION IN UTILIZATION OF URETEROSCOPY OVER SHOCKWAVE LITHOTRIPSY IN CALIFORNIA Scott Wiener, Marshall Stoller, and Anne Suskind Scott WienerScott Wiener More articles by this author , Marshall StollerMarshall Stoller More articles by this author , and Anne SuskindAnne Suskind More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1620AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteroscopy (URS) and shockwave lithotripsy (SWL) are the most common procedures for renal and ureteral calculi. The percentage of stones treated by URS has risen over the past decade, surpassing the percentage treated by SWL as of 2010. The drivers behind this change remain unknown and likely vary by region. We sought to explore regional variation in utilization of URS and SWL over time in the state of California (CA) and to identify associated factors. METHODS We queried CA′s Office of Statewide Health Planning and Development (OSHPD) public inpatient and ambulatory surgical databases from 2005-2013. URS and SWL procedures for nephrolithiasis were identified via ICD-9/10 and CPT4 codes for inpatient and ambulatory procedures, respectively (codes for malignancy or ureteral stricture were excluded). Geographic regions were defined according to the CA Labor Market Information Division′s economic sub-regions (19 groups of counties where people live and work as assessed by population centers, commute patterns, and industry analysis). Information from the 2016 AUA and 2010 US censuses were incorporated, and Chi-square tests were used for comparisons. RESULTS A total of 237,461 URS and SWL procedures were identified from 2005-2013. URS accounted for 40% of stone procedures in 2005 and 57% of procedures by 2013. Between URS and SWL, category counts for age, gender, race, insurance, disposition, and comorbidities exhibited statistically significant but clinically irrelevant differences. However, 75% of URS versus 93% of SWL procedures were performed on an ambulatory basis (p<0.0001). Urologists practiced in all 19 regions in CA. Over time, 7 out of 19 regions (37%) shifted from SWL to URS predominance (Fig 1). These 7 regions contain 10 of 11 urology residency programs, 67% of the state population, and 68% of procedures performed. CONCLUSIONS Significant regional variation in practice patterns for the management of renal and ureteral calculi exists in the state of California and changes over time. Two patterns of practice emerge: some regions have adopted URS as the primary management, while others continue rely on SWL. The 7 regions which have predominantly adopted URS contain a majority of the population, almost all urology residency programs, and are the principal drivers of the statewide switch to URS based on the volume of URS performed. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e678-e679 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Scott Wiener More articles by this author Marshall Stoller More articles by this author Anne Suskind More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP27-03 PRE-OPERATIVE URODYNAMIC EVALUATION IN FEMALE MEDICARE PATIENTS UNDERGOING A STRESS URINARY INCONTINENCE PROCEDURE: RATES BEFORE AND AFTER THE VALUE TRIAL

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2018MP27-03 PRE-OPERATIVE URODYNAMIC EVALUATION IN FEMALE MEDICARE PATIENTS UNDERGOING A STRESS URINARY INCONTINENCE PROCEDURE: RATES BEFORE AND AFTER THE VALUE TRIAL Annah Vollstedt, Rachel Moses, and E. Ann Gormley Annah VollstedtAnnah Vollstedt More articles by this author , Rachel MosesRachel Moses More articles by this author , and E. Ann GormleyE. Ann Gormley More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.882AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The American Urologic Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) Guideline outlines the evaluation and treatment of stress urinary incontinence (SUI) and state that urodynamic (UDS) testing may be omitted in healthy females who have not undergone a prior SUI procedure. This recommendation is largely based on the data reported in the seminal Value of Urodynamic Evaluation (ValUE) trial. We sought to investigate the rates of UDS testing in those undergoing a SUI procedure before and after the ValUE trial publication. METHODS Using the Dartmouth Institute’s Atlas Rate Generator exploring a 100% Medicare claims data, we identified females with a diagnosis of SUI by ICD-9 codes and a CPT code for either urethral bulking or urethral sling procedure, within 306 hospital referral regions (HRR). We then identified the proportion of those who also had a CPT code for UDS within one year prior to their SUI procedure. RESULTS Complete 2011 and 2013 data was available for 151 of the 306 HHRs. The national percentage of pre-operative UDS evaluation was 53% (16020/30131) in 2011, compared to 55% (11,772/21579) in 2013, after the publication of the ValUE trial (p=0.157). In 2011, the highest percentage of UDS testing in was performed in Monroe, LA at 81% (48/59) and the lowest in Jonesboro, AR at 22% (14/64). In 2013, the highest percentage of UDS testing was performed in Longview, TX at 88% (43/49) and the lowest in Springfield, MO at 22% (22/99). Only 40% (61/151) of HHRs decreased their use of UDS, while 52% (79/151) increased UDS rates, and 8% (11/151) HHRs stayed the same. CONCLUSIONS There is significant regional variation in utilization of UDS in those undergoing a SUI procedure. Nationally, the overall rates of UDS, diagnostic testing did not change significantly after the publication of the ValUE trial. When evaluating at the HRR level, a larger proportion of HRRs demonstrated increased or unchanged rates between 2011 and 2013. Further research is needed to investigate the differences in UDS testing after the distribution of the SUI AUA/SUFU guidelines as well the rates of UDS testing in populations other than Medicare beneficiaries. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e347 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Annah Vollstedt More articles by this author Rachel Moses More articles by this author E. Ann Gormley More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Regional Variation in Utilization, In-hospital Mortality, and Health-Care Resource Use of Transcatheter Aortic Valve Implantation in the United States

We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation.

Urban-rural differentials in the uptake of mammography and cervical cancer screening in Kenya

Regular uptake of breast and cervical cancer screening are recommended for early detection of these two most common types of carcinoma among women in developing countries. Previous studies have demonstrated the occurrence of a strong urban/rural differential in several health indicators and the rate of utilization of health services in the areas of infectious and chronic diseases, mental and maternal healthcare utilization in Kenya. However, that of breast and cervical cancer screening has not been reported. In this study we aim to measure the prevalence of uptake of mammography and cervical cancer screening, and assess urban/rural differences in the uptake of the screening services for these two diseases. MethodsCross-sectional data were extracted from the latest KDHS conducted in the country. Subjects were 11,138 women ageing between 15 and 49 years. Outcome variables were self-reported screening status of breast and cervical cancer. Bivariate and multivariable logistic regression results were generated to explore the regional variation in utilization of cervical cancer and mammography screening. ResultWomen who took both of types of screenings were more likely to be residing in the urban areas (54.3% vs 45.7% for cervical cancer and 55.7% vs 44.3% for breast cancer). In the univariate analysis, urban women had respectively 62% and 90% higher odds of taking cervical and breast cancer screening compared to rural women. The association remained significant even after adjusting for the covariates in the multivariate analyses which showed respectively 12% and 14% higher odds of breast and cervical cancer screening among urban women compared to rural women. ConclusionFindings suggest that interventions to promote breast and cervical cancer screening utilization are necessary for rural women. Regional barriers that are preventing rural women from using the screening services as well as their urban counterparts needs to be identified.

Regional variation in utilization of Antenatal care services in the state of Andhra Pradesh.

Background:Delivery of maternal health care services is a major challenge to the health system in developing countries. Provision of antenatal care (ANC) services is the major function of public health delivery system in India to improve maternal health outcomes and its impact on maternal morbidity and mortality. Studies are lack in documenting variation in utilization of ANC services between geographical regions of Andhra Pradesh (AP).Objective:The objective of this study is to assess variation in utilization of ANC services stratified by geographical region, type of delivery and determinants of utilization of ANC services in AP.Methodology:It is a cross-sectional study of District Level Household and Facility Survey-4 of the state of AP. Multistage, stratified and probability proportional to size sample with replacement was used. Around 3982 women who delivered after the year 2007 were considered for analysis. Binomial logistic regression was carried out to determine association of demographic, system level variables with adequate ANC.Results:Study reveals wide variation across four regions of AP in utilization of ANC services. Reception of adequate ANC was low in Rayalaseema region (27.9%) and high in North-coastal region (42.4%). The utilization of private health facilities for ANC services were highest in South-coastal region (73.2%) and lowest in North-coastal region (43.2%).Conclusion:Policy measures are to be adopted and implemented by government to address the demand-supply imbalance such as public health infrastructure and quality of services in underperforming districts of AP and to increase outreach of current programs by engaging communities.

New pricing approaches for bundled payments: Leveraging clinical standards and regional variations to target avoidable utilization

ObjectivesDevelop pricing models for bundled payments that draw inputs from clinician-defined best practice standards and benchmarks set from regional variations in utilization. DataHealth care utilization and claims data for a cohort of incident Ontario ischemic and hemorrhagic stroke episodes. Episodes of care are created by linking incident stroke hospitalizations with subsequent health service utilization across multiple datasets. Study designCosts are estimated for episodes of care and constituent service components using setting-specific case mix methodologies and provincial fee schedules. Costs are estimated for five areas of potentially avoidable utilization, derived from best practice standards set by an expert panel of stroke clinicians. Alternative approaches for setting normative prices for stroke episodes are developed using measures of potentially avoidable utilization and benchmarks established by the best performing regions. Principal findingsThere are wide regional variations in the utilization of different health services within episodes of stroke care. Reconciling the best practice standards with regional utilization identifies significant amounts of potentially avoidable utilization. Normative pricing models for stroke episodes result in increasingly aggressive redistributions of funding. ConclusionsBundled payment pilots to date have been based on the costs of historical service patterns, which effectively ‘bake in’ unwarranted and inefficient variations in utilization. This study demonstrates the feasibility of novel clinically informed episode pricing approaches that leverage these variations to target reductions in potentially avoidable utilization.

Appropriate And Inappropriate Imaging Rates For Prostate Cancer Go Hand In Hand By Region, As If Set By Thermostat

Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.

Variation in Cardiologists’ Propensity to Test and Treat

Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions. We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization. Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.

Geographic Variation in Health Care: The Role of Private Markets

The Dartmouth Atlas of Health Care has documented substantial regional variation in health care utilization and spending, beyond what would be expected from such observable factors as demographics and disease severity. However, since these data are specific to Medicare, it is unclear to what extent this finding generalizes to the private sector. Economic theory suggests that private insurers have stronger incentives to restrain utilization and costs, while public insurers have greater monopsony power to restrain prices. We argue that these two differences alone should lead to greater regional variation in utilization for the public sector, but either more or less variation in spending. We provide evidence that variation in utilization in the public sector is about 2.8 times as great for outpatient visits ( p &lt; 0.01) and 3.9 times as great for hospital days ( p = 0.09) as in the private sector. Variation in spending appears to be greater in the private sector, consistent with the importance of public sector price restraints.

Regional variation and adherence to guidelines for drug treatment of asthma

To describe the utilization of antiasthmatic drugs in Sweden and to explore regional variations in drug utilization and adherence to guidelines for rational drug prescribing of antiasthmatics and their rationale. Data on antiasthmatic drugs dispensed between July 2005 and December 2008 to all Swedish citizens aged between 18 and 44 years were obtained from the Swedish National Prescribed Drug Register. The period prevalence was determined by analyzing the number of users/1000 inhabitants, and the incidence by analyzing the number of new users after an 18-month drug-free wash-out period. Three drug-related indicators were used to assess the adherence to guidelines. All measures were analyzed by gender and region. A total of 161,000 patients were dispensed antiasthmatics in 2007, corresponding to a prevalence of 4 and 6% among men and women, respectively; the incidence rates were 2 and 3%, respectively. The total drug utilization and adherence to guidelines varied between regions. The total drug expenditures of antiastmatics were 258 million SEK (28 million euro), with fixed dose combinations accounting for 46% of the expenditure. No relation was found between models for allocating prescribing budgets or clear Drug and Therapeutics Committee recommendations and adherence to guidelines. There are large regional variations in the utilization of antiasthmatics between Swedish regions, with substantial room for improvement in the adherence to guidelines. New methods of influencing physician behavior may be needed in the future to enhance adherence.

New technique to measure mucosal metabolism and its use to map substrate utilization in the healthy human large bowel.

A new method of assessing substrate utilization in gastrointestinal mucosal specimens is described. Small human endoscopic biopsy specimens with wet weights ranging between 1.4 and 12.2 mg were used to quantify the oxidation of three metabolic substrates, glucose, glutamine and butyrate, through to carbon dioxide over a 2-h period. The technique proved to be reproducible and capable of distinguishing variations in mucosal metabolism between individuals (P < 0.0001 for each substrate). Results were similar to those obtained previously using human and rat colonocytes. To characterize the metabolism of the healthy large bowel, specimens were obtained from five regions in 15 patients who had a normal colonoscopic examination. The results show that butyrate is the preferred fuel source of large bowel mucosa, followed by glutamine, then glucose (P < 0.01). There was no significant regional variation in utilization of the three substrates between the five regions; with respect to glutamine, this is contrary to previous findings.

Variation in health care utilization and outcomes in ischemic stroke

P125 Objectives: Little data is available about regional variation in utilization and outcomes during and after ischemic stroke (IS). Examining these relationships can lead to better understanding of the patient and process characteristics that influence stroke outcomes. Methods: Index IS admissions were identified using primary position ICD-9 codes 434 and 436 in a national cohort of veterans hospitalized at any VAMC from 10/90 to 10/97. Demographic, admission, mortality and outpatient data were extracted from VA administrative databases for the regions Northeast (NE), South (S), Midwest (MW) and West (W). Discharge diagnoses were used to assess risk factors and to construct the Charlson Index (CI), a predictor of mortality risk (↑ CI = ↑ risk). Time to death was modeled with Cox regression. Results: We identified 55,094 IS patients (98% male, 73% white, mean age 68). Regional data are summarized in the Table. NE patients were sicker (higher CI), had longer LOS and higher in-hospital mortality. However, adjusted subsequent mortality was lower in the NE and W (hazard ratio NE = .82, W = .91, p&lt;.001 for both). More NE and W patients had a neurology or primary care visit within 60 days or 1 year. Conclusions: Regional variations exist in outcomes and patterns of care after IS. Adjusted subsequent mortality is lower in regions where more patients have follow-up. Prospective studies evaluating these variations are needed to determine the best strategies for providing optimal stroke care.