Staff-model Health Maintenance Organization Research Articles

Interobserver Reliability of the Chest Radiograph in Community-Acquired Pneumonia

<h3>Objective</h3> To evaluate the interobserver reliability of pulmonary radiographic findings in patients with community-acquired pneumonia (CAP). <h3>Design</h3> A prospective, multicenter study. <h3>Setting</h3> Physician offices, medical walk-in clinics, emergency departments, and inpatient wards affiliated with three university hospitals, one community hospital, and one staff model health maintenance organization in three geographic areas. <h3>Methods</h3> Copies of the initial chest radiograph of patients suspected of having CAP were independently read by two staff radiologists at the coordinating university hospital. Interobserver reliability for the interpretation for radiographic findings was assessed by calculation of agreement rates and the kappa statistic. <h3>Participants</h3> Adults (age ≥18 years) with symptoms or signs of CAP and a pulmonary radiographic infiltrate documented by a local study site radiologist. <h3>Results</h3> Among the 282 patients whose initial pulmonary radiographs were evaluated, there was agreement between the two staff radiologists on the presence of infiltrate in 79.4% and on the absence of an infiltrate in 6.0% (kappa=0.37; 95% confidence interval [CI]=0.22 to 0.52). For the 224 patients with an infiltrate identified by both radiologists, there was further agreement that the infiltrate was unilobar in 41.5% and multilobar in 33.9% (kappa=0.51; 95% CI=0.28 to 0.62), pleural effusion was present in 10.7% and absent in 73.2% (kappa=0.46; 95% CI=0.33 to 0.50), and the infiltrate was alveolar in 96.3% of patients and interstitial in no patients (kappa=-0.01; 95% CI=-0.03 to 0.00). Among the 210 patients with an alveolar infiltrate, both radiologists classified the infiltrate as lobar in 74.6% and bronchopneumonia in 2.4% (kappa=0.09; 95% CI=-0.04 to 0.22), and agreed on the presence of air bronchograms in 7.6% and their absence in 52.9% (kappa=0.01; 95% CI=-0.13 to 0.15). <h3>Conclusion</h3> In patients with CAP, two university radiologists identified the presence of infiltrate, multilobar disease, and pleural effusion with fair to good interobserver reliability. However, interobserver reliability for the pattern of infiltrate and the presence of air bronchograms was poor.

Age and gender differences in health services utilization.

The purpose of this study was to examine the health service utilization patterns of elderly male and female enrollees of a large urban staff model Health Maintenance Organization (HMO). This HMO offered a wide spectrum of managed care services for its beneficiaries. A cross-sectional design was employed. The 759 randomly sampled elderly enrollees ranged in age from 66 to 99, with an average of 77.15 years. Approximately 60% were male and 40% were female; thus, the sample was not representative of the national older adult population. Three utilization patterns indicated that there were (a) nonsignificant relationships between age or gender and urgent care visits, prescribed pharmaceuticals, and out-of-pocket costs for pharmaceuticals; (b) linear relationships between age and gender and visits to HMO primary care providers (-), home-health care visits (+), emergency care visits (+), hospitalizations (+), and MD visits during hospitalizations (+); and (c) age was curvilinearly related to use of both HMO specialists and non-HMO specialists. These findings suggest that use of acute care services, including hospitalizations, inpatient physician visits, and emergency services increase with age but the use of primary care providers decreases with age. Gender was not a significant modifier of the relationship between age and utilization.

Initial Antidepressant Choice in Primary Care

To compare the clinical, functional, and economic outcomes of initially prescribing fluoxetine with outcomes of initially selecting imipramine or desipramine. Randomized controlled trial. Primary care clinics of a Seattle, Wash, area staff-model health maintenance organization from 1992 through 1994. A total of 536 adults beginning antidepressant treatment for depression. Random assignment of initial antidepressant prescription (desipramine, fluoxetine, or imipramine). Subsequent antidepressant treatment (doses, medication changes or discontinuation, specialty referral) was managed by the primary care physician. Assessments after 1, 3, and 6 months examined clinical outcomes (Hamilton Depression Rating Scale and the depression subscale of the Hopkins Symptom Checklist) and quality-of-life outcomes (Medical Outcomes Study SF-36). Medication use and health care costs were assessed using the health maintenance organization's computerized data. Patients assigned to receive fluoxetine reported fewer adverse effects, were more likely to continue the original medication, and were more likely to reach adequate doses than patients beginning treatment with either tricyclic drug. The fluoxetine group reported marginally better clinical outcomes after 1 month, but these differences were not statistically significant and disappeared by the 3-month assessment. Quality-of-life outcomes in the 3 groups did not differ. Total health care costs over 6 months were approximately equal for the 3 groups, with higher antidepressant costs in the fluoxetine group balanced by lower outpatient visit and inpatient costs. Clinical outcomes, quality-of-life outcomes, and overall treatment costs provide no clear guidance on initial selection of fluoxetine or tricyclic drugs. Thus, patients' and physicians' preferences are an appropriate basis for treatment selection.

Clinical Predictors of Functioning in Persons with Acquired Immunodeficiency Syndrome

To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. Clinical diagnoses, comorbidities, health habits such as smoking, laboratory results, and selected medication use were assessed by chart review. Significant predictors of physical functioning P < 0.01, R2 = .58) in a multivariable regression model included energy/fatigue, neurologic symptoms, fever symptoms, a lower hemoglobin level, and current non-pneumonia bacterial infection. Ninety-six percent of the explained variance in physical functioning was accounted for by three symptom complexes: energy/fatigue, neurologic symptoms, and fever symptoms. Significant predictors of energy/fatigue in multivariable models included poorer mental health, lower white blood cell count, longer time since diagnosis, and weight loss (P < 0.01, R2 =.36). Significant predictors of neurologic symptoms included poorer mental health, weight loss, and no zidovudine use (P < 0.001, R2 = .30). Predictors of fever symptoms included poorer mental health, no zidovudine use, weight loss, and history of asthma or chronic obstructive pulmonary disease (P < 0.05, R2 = .25). In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.

Back pain in primary care: predictors of high health-care costs

The objective of this study was to describe the health care utilization and prospective predictors of high-cost primary-care back pain patients. In the primary-care clinics of a large, staff model health maintenance organization in western Washington State, 1059 subjects were selected from consecutive patients presenting for back pain. The design was a 1-year prospective cohort study. Patients' were interviewed 1 month after an index primary-care back pain visit. Costs (back pain and total) and utilization (back pain primary-care follow-up visits, back pain specialty visits, back pain hospitalizations, back pain radiologic procedures, and pain medicine fills) were tracked over the next 11 months. Predictors assessed at 1 month were back pain diagnosis (disc disorder/sciatica, arthritis, vs. other), chronic pain grade (measure of pain intensity and related dysfunction), pain persistence (days with pain in prior 6 months), depressive symptomatology, and back pain-related disability compensation (ever/never). For the sample, 21% of patients with back pain costs ≥$600 (high back pain costs) accounted for 66% of back pain costs, 42% of total costs, 55% of primary-care follow-up visits for back pain, 91% of back pain specialty visits, 100% of back pain hospitalizations, 51% of back pain radiologic procedures, and 52% of pain medicine fills. The 21% with total costs ≥ $2700 (high total costs) accounted for 67.7% of total costs, 52% of back pain costs, 29% of primary-care follow-up visits for back pain, 66% of back pain specialty visits, 100% of back pain hospitalizations, 39% of back pain radiologic procedures, and 42% of pain medicine fills. Multivariable logistic regression analyses indicated that increasing chronic pain grade, more persistent pain, and disc disorder/sciatica were strong independent predictors of high total and high back pain costs. Increasing depressive symptoms significantly predicted high total but not high back pain costs. Back pain disability compensation predicted high back pain but not high total costs. A minority of primary-care back pain patients accounted for a majority of health-care costs. Patients with high back pain costs accounted for more back pain-related health-care utilization than did patients with high total costs. Factors predicting subsequent high costs suggest behavioral interventions targeting dysfunction, pain persistence, and depression may reduce health-care utilization and prevent accumulation of high health-care costs among primary-care back pain patients.

Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival.

Previous studies have found that patients with the acquired immunodeficiency syndrome (AIDS) who are admitted to hospitals that admit many such patients have lower mortality rates than patients in hospitals with less experience with AIDS. We examined the relation between physicians' experience with AIDS and the survival of their patients with AIDS. We studied 403 adult male patients enrolled in a staff-model health maintenance organization in whom first AIDS-defining illnesses were diagnosed from 1984 through mid-1994; we determined that these illnesses met the 1987 case definition of the Centers for Disease Control. We defined three levels of experience for the patients' 125 primary care physicians according to their experience with AIDS during residency training and the cumulative number of patients with AIDS they had cared for in their practices. The median survival of the patients of physicians with the least experience in the management of AIDS was 14 months, as compared with 26 months for the patients of physicians with the most experience (P<0.001). Controlling for the severity of illness and the year of diagnosis, we found that the patients cared for by physicians with the most experience had a 31 percent lower risk of death than the patients cared for by physicians with the least experience (P<0.02). Among 244 patients with an AIDS-defining illness diagnosed from 1989 through 1994, after adjustment for the CD4+ cell count and the severity of illness, the risk of death was 44 percent lower for patients of the most experienced physicians than for patients of the least experienced (P<0.02). The experience of primary care physicians in the management of AIDS is significantly associated with survival among their patients.

Referring for knowledge base: What is the case for referral?

Referring for knowledge base: What is the case for referral?

Impact of visit copayments on outpatient mental health utilization by members of a health maintenance organization

The authors examined the impact of increasing cost sharing on use of outpatient mental health services. A quasi-experimental design was used to study outpatient utilization by members of a health maintenance organization (HMO) who were subject to increasing copayments for mental health visits (state government employees and dependents). Their outpatient mental health utilization was compared with that of similar HMO members who were not subject to cost sharing (federal government employees and dependents). Analyses compared both likelihood of any service use and number of visits per year among service users. Institution of $20/visit copayments was associated with a 16% decrease in likelihood of service use but no change in visit rate among service users. A subsequent copayment increase to $30/visit resulted in no significant change in likelihood of use but was associated with a 9% decrease in visits per year among those using services. The impact of the first copayment change on likelihood of using services did not vary according to level of clinical need (as measured by prior service use and psychotropic drug use). In this staff-model HMO, modest visit copayments significantly reduced initial access to mental health treatment and had a smaller effect on treatment intensity. Copayments restricted access regardless of clinical need. Designers of mental health benefits must consider the impact of copayments on those with the greatest need for treatment.

Perspectives on the physician workforce to the year 2020

Physician supply and demand for the period extending to 2020 were assessed from three perspectives: physician utilization in group- and staff-model health maintenance organizations, physician distribution, and the future supply of nonphysician clinicians. The national norm for physician demand in 1993 was estimated to be 205 per 100000 population. Demand is projected to increase 18% by 2020, because of both an expansion in beneficial services and a reduction in physician work effort. Supply initially will increase more rapidly, resulting in a surplus of 31 000 physicians (5% of patient care physicians) in the year 2000 and increasing to 62 000 physicians (8%) in 2010, after which the gap will narrow. Similar results were obtained when previous studies that had projected surpluses of 73 000 to 165 000 physicians (15% to 30%) in the year 2000 were reevaluated. However, physician distribution is not homogeneous, and the number of physicians per capita currently varies by more than twofold among states. Relative to the national norm, surpluses already exist in some states and shortages in others. In addition, the supply of nonphysician clinicians with independent practice authority is increasing. Their numbers are projected to double by 2010, equaling 60% of the number of patient care physicians. Measured as physician equivalents, their growth will equal the growth in physician supply. Thus, in terms of physicians alone, there is no evidence of a major impending national surplus. Local surpluses will be influenced principally by how physicians distribute themselves geographically. The major determinant of overall physician surpluses in the future will be the extent to which patients continue to seek physicians for services that also will be offered by an expanded work-force of nonphysician clinicians. Policy is needed that encompasses the universe of clinicians who will be providing care to patients in the next century. (JAMA. 1995;274:1534-1543)

Procedural Protections for Patients in Capitated Health Plans

In the American health care system, payers are rapidly moving toward the use of capitation as the preferred method for paying for health care services for sponsored patients. n capitation, the payer pays a provider organization a set rate per patient to care for a group of patients. The provider organization assumes the risk of the actual costs of caring for these covered lives. The theory of capitation is that providers, by assuming risk, will have incentives to contain their costs.The provider entity that provides the care can take many corporate forms. A capitated provider can be a small group of physicians with admitting privileges at a single hospital or a complex integrated delivery network comprised of hospitals, physicians, and other health care professionals and institutions with integrated case management and data systems. Currently such integrated delivery networks assume a variety of organizational forms, ranging from traditional staff model health maintenance organizations (HMOs) in which physicians are employees of the health plan to physician hospital organizations (PHOs) in which physicians and hospitals join together for purposes of contracting with payers. Hospitals and physicians belonging to their medical staffs are motivated to form integrated delivery networks or other consolidated business organizations in order to contract with payers that seek providers willing to accept financial risk for the care of sponsored patients. Providers join such arrangements out of fear of losing patients if they do not.

Women's health and managed care: Promises and challenges

T his is an appropriate time to examine women’s health and managed care. With the rapid growth of managed care in today’s health care delivery system, managed care organizations are playing an increasingly important role in the health of women. As managed care quickly becomes the dominant source of health care delivery for women in both the public and private sectors, understanding its impact on the health of women is crucial. It is increasingly difficult to define what the term managed care means. According to the Congressional Budget Office, managed care encompasses a broad range of health care organizational arrangements that are intended to eliminate unnecessary and inappropriate care and to reduce costs.’ The spectrum of managed care includes tightly structured group and staff model health maintenance organizations (HMOs), more loosely structured network and preferred provider organization (PPO) models, and various hybrid products such as point of service (POS) arrangements. Although comparisons of the different models are limited, it is likely that each model will vary with respect to patient care, satisfaction, and costs. Managed care plans now finance care for more than half of privately insured individuals, 9% of Medicare beneficiaries, and 23% of Medicaid beneficiaries.2A The most rapid enrollment growth, particularly among the privately insured population, is occurring among the less-structured managed care arrangements. The number of enrollees in network and independent practice association (IPA) arrangements increased from 19 million in 1988 to 35 million in 1994, whereas group/staff HMO enrollment grew from 14 million to 16 million over the same period.’ The managed care industry also is characterized increasingly by for-profit health plans. More than half of managed care enrollees (58%) were in for-profit plans in 1994, compared with one-quarter in 1985.6 Given this changing managed care environment, there are many unknowns with respect to changes in access to and quality of patient care as well as health care costs.7 Studies are just beginning to provide information on how these different plans perform. This paper examines the impact that managed care is having on privately o 1996 by x-he Jacobs Institute insured women and on low-income women with Medicaid coverage. To unof Women’s Health derstand managed care’s effect on women with private insurance, an analysis Published by Elsevier Science Inc

The growth of medical groups paid through capitation in California.

In California, it is common for health maintenance organizations (HMOs) to contract with large medical groups that are paid through capitation and are responsible for managing a full spectrum of medical services. We studied six large medical groups in California--Bristol Park Medical, Friendly Hills HealthCare Network, HealthCare Partners Medical Group, Mullikin Medical Centers, Palo Alto Medical Foundation, and San Jose Medical Group--that are paid through capitation and that are growing as a result of contracts with managed-care organizations. We conducted interviews and obtained data on factors such as patient enrollment, capitation and other revenue, numbers of days spent by enrollees in the hospital, and numbers of visits to physicians per enrollee. Between 1990 and 1994, the number of HMO enrollees whose care was paid for through capitation in the six medical groups increased by 91 percent, from 398,359 to 759,474. In 1994, the mean number of hospital days per 1000 HMO enrollees ranged from 120 to 149 for non-Medicare patients and from 643 to 936 days for Medicare patients. By comparison, in 1993 the mean numbers of hospital days per 1000 HMO enrollees not covered by Medicare were 232 for California and 297 for the United States; for HMO enrollees covered by Medicare, the numbers were 1337 for California and 1698 for the United States. In 1994, the average annual number of visits to physicians for HMO patients in the six groups not covered by Medicare ranged from 3.1 to 3.9; for Medicare patients, it ranged from 7.2 to 9.3; these rates were slightly lower than statewide and national rates. Four of the groups have sold their assets (such as facilities, supplies, equipment, and patients' charts) to outside investors; the physicians remain employed by physician-owned professional corporations. Medical groups paid through capitation offer a model for the status of physicians in managed-care systems that differs from the employee status offered by staff-model HMOs and the subcontractor status offered by HMOs that negotiate directly with individual physicians. Despite their growth, such medical groups in California face substantial challenges, such as obtaining the financial assets necessary to sustain rapid growth.

A national survey of the arrangements managed-care plans make with physicians.

Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians. In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs). Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs. Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

Estimating Physician Workforce Requirements

Richard Cooper's article in this issue of JAMA titled Perspectives on the Physician Workforce to the Year ignites controversy. 1 Cooper, extrapolating from physician staffing patterns in group- or staff-model health maintenance organizations (HMOs), forecasts the physician surplus to be trivial in the year 2000 and nonexistent by the year 2020 (his Figure 1). He proclaims that the contradiction of his forecast with the reports of the Graduate Medical Education National Advisory Committee (GMENAC) in 1981, 2 Weiner in 1994 and 1995, 3,4 the Council on Graduate Medical Education in 1994, 5 and the Bureau of Health Professions of the US Department of Health and Human Services in 1995 6 is attributable to the use of insupportable assumptions in the other studies. Cooper believes that newer data now available for US population projections, HMO staffing patterns, and physician work effort justify the assumptions he has adopted. See also p

Perspectives on the physician workforce to the year 2020

Physician supply and demand for the period extending to 2020 were assessed from three perspectives: physician utilization in group- and staff-model health maintenance organizations, physician distribution, and the future supply of nonphysician clinicians. The national norm for physician demand in 1993 was estimated to be 205 per 100000 population. Demand is projected to increase 18% by 2020, because of both an expansion in beneficial services and a reduction in physician work effort. Supply initially will increase more rapidly, resulting in a surplus of 31 000 physicians (5% of patient care physicians) in the year 2000 and increasing to 62 000 physicians (8%) in 2010, after which the gap will narrow. Similar results were obtained when previous studies that had projected surpluses of 73 000 to 165 000 physicians (15% to 30%) in the year 2000 were reevaluated. However, physician distribution is not homogeneous, and the number of physicians per capita currently varies by more than twofold among states. Relative to the national norm, surpluses already exist in some states and shortages in others. In addition, the supply of nonphysician clinicians with independent practice authority is increasing. Their numbers are projected to double by 2010, equaling 60% of the number of patient care physicians. Measured as physician equivalents, their growth will equal the growth in physician supply. Thus, in terms of physicians alone, there is no evidence of a major impending national surplus. Local surpluses will be influenced principally by how physicians distribute themselves geographically. The major determinant of overall physician surpluses in the future will be the extent to which patients continue to seek physicians for services that also will be offered by an expanded work-force of nonphysician clinicians. Policy is needed that encompasses the universe of clinicians who will be providing care to patients in the next century. (<i>JAMA</i>. 1995;274:1534-1543)

Perspectives on the Physician Workforce to the Year 2020

Physician supply and demand for the period extending to 2020 were assessed from three perspectives: physician utilization in group- and staff-model health maintenance organizations, physician distribution, and the future supply of nonphysician clinicians. The national norm for physician demand in 1993 was estimated to be 205 per 100,000 population. Demand is projected to increase 18% by 2020, because of both an expansion in beneficial services and a reduction in physician work effort. Supply initially will increase more rapidly, resulting in a surplus of 31,000 physicians (5% of patient care physicians) in the year 2000 and increasing to 62,000 physicians (8%) in 2010, after which the gap will narrow. Similar results were obtained when previous studies that had projected surpluses of 73,000 to 165,000 physicians (15% to 30%) in the year 2000 were reevaluated. However, physician distribution is not homogeneous, and the number of physicians per capita currently varies by more than twofold among states. Relative to the national norm, surpluses already exist in some states and shortages in others. In addition, the supply of nonphysician clinicians with independent practice authority is increasing. Their numbers are projected to double by 2010, equaling 60% of the number of patient care physicians. Measured as physician equivalents, their growth will equal the growth in physician supply. Thus, in terms of physicians alone, there is no evidence of a major impending national surplus. Local surpluses will be influenced principally by how physicians distribute themselves geographically. The major determinant of overall physician surpluses in the future will be the extent to which patients continue to seek physicians for services that also will be offered by an expanded workforce of nonphysician clinicians. Policy is needed that encompasses the universe of clinicians who will be providing care to patients in the next century.

Health care costs of primary care patients with recognized depression.

While an extensive literature documents the influence of depression on general medical services utilization, estimates of the economic burden of depression have focused on the direct costs of depression treatment. Higher use of general medical services may contribute significantly to the true cost of depressive illness. Computerized record systems of a large staff-model health maintenance organization (HMO) were used to identify consecutive primary care patients with visit diagnoses of depression (n = 6257) and a comparison sample of primary care patients with no depression diagnosis (n = 6257). The HMO accounting records were used to compare components of health care costs. Patients diagnosed as depressed had higher annual health care costs ($4246 vs $2371, P < .001) and higher costs for every category of care (eg, primary care, medical specialty, medical inpatient, pharmacy, laboratory). Similar cost differences were observed for each of the subgroups examined (patients treated with antidepressants, those not treated with antidepressants, and those diagnosed at routine physical examination visits). Pharmacy records indicated greater chronic medical illness in the diagnosed depression group, but large cost differences remained after adjustment ($3971 vs $2644). Twofold cost differences persisted for at least 12 months after initiation of treatment. Diagnosis of depression is associated with a generalized increase in use of health services that is only partially explained by comorbid medical conditions. In the primary care sector, this greater medical utilization exceeds direct treatment costs for depression. The persistence of utilization differences suggests that recognition and initiation of treatment alone are not adequate to reduce utilization differences.

Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals

Objectives. This study sought to compare the use of invasive procedures and length of stay for patients admitted with acute myocardial infarction to health maintenance organization (HMO) and fee-for-service hospitals.Background. The HMOs have reduced costs compared with fee-for-service systems by reducing discretionary admissions and decreasing hospital length of stay. It has not been established whether staff-model HMO hospitals also reduce the rate of procedure utilization.Methods. Using data from a retrospective cohort, we performed univariate and multivariate comparisons of the use of cardiac procedures, length of stay and hospital mortality in 998 patients admitted to two staff-model HMO hospitals and 7,036 patients admitted to 13 fee-for-service hospitals between January 1988 and December 1992.Results. The odds of undergoing coronary angiography were 1.5 times as great for patients admitted to fee-for-service hospitals than for those admitted to HMO hospitals (odds ratio 1.5, 95% confidence interval [CI] 1.3 to 1.9). Similarly, the odds of undergoing coronary revascularization were two times greater in fee-for-service hospitals (odds ratio 2.0, 95% Cl 1.6 to 2.5). However, higher utilization was strongly associated with the greater availability of on-site cardiac catheterization facilities in fee-for-service hospitals. The length of hospital stay, by contrast, was ∼1 day shorter in the fee-for-service cohort (7.3 vs. 8.0 days, p < 0.05).Conclusions. Physicians in staff-model HMO hospitals use fewer invasive procedures and longer lengths of stay to treat patients with acute myocardial infarction than physicians in fee-for-service hospitals. This finding, however, appears to be associated with the lack of on-site catheterization facilities at HMO hospitals.

Satisfaction with ambulatory care of persons with AIDS: predictors of patient ratings of quality.

To examine the relation of patient characteristics and site of care to the perception of ambulatory care quality by persons with AIDS (PWAs). Patient surveys and medical record review were used to determine PWAs' perceptions of their ambulatory care, self-perceived health status, primary care relationships, sociodemographic characteristics, and severity of illness. A public-hospital HIV clinic, an academic group practice, and a staff-model health maintenance organization (HMO) that together care for 20% of all Massachusetts PWAs. All active patients as of February 12, 1990, and all new AIDS patients at each of the three sites during the subsequent 13 months. The primary outcome measure was a six-item scale of patient-rated quality of care (PRQC), a newly developed measure that combined patients' ratings of their physician care, nursing care, involvement in medical decisions, and overall quality of care. Multiple logistic regression was carried out with low PRQC (lowest quartile) as the dependent variable, to identify correlates of patient perceptions of poor quality. Patients who had a primary nurse were significantly less likely to have low PRQC scores (OR = 0.50, 95% CI = 0.26 to 0.97). Black patients and patients who used injection drugs were significantly more likely to rate their care in the lowest quartile (OR = 2.22, 95% CI = 1.04 to 4.78; and OR = 2.43, 95% CI = 1.13 to 5.23, respectively), as were those who had lower self-perceived health status, after controlling for confounders; no association was found by site or severity. These results show that primary nursing may be an important determinant of how PWAs rate the quality of their ambulatory care. Furthermore, PWAs who are black or who are injection drug users are less satisfied than are others with the quality of their ambulatory AIDS care.

Terfenadine-associated ventricular arrhythmias and QT c interval prolongation : A retrospective cohort comparison with other antihistamines among members of a health maintenance organization

This study compared the occurrence of syncope, ventricular arrhythmias, and corrected QT interval (QT c) prolongation over a 2 1 2 -year period in persons prescribed terfenadine versus other prescription antihistamines among 265,000 members of the Harvard Community Health Plan (HCHP), the largest staff-model health maintenance organization in New England. HCHP maintains an automated medical record system with coded diagnoses for each ambulatory and hospital visit, and a similar automated pharmacy system with information for each member on all prescriptions filled at its pharmacies. Among 0.86 million exposure days of terfenadine and 1.04 million exposure days of other antihistamines, we found no excess risk of either clinical/arrhythmia events (odds ratio (OR), 0.86; 95% confidence interval (CI), 0.52 to 1.44) or QT c prolongation (OR, 1.00; 95% CI, 0.64 to 1.57) during courses of terfenadine versus those of other antihistamines. Joint courses of antihistamines and oral erythromycin were associated with an increased risk of QT c prolongation (OR, 2.33; 95% CI, 1.31 to 4.15), and there was a trend for this to be observed more frequently with terfenadine (OR, 2.37; 95% CI, 0.73 to 7.51; P = 0.14).