Total Caseload Research Articles

Private Regulation of Consumer Arbitration

Arbitration providers, such as the American Arbitration Association (“AAA”) and JAMS, have promulgated due process protocols to regulate the fairness of consumer and employment arbitration agreements. A common criticism of these due process protocols, however, has been that they lack an enforcement mechanism. While arbitration providers state that they enforce the protocols by refusing to administer cases in which the arbitration agreement materially fails to comply with the relevant protocol, the private nature of arbitral dispute resolution makes it difficult to verify whether providers in fact refuse to administer such cases.This article reports the results of the first empirical study of the AAA’s enforcement of its Consumer Due Process Protocol. We find that the AAA’s review of arbitration clauses for protocol compliance appears to be effective at identifying and responding to those clauses with protocol violations. During the time period studied, the AAA refused to administer a substantial number of cases (almost 10% of its total consumer caseload) that involved a protocol violation. Moreover, in response to AAA protocol compliance review, over 150 businesses have either waived problematic provisions or revised arbitration clauses to remove provisions that violated the Consumer Due Process Protocol.Our findings support the proposition that private regulation by the AAA complements existing public regulation of the fairness of consumer arbitration clauses. Any consideration of the need for future legislative action should take into account the effectiveness of this private regulation. That said, we do not assert that private regulation alone - with no public regulatory backstop, such as through court oversight - suffices to ensure the fairness of consumer arbitration proceedings. Rather, we suggest ways that courts and policy makers could reinforce the AAA’s enforcement of the Consumer Due Process Protocol as well as ways the AAA could improve its own review process.

Changing Patterns in Endotracheal Intubation for Anaesthesia Trainees: A Retrospective Analysis of 80,000 Cases over 10 Years

Several overseas studies have suggested that opportunities for anaesthesia trainees to learn and practise endotracheal intubation have decreased over time. We analysed the operating theatre data collection system at a large Australian metropolitan teaching hospital from 1998 to 2008 to determine if numbers for trainees' caseloads in general, and endotracheal intubation in particular had changed. The total caseload per trainee of approximately 800 cases per year was stable throughout the study period. The number of gastrointestinal endoscopies per trainee increased significantly with a corresponding decrease in the number of other cases. The mean number of endotracheal intubations per trainee per year fell by 10% and of supraglottic devices by 16%, neither of which was statistically significant. Endotracheal intubation for caesarean sections did however fall significantly from an average of nine to an average of six cases per trainee per year. Our findings contrast with other reports of much larger decreases in the number of endotracheal intubations performed by trainees over the last decade, but suggest that our local practice is similar to the international experience of decreasing opportunities for endotracheal intubation in obstetric anaesthesia.

Volume analysis of outcome following restorative proctocolectomy

This observational study aimed to determine national provision and outcome following pouch surgery (restorative proctocolectomy, RPC) and to examine the effect of institutional and surgeon caseload on outcome. All patients undergoing primary RPC between April 1996 and March 2008 in England were identified from the administrative database Hospital Episode Statistics. Institutions and surgeons were categorized according to the total RPC caseload performed over the study interval. Some 5771 primary elective pouch procedures were undertaken at 154 National Health Service hospital trusts. Median follow-up was 65 (interquartile range (i.q.r.) 28-106) months. The 30-day in-hospital mortality rate was 0·5 per cent and the 1-year overall mortality rate 1·5 per cent. Some 30·5 per cent of trusts performed fewer than two procedures per year, and 91·4 per cent of surgical teams (456 of 499) carried out 20 or fewer RPCs over 8 years. Median surgeon volume was 4 (i.q.r. 1-9) cases. Failure occurred in 6·4 per cent of cases. Low-volume surgeons operated on more patients at the extremes of age (P < 0·001) and a lower proportion with ulcerative colitis (P < 0·001). Older age, increasing co-morbidity, increasing social deprivation, and both lower provider and surgeon caseload were independent predictors of longer length of stay. Older patient age and low institutional volume status were independent predictors of failure. Many English institutions and surgeons carry out extremely low volumes of RPC surgery. Case selection differed significantly between high- and low-volume surgeons. Institutional volume and older age were positively associated with increased pouch failure.

Multidrug- and extensively drug-resistant tuberculosis: a persistent problem in the European Union and European Economic Area

Since 2008, the European Centre for Disease Prevention and Control has been collecting data from the European Union (EU) and European Economic Area (EEA) on resistance to first- and second-line drugs against tuberculosis (TB). In 2008, the proportion of multidrug-resistant tuberculosis (MDR TB) was 6.0% of the total case load for 25 countries reporting data. Extensively drug-resistant (XDR TB) reporting has increased since 2007 and was observed in 7.3% of the MDR TB cases in 13 reporting countries. MDR TB remains a threat and XDR TB is now established within the EU/EEA borders.

Changes in and characteristics of admissions to treatment related to problematic prescription opioid use in Ontario, 2004–2009

Background North America is the region with the world's highest prescription opioid (PO) use. Non-medical use of prescription opioids and PO-related morbidity and mortality have strongly increased in the US in recent years. It is assumed that similar trends are occurring in Canada, but there is less empirical evidence to support this. Treatment demand for problematic PO use is an important indicator of PO-related morbidity. Methods Levels and changes related to the caseload of PO-related treatment admissions were assessed using system-level data from the Drug and Alcohol Treatment Information System (DATIS), the reporting system for publicly funded addiction treatment services in the province of Ontario (Canada) for the period April 2004–March 2009 ( n = 500,217). In addition, basic socio-demographic and clinical characteristics of PO-related treatment admissions in the final year of study ( n = 10,125) were examined. Results The number of PO-related treatment admissions in DATIS rose by 60%, and their prevalence in the total caseload increased from 9.4% to 15.7% in the study period. Three-quarters of PO-clients reported other problem substances; the most common co-occurring problem substance was cocaine/crack. The majority of PO-clients were <35 years of age, unemployed, and referred to treatment by others. Interpretation Demand for treatment for problematic PO use has risen substantially in Ontario in the past five years in the wider context of substantially increased overall PO use and related harms in Canada. The interaction dynamics between these different indicators need to be systematically examined and monitored as the basis for evidence-based interventions.

Where's the Mouse Pathology Training?

Phenotypic analysis of genetically engineered mice and detailed evaluations of mouse models of disease have become increasingly important areas of expertise for the veterinary pathologist. Over the last few years, several articles, editorials, and letters have appeared in journals and in the news media, emphasizing the common theme of ‘‘one medicine —one pathology.’’ These articles highlight a few key observations: 1) pathologists are the ‘‘gatekeepers of translational research,’’ 2) mice represent 90% or more of the animals used in National Institutes of Health (NIH)–funded research, 3) there is an acute shortage of mouse pathologists in biomedical research, and 4) the lack of pathology support has, on occasion, led to erroneous interpretations that have been published in scientific journals. 1–8,10,12 Unfortunately, while veterinary pathology residents leave training programs well prepared for diagnostic pathology, it appears that most residents get only limited, if any, exposure to either routine or unusual lesions unique to mice. In support of this observation, unpublished data derived from the Veterinary Student and Resident Forum, a forum held at the American College of Veterinary Pathologists’ (ACVP) meeting for veterinary students interested in pathology residencies, revealed that 67% of the responding programs stated that ,5% of their total caseload was composed of laboratory animals. Thus it can be assumed that these trainees have minimal exposure to mice despite the fact that mice are used far more often in biomedical research than any other animals. 11 In the fall of 2007, a small, informal group of members of the ACVP began discussing the unique challenges facing veterinary pathologists who provide research pathology support in medical schools or research institutions. These pathologists are often the sole veterinary pathologist, and the majority of the casework involves experimental mouse pathology and genetically engineered mice. These mouse models often display complex or unique pathologic alterations, which are often compounded by experimental studies. A networking system of ‘‘mouse pathologists’’ would be a valuable resource for those of us currently in such positions—hence the formation of ‘‘The Mouse Pathologists’ Consortium’’ (MPC). The goal of this group was to formalize the loose network of mouse pathologists into a supportive community that could serve as a resource for those working in the research diagnostic environment. With this consortium, the foundation has been placed to promote the dissemination of information and the education of present and future mouse pathologists. At present, the group has over 50 members not only from research academics but also from veterinary schools and industry. This collegial interaction has resulted in a close common interest group and established a useful Web-based

Training and the European Working Time Directive: a 7 year review of paediatric anaesthetic trainee caseload data

The implementation of the European Working Time Directive (WTD) has reduced the hours worked by trainees in the UK to a maximum of 56 h per week. With a further and final reduction to 48 h per week scheduled for August 2009, there is concern amongst doctors about the impact on training and on patient care. Paediatric anaesthesia is one of the specialist areas of anaesthesia for which the Royal College of Anaesthetists (RCoA) recommends a minimum caseload during the period of advanced training. We conducted a retrospective analysis of theatre logbook data from 62 Specialist Registrars (SpRs) who had completed a 12 month period of advanced training in paediatric anaesthesia in our institution between 2000 and 2007. After the implementation of the WTD 56 h week in 2004, the mean total number of cases performed by SpRs per year decreased from 441 to 336, a 24% reduction. We found a statistically significant reduction across all age groups with the largest reduction in the under 1 month of age group. The post-WTD group did not meet the RCoA recommended total minimum caseload or the minimum number of cases of <1 yr of age. Since the implementation of the WTD, there has been a significant reduction in the number of cases performed by SpRs in paediatric anaesthesia and they are no longer achieving the RCoA recommended minimum numbers for advanced training.

The Orthopedic Specialty Care Management Team: The McDonald Army Health Center Experience

The influx of war injuries taxes the military health care system already hard hit by large numbers of deployed military medical personnel. The purpose of this article is to present the business practices and results of our Orthopedic Specialty Care Management Team program for evaluation and possible replication at sister military treatment facilities who care for "Warriors in Transition". Our program witnessed a 10-week decrease in time until initial orthopedic evaluation and a 16-week decrease in time until initial surgical scheduling. There was a 77.5% increase in surgeries performed (group 1, 129 vs. group 2, 229). The total surgical case load for the orthopedic surgery service increased by 28.3% (group 1, 412 vs. group 2, 529). Our service productivity increased by 76% or 6801 relative value units, although the mean length of stay decreased by 4.1% or 6.9 days. The total cost savings is an estimated $373,766. The program, as modeled, increased access to care for the war-injured soldiers without negatively impacting the usual business practices of the service.

Estimating the Incidence of Autism

To the Editor: Hertz-Picciotto and Delwiche1 analyze the databases of the California Department of Developmental Services (DDS) to ascertain the incidence of autism and determine whether increasing incidence can be explained by changing age at diagnosis and by shifting criteria. They conclude there is a true increase in incidence that cannot be accounted for by these factors. Because an increasing number of investigators are drawing conclusions from these data, it is crucial to identify problems with the datasets and temper overly ambitious conclusions. First, the databases should not be employed to ascertain incidence,2 and yet the authors use both individual client records and quarterly reports to measure incidence. As the DDS explains in its quarterly reports: “Increases in the number of persons reported from one quarter to the next do not necessarily represent persons who are new to the DDS system.”3 “Differences in the numbers from quarter to quarter reflect the net changes between individuals who are newly reported (ie, included in the later report but not included in the earlier report) and individuals who dropped out.”4 Furthermore, caseload numbers from DDS Regional Centers suggest a prevalence rate far below the prevalence estimates in widely accepted studies.5 Thus, the California data seriously underestimate the prevalence of autism, and do not reflect the total population prevalence pool. They should not be used for incidence studies. Second, the authors included in their analysis children between birth and 36 months of age identified in California's Early Start program. Because the goal of Early Start is to identify an at-risk population, the program's criteria are less restrictive than those used for older children and potentially overestimate the rate of autism. This program may also underestimate the children with autism because many evaluators are reluctant to give (and are not required to give) diagnoses. Third, the authors place undue confidence on age of first appearance in the DDS dataset as a proxy for date of diagnosis. They also unjustifiably diminish the influence of qualitative factors, such as increased awareness, geographic disparities in caseload, and an emerging industry of therapies for individuals with an autism classification. The authors also dismiss diagnostic substitution, despite the fact that the total DDS caseload of developmental disabilities has remained stable over the last decade, and despite increasing evidence that substitution significantly increases autism classifications.6 Fourth, classifications are made by dozens of field evaluators throughout California's Regional DDS Centers. DDS has no control over the practices of individual Center diagnostic procedures. Some comply with DDS practice standards, whereas others do not. Although diagnosticians use a standard form (Client Development Evaluation Report), it was not designed to be a research tool. Moreover, the evaluators are not engaged in epidemiologic research. Fifth, the authors note that neither Asperger disorder nor “pervasive developmental disorders not otherwise specified” qualify for “autism” under DDS guidelines, but evaluators routinely include milder cases under the category of autism, to enable these children to receive services. More importantly, neither the Client Development Evaluation Report nor the gold-standard Autism Diagnostic Observation Schedule and Autism Diagnostic Interview-Revised can clearly distinguish among the autism spectrum disorders. DDS autism classifications need to be subjected to the same scrutiny as other databases used for the evaluation and surveillance of disease. Numerous studies highlight the poor diagnostic accuracy in prevalence studies that rely on administrative data.7,8 Do diagnosticians in the California regional centers receive reliability training? To what extent are the gold-standard diagnostic procedures employed? Are the caseload data representative of the general population? Do DDS classifications have positive predictive value? Before researchers make bold interpretations from these data, they must acknowledge the limitations of their scientific value. Roy Richard Grinker Anthropology and the Human Sciences The George Washington University Washington, DC [email protected] Bennett L. Leventhal University of Illinois Chicago, IL

A retrospective study of anaesthetic caseload of Specialist Registrars following the introduction of new working patterns in the Wessex region*

The impact of implementing the European Working Time Directive (EWTD) and the consequent reduction in hours of work has led to concerns about training. This retrospective study compared total caseload, obstetric caseload, out-of-hours caseload and supervision levels of trainee anaesthetists in one region of the UK (Wessex) before and after the implementation of EWTD compliant rotas. Anaesthetic trainee logbooks submitted at the annual Record of In-Training Assessment were compared between the years 1999 and 2006. The logbook data was divided into two groups, group A (13-h shift) and group B (24-h on-call rota). There was no difference in total caseload, obstetric caseload or supervision. Out-of-hours caseload was greater in group A (p < 0.01).

Pediatric Urology Training: Performance-Based Assessment Using the Fundamentals of Laparoscopic Surgery

Despite the proven utility of laparoscopy in pediatric urology, widespread adoption of the surgical approach has been limited. The Fundamentals of Laparoscopic Surgery (FLS) is a reliable teaching mode for surgeons. Our study objective was to evaluate the effectiveness of a laparoscopic training course via a performance based assessment of participants' technical skills on the FLS module. The laparoscopic pediatric urology course, administered to 18 fellows, consisted of a 6-h didactic session and a full d practice on a live porcine model. FLS skills were practiced prior to and immediately following the course, and included peg transfer, precision pattern cutting, securing a ligating loop, and intracorporeal suturing. Written exams were used to evaluate participants' cognitive knowledge about laparoscopic procedures. Pretest and post-test performances were compared using paired t-tests. Previous laparoscopic caseload was addressed as a potential predictor of performance using two separate Pearson correlations between total caseload and performance scores. Participation in the course led to significant improvements in FLS and written exam scores. Laparoscopic caseload was correlated with pretest performance (R = 0.53, P < 0.05) though this correlation was not significant at post-test (R = 0.41, P > 0.05). However, the improvement from pretest to post-test (i.e., difference score) was significantly related to the participants' pediatric laparoscopic caseload (R = -0.47, P < 0.05). Operative experience is instrumental in attaining laparoscopic skills. However, intensive simulation-based training improves technical performance and cognitive knowledge competence, especially for novice trainees. Long-term assessment of trainees is required to ascertain the effectiveness of this approach to laparoscopic training.

Factors Affecting Attending Agreement with Resident Early Readings of Computed Tomography and Magnetic Resonance Imaging of the Head, Neck, and Spine

This study examines the joint effect of several factors on radiology resident performance in the task of interpreting after-hours neuroradiology examinations. As part of a quality assessment process, we conducted a prospective evaluation of all (N = 21,796) after-hours preliminary readings of neuroradiology examinations performed by radiology residents over a 62-month period at our academic medical center. Each reading was scored by the interpreting neuroradiologist as "agree," "disagree with minimal clinical impact," and "disagree with significant clinical impact." Coded resident and attending identities were also recorded for each case along with modality, body area studied, and the date of examination. These raw data were used to create an analytic data set with level of resident/attending agreement as the outcome and six predictors, including two date-derived variables: months 1-62 representing when the case occurred during the study and quartiles 1-4 accounting for the timing of the case in each resident's own experience. Cross tabulations, plots, bivariate statistics, and logistic regression were used to examine the relationships between study variables and the outcome (level of agreement). Over about 5 years of the study, the absolute number of significant disagreements remained stable at about three per month. The total caseload increased at a rate of 4.1 per month with most of the increase falling into the agree category, whereas the minimal disagreements actually decreased slightly (0.2 per month). In the logistic model for disagreement, three of the factors accounted for most of the variance: attending (61%), resident (15%), and month (15%). Study type (modality and area examined) accounted for another 10%. There was no significant contribution from the variable (quartile) constructed to test for individual resident learning during the on-call experience. Although residents differ somewhat in the extent of attending agreement with their on-call work, evaluation or remediation made on the basis of simple comparison of these rates should be done with caution. Improved agreement over time seems to be a collective experience shared by residents.

24-Locus MIRU-VNTR genotyping is a useful tool to study the molecular epidemiology of tuberculosis among Warao Amerindians in Venezuela

While the gold standard for molecular epidemiological studies on tuberculosis is changing towards MIRU-VNTR typing because this technique generates easily analyzed numerical results, it is less labor intensive and has a discriminative power comparable to that of IS6110-based RFLP, especially when 24 loci are analyzed; more extensive and representative validation studies are needed to confirm this. In this study we genotyped 41 Mycobacterium tuberculosis isolates, about 40% of the total case load of the study year, from the Warao people, an indigenous population who live in a geographically isolated area in Venezuela and have a high TB incidence of 450/100,000. IS6110-based RFLP analysis on these isolates indicates that 78% of the strains are in clusters, suggesting a very high transmission rate. We show that both the 15-locus MIRU-VNTR combined with spoligotyping, as well as the 24-locus MIRU-VNTR typing have sufficient discrimination power (an HGI of 0.93 and 0.95, respectively) to replace IS6110-based RFLP (HGI=0.93) and thus are useful tools to study the molecular epidemiology of tuberculosis in this high TB incidence population.

Impact of Mobile Radiographic Screening on Tuberculosis among Drug Users and Homeless Persons

In 2002, a mobile radiographic screening program was started in Rotterdam to respond to high rates of tuberculosis (TB) among illicit drug users and homeless persons. We studied trends and characteristics of TB among these risk groups and assessed the impact of the screening program on transmission, using molecular typing. Description of trends, and of demographic and disease-related characteristics of tuberculosis cases among these risk groups between 1993 and 2005. TB was considered to result from recent transmission if the mycobacterial DNA fingerprints of cases were identical to those of other cases in the risk groups in the previous 2 years. During the study period, 206 individuals with TB among illicit drug users and homeless persons were notified, representing 11.4% of the total case load of 1,811 in Rotterdam. The annual number of tuberculosis cases declined from 24 at the start of the screening program to 11 cases in 2005. The screening program identified 28 cases (a prevalence rate of 327 per 100,000 radiographs), of which 12 were smear positive. In 1997-2002, more than 80% of the illicit drug users or homeless persons with TB were infected with one of the Mycobacterium tuberculosis strains prevalent among these risk groups. After nearly 4 years of systematic radiographic screening this proportion declined to 45% in 2005. DNA fingerprinting can be a useful tool to evaluate the impact of a TB screening program. We advocate that screening of illicit drug users and homeless persons should be continued to prevent a resurgence of TB.

Histoid leprosy as reservoir of the disease; a challenge to leprosy elimination

In the month of January, 2006, India was declared to have eliminated leprosy. In an article by the Director General of Health Services, Government of India, the graphical representation of the progressively decreasing prevalence rate and new case detection rate for leprosy was quite encouraging and the goal of elimination by December, 2005 was supposed to be in sight. However, as dermatologists, from our day to day experience in dealing with the patients with leprosy, it was rather difficult to accept this contention. Histoid leprosy is an uncommon form of multibacillary disease, characterized by distinct clinical, histopathological, bacteriological and immunological features. It is quite rare and mostly occurs among patients with leprosy who had received dapsone monotherapy in the past. However, it was reported in previously untreated patients, as a manifestation of relapse several years after effective completion of an adequate course of MDT and in HIV infected patients with severe immunosuppression. As the bacillary load is very high in these patients, they can form a potential reservoir of the disease. While reporting a patient of histoid leprosy presenting as relapse following complete and effective MDT, it was appropriately stated by Ebenezer et al.: ‘occurrence of such cases reminds us that the road to elimination is not an easy one.’ Continued occurrence of histoid leprosy in areas of low endemicity and in areas from where leprosy has been declared as eliminated as in the state of Karnataka is a matter of concern. Moreover, the authors have been diagnosing histoid leprosy regularly (13 cases in 9 years) in their leprosy clinic in a smaller town of Karnataka, Bijapur, even though the total case load is not very heavy (Table 1). New cases of histoid leprosy turning up even in areas of low endemicity leave us in doubt, and raise few pertinent questions:

Inequitable provision of optimal services for patients with chronic heart failure: a national geo‐mapping study

To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF. Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology. Distance of populations with CHF to CHF management programs and general practice services. The highest prevalence of CHF (20.3-79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004-2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15-3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0-656 km). There is an inequity in the provision of CHF management programs to rural Australians.

Older persons’ AIDs knowledge and willingness to provide care in an impoverished nation: Evidence from Cambodia

Since the beginning of the global pandemic, assessing knowledge and attitudes regarding AIDS has been an important subject of research and for good reasons. Given the unusual features of HIV/AIDS, there is considerable potential for misunderstanding important aspects of the disease that could affect both behaviours related to risk exposure, as well as reactions to those known or believed to have contracted HIV. Most research on knowledge and attitudes has focused on young or prime aged adults. Far less common are systematic assessments of knowledge and attitudes among older persons, especially for developing countries, presumably because they are thought to be at less risk of exposure. In fact, older persons are also at risk of infection even if less so than prime age adults and their numbers will grow as effective treatments increasingly allow those infected at earlier ages to survive to old ages. Still, infected persons aged over 50 constitute a relatively modest share of the total caseload, especially in the developing world (Knodel, Watkins and VanLandingham, 2003).

Racial and Ethnic Disparities in SSRI Availability in Substance Abuse Treatment

Racial and Ethnic Disparities in SSRI Availability in Substance Abuse Treatment

The Prevalence of Concern About Weight Loss and Change in Eating Habits in People with Advanced Cancer

Weight loss and anorexia are commonly reported symptoms in people with advanced cancer. Little is known about patient experience of these phenomena, in particular whether they find them of concern. In this study, the prevalence of weight loss and eating-related concern was evaluated in patients with advanced cancer receiving specialist palliative homecare. The survey was a component of a larger study exploring the potential for helping patients and their families live with weight loss and change in eating habits. Patients were under the care of two specialist palliative homecare teams in the south of England in 2003. The questionnaire was distributed to the total eligible caseload of 233 patients with advanced cancer. The response rate was 85%. More than three-quarters of the 199 patients who returned the questionnaires reported weight loss (79%) and/or eating less (76%). Excluding the 32 patients (16%) who had sought help from a family member or friend to complete the questionnaires, more than half (52%) reported concern about weight loss and/or eating. Concern about weight loss or eating was found irrespective of proximity to death. Weight loss and eating-related concerns are commonly experienced by people with advanced cancer receiving palliative homecare. Further work is needed to establish if concerns are amenable to interventions that translate into meaningful outcomes for patients and their families.

Characteristics of Telephone Calls in a Psychiatric Outpatient Practice

The goal of this study was to document the volume and characteristics of telephone calls from patients in an outpatient psychiatric clinic. Telephone calls from a psychiatric resident's patients were logged over a 6-month period. Information collected included sex of the caller, reason for the call, deemed importance of the call, primary psychiatric diagnosis, and insurance type. A total of 291 calls occurred during the 6-month period, with an average of 2.4 calls per work day. The physician deemed 1.5% of calls to be an emergency and 15% to be urgent. Of the resident's total case load of 115 patients over the 6 month period, 29% (n = 33) of patients never made physician-patient telephone contact. Female patients were significantly more likely to call than males. Requests for medication refills were the most frequent type of call (38%). The mean number of calls per patient in the caseload was significantly different across diagnostic groups, with patients with personality disorders and anxiety spectrum disorders making more calls than other groups. There was no significant difference in the volume of telephone calls between patients with private health insurance and those without. This study may be of particular interest to physicians and managed care systems who are interested in reimbursement for telephone psychiatry. This study confirms and extends the previously reported association between certain psychiatric disorders (personality disorders, anxiety spectrum disorders) and relative frequency of telephone calls to the physician. In addition, the high volume of calls for prescription refills is an important issue in telephone management.