Effect of written and computerized decision support aids for the U.S. Agency for Health Care Policy and Research depression guidelines on the evaluation of hypothetical clinical scenarios.

OBJECTIVE: The objective of this study was to compare the effects of written and computerized decision support aids (DSAs) based on U.S. Agency for Health Care Policy and Research depression guidelines. METHODS: Fifty-six internal medicine residents were randomized to evaluate clinical scenarios using either a written or a computerized DSA after first assessing scenarios without a DSA. The paired difference between aided and unaided scores was determined for diagnostic accuracy, treatment selection, severity and subtype classification, antipsychotic use, and mental health consultations. RESULTS: Diagnostic accuracy with the written DSA increased from 64% to 73%, and with the computerized DSA decreased from 67% to 64% (P=0.0065). Residents using the computerized DSA (vs. no DSA) requested fewer consultations (65% vs. 52%, P=0.028). In post hoc analysis, the written DSA increased sensitivity (66% to 89%, P<0.001) and the computerized DSA improved specificity (66% to 86%, P=0.0020) but reduced sensitivity (67% to 49%, P = 0.011). CONCLUSIONS: A written DSA improved diagnostic accuracy, whereas a computerized DSA did not. However, the computerized DSA improved specificity and reduced mental health consultations.

Measuring the physician perspective on quality of care in health plans.

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their underlying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians' perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.

Who is at risk of nondetection of mental health problems in primary care?

OBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians. DESIGN: Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study. PARTICIPANTS: We studied 19,309 patients and 349 internists and family physicians. MEASUREMENTS AND MAIN RESULTS: We counted "detection" of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection. CONCLUSIONS: Patients' race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.

An evaluation of radical prostatectomy at Veterans Affairs Medical Centers: time trends and geographic variation in utilization and outcomes.

OBJECTIVE: To examine temporal trends and geographic variation in utilization of radical prostatectomy (RP) as well as 30-day mortality and complication rates. DESIGN: Administrative data-base study of radical prostatectomy (RP) using the Department of Veterans Affairs Patient Treatment File and Outpatient Clinic File between 1986 to 1996. Logistic regression was used to estimate temporal and geographic effects on the use of RP. SETTING: All Departments of Veterans Affairs Medical Centers (VAMC) in the contiguous United States. PATIENTS: Men aged 45 to 84 years who underwent RP at a VAMC (n = 13,398). MAIN OUTCOME MEASURES: Number and utilization of RP, rate of 30-day mortality, major cardiopulmonary or vascular complications, and colorectal injuries requiring surgical repair within 30 days of RP. RESULTS: From 1986 to 1996, the annual number of RP at VAMCs (range, 695-1,545 RP) more than doubled, and the rate of RP at VAMCs per male VA user increased by 40% (range, 48/100,000-66/100,000). After controlling for age and year, the utilization of RP in West North Central, Mountain, West South Central, and Pacific census divisions was 70%, 14%, 10%, and 8% higher, respectively, whereas the utilization of RP in New England, East North Central, and Mid-Atlantic divisions was 38%, 31%, and 25% lower, respectively, than the rest of the nation (P<0.001). Geographic variation in utilization decreased during the period between 1986 and 1996, but a twofold difference in RP utilization in 1996 remained between high- and low-utilization divisions. Major cardiopulmonary complications, vascular complications, and colorectal injuries occurred in 1.7%, 0.2%, and 1.8% of men, respectively. Thirty-day mortality was 0.73%, declined from 1986 to 1996, and was associated with a history of diabetes and congestive heart failure. CONCLUSION: Utilization of RP at VAMCs increased over time and varied across geographic areas. Thirty-day mortality was less than 1% and decreased with time. Differences in utilization may be caused by uncertainty regarding the effectiveness of early detection and treatment of prostate cancer.

Dual use of VA and non-VA primary care.

OBJECTIVE: To determine how frequently veterans use non-Department of Veterans Affairs (VA) sources of care in addition to primary care provided by the VA and to assess the association of this pattern of "dual use" to patient characteristics and satisfaction with VA care. DESIGN: Cross-sectional telephone survey of randomly selected patients from four VA medical centers. PARTICIPANTS: Of 1,240 eligible veterans, 830 (67%) participated in the survey. MEASUREMENTS AND MAIN RESULTS: Survey data were used to assess whether a veteran reported receiving primary care from both VA and non-VA sources of care, as well as the proportion of all primary care visits made to non-VA providers. Of 577 veterans who reported VA primary care visits, 159 (28%) also reported non-VA primary care visits. Among these dual users the mean proportion of non-VA primary care visits was 0.50. Multivariate analysis revealed that the odds of dual use were reduced for those without insurance (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.18, 0.66) and with less education (OR 0.60; 95% CI 0.38, 0.92), while increased for those not satisfied with VA care (OR 2.40; 95% CI 1.40, 4.13). Among primary care dual users, the proportion of primary care visits made to non-VA providers was decreased for patients with heart disease ( p <.05) and patients with alcohol or drug dependence ( p <.05). CONCLUSIONS: Primary care dual use was common among these veterans. Those with more education, those with any type of insurance, and those not satisfied with VA care were more likely to be dual users. Non-VA care accounted for approximately half of dual users' total primary care visits.

Internal medical residents' ability to diagnose and characterize major depression.

The purpose of this study was to assess medical residents' knowledge of symptom criteria and subtypes of major depressive episode and their accuracy in diagnosing major depressive disorders and classifying episode severity and subtype according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Thirty-five third-year internal medicine residents completed a self-administered, written instrument containing 2 open-ended questions and 21 hypothetical scenarios. The sensitivity for recognizing major depressive disorder was 64%, and the specificity was 69%. The sensitivity for classifying severity was 86% for mild, 66% for moderate, 71% for severe, and 66% for severe with psychosis. Misclassification of severity was most commonly to a less severe class. For scenarios with a diagnosable subtype of a major depressive disorder, the sensitivity for classification was 34% for atypical, 51% for catatonic, 74% for melancholic, 100% for postpartum, and 94% for seasonal depression. When asked to enumerate the criteria symptoms for depression, 80% or more of the residents listed sad mood, loss of interest, weight change, and sleep disturbances; 14 to 21 (40%-60%) listed thoughts of death and worthlessness; other criteria were listed by 7 to 11 (20%-31%). When asked to list the episode subtypes, none was listed by more than 3 (9%) residents, although 13 (37%) residents volunteered psychotic as a subtype. Residents frequently failed to recognize the presence or absence of major depressive disorder and often misclassified episode severity and subtype on scenarios. Few could spontaneously list the episode subtypes. Methods must be developed to improve the recognition and classification of major depressive episodes to better direct treatment.

Referrals by general internists and internal medicine trainees in an academic medicine practice.

Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed.

Are all health plans created equal? The physician's view.

CONTEXT: The health care market is demanding increasing amounts of information regarding quality of care in health plans. Physicians are a potentially important but infrequently used source of such information. OBJECTIVE: To assess physicians' views on health plan practices that promote or impede delivery of high-quality care in health plans and to compare ratings between plans. SETTING: Minneapolis-St Paul, Minn. PARTICIPANTS: One hundred physicians in each of 3 health plans. Each physician rated 1 health plan. MAIN OUTCOME MEASURES: Likert-type items that assessed health plan practices that promote or impede delivery of high-quality care. RESULTS: A total of 249 physicians (84%) completed the survey. Fewer than 20% of all physicians gave plans the highest rating (excellent or strongly agree) for health plan practices that promote delivery of high-quality care (such as providing continuing medical education for physicians, identifying patients needing preventive care, and providing physicians feedback about practice patterns). Barriers to delivering high-quality care related to sufficiency of time to spend with patients, covered benefits and copayment structure, and utilization management practices. Ratings differed across health plans. For example, the percentage of physicians indicating that they would recommend the plan they rated to their own family was 64% for plan 1, 92% for plan 2, and 24% for plan 3 (P<.001 for all comparisons). CONCLUSIONS: Physician surveys can highlight strengths and weaknesses in health plans, and their ratings differ across plans. Physician ratings of health plan practices that promote or impede delivery of high-quality care may be useful to consumers and purchasers of health care as a tool to evaluate health plans and promote quality improvement.

Under use of coronary angiography: application of a clinical method.

OBJECTIVE: To estimate the extent of under use of coronary angiography and to determine whether women, ethnic minorities and poor and uninsured patients are less likely than their counterparts to receive necessary coronary angiography. DESIGN: Retrospective cohort study employing chart review and patient interviews. SETTING: Four teaching hospitals: three government owned (public) and one private university medical center in Los Angeles, California. PATIENTS: Three hundred and fifty two patients who had a positive exercise stress test between 1 January 1990 and 30 June 1991 and met explicitly defined criteria for the necessity of coronary angiography established by a multidisciplinary expert panel. MAIN OUTCOME MEASURES: Percentage of patients who received necessary coronary angiography within 3 and 12 months following exercise stress testing, adjusted for demographic and clinical characteristics using logistic regression. RESULTS: Overall 43% received necessary coronary angiography within 3 months and 56% within 12 months of the stress test. Women were less likely than men to receive necessary coronary angiography. Adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI) 0.34-0.90 for angiography within 3 months of the stress test; AOR 0.47, 95% CI 0.29-0.77 for angiography within 12 months of the stress test. Public hospital patients underwent necessary coronary angiography less often than private hospital patients. AOR 0.40, 95% CI 0.23-0.79 for within 3 months; AOR 0.52, 95% CI 0.30-0.91 for within 12 months. CONCLUSIONS: Under use of coronary angiography can be measured and occurs to a significant degree. It is important to develop standards of quality to address and safeguard against under use of necessary medical care.

Effect of physician specialty on use of necessary coronary angiography.

OBJECTIVES: This study sought to determine whether having a cardiologist as a regular source of care influences likelihood of undergoing necessary coronary angiography. BACKGROUND: An important element of the current health policy debate is the respective roles of primary care and specialist physicians. However, there are few data on interspecialty differences in quality of care for patients with ischemic heart disease. METHODS: We contacted 243 patients by telephone (response rate 72%) who had positive (or very positive) exercise stress test results and met additional clinical criteria for necessary coronary angiography. Study patients were randomly sampled from those undergoing exercise stress testing at one university and three public hospitals in Los Angeles between January 1, 1990 and June 30, 1991. Patients were asked whether they had a regular source of care during the time after their exercise stress test and, if so, whether that provider was a cardiologist or cardiology clinic. RESULTS: Among survey responders, 47% underwent necessary coronary angiography within 3 months of exercise testing and 61% within 12 months. After adjustment for sociodemographics and clinical presentation, patients with a cardiologist as a regular source of care were more likely than all other patients to have undergone necessary angiography within 3 months (52% vs. 38%, p = 0.05) and within 12 months (74% vs. 44%, p = 0.0001) of the exercise test. At 3 months, there was a trend toward a more pronounced effect of ongoing cardiologic care within the public hospitals compared with the private hospital (p = 0.09 for interaction between hospital types). CONCLUSIONS: Patients with a cardiologist as a regular source of care were more likely than all other patients to undergo clinically necessary coronary angiography within both 3 and 12 months of exercise stress testing.

Elevation of serum angiotensin-converting enzyme level. Occurrence in alcoholic liver disease.

Serum angiotensin-converting enzyme (ACE) levels were measured in 151 patients with chronic alcoholism and alcoholic liver disease. The mean serum ACE level was elevated to 30.8 +/- 13 units/mL compared with 22.8 +/- 6 units/mL in control subjects. Approximately 30.0% of the patients had elevated ACE levels. Abstinence from alcohol for six to 27 months by 11 patients was associated with persistently normal serum ACE levels. Angiotensin-converting enzyme level elevations did not correlate with abnormalities of other liver function test results or with any acute clinical condition associated with alcoholic cirrhosis. Hypoxemia was not present in the patients with elevated serum ACE levels. Elevations of serum ACE levels in patients with alcoholic liver disease may relate to an effect of alcohol on the hepatic-sinusoidal lining cells. This elevation could interfere with the use of this test for supporting the diagnosis of sarcoidosis.

Measurement of somatomedin-related peptides in fetal, neonatal, and maternal rat serum by insulin-like growth factor (IGF) I radioimmunoassay, IGF-II radioreceptor assay (RRA), and multiplication-stimulating activity RRA after acid-ethanol extraction.

Previous measurements of somatomedins (Sms) and insulin-like growth factors (IGFs) in maternal and fetal serum have yielded contradictory results. We have, therefore, measured maternal, fetal, and neonatal rat serum with two highly specific assays: 1) IGF-I/Sm-C RiA and 2) a highly specific IGF-II/rat placental membrane radioreceptor assay (RRA). In addition, we have made measurements with a less specific multiplication-stimulating activity (MSA)-rat placental membrane RRA. To avoid possible serious artifacts created by Sm-binding proteins, preliminary acid-ethanol extraction of serum was performed. Results are expressed in terms of a reference human serum with an assigned potency of 1 U/ml. Maternal RIA IGF-I fluctuated between 1.1-1.4 U/ml from the 17th day of pregnancy to the 25th day after delivery (nonpregnant rat serum pool, 1.25 +/- 0.22 U/ml). On day 21 of gestation, fetal serum radioimmunoassayable IGF-I was 1.03 +/- 0.03 U/ml. After birth, radioimmunoassayable IGF-I fell and reached .19 +/- 0.03 U/ml at 18 days of age, but rose to 0.71 +/- 0.04 U/ml at 25 days of age. At term, maternal radioreceptor assayable IGF-II was 2.18 +/- 0.27 U/ml (nonpregnant female pool, 1.4 +/- 0.12). By the 25th postpartum day, radioreceptor assayable IGF-II was 1.39 +/- 0.12 U/ml. Radioreceptor assayable IGF-II in fetal serum on day 19 was 3.26 +/- 0.48 U/ml and rose to 5.37 +/- 0.66 U/ml on the day of delivery. A further rise to 8.92 +/- 1.03 occurred on day 5. A subsequent fall to 2.41 +/- 0.05 U/ml was observed on day 25. The patterns of results of the MSA RRA in fetal and neonatal rat serum were similar to that obtained with the IGF-II RRA. We now conclude that radioimmunoassayable IGF-I is present in higher concentrations than previously reported in term fetal rat serum and that radioreceptor assayable IGF-II is selectively elevated in rat fetal and neonatal life and may have unique metabolic and growth-promoting significance.U

Continued heavy drinking and survival in alcoholic cirrhotics.

Survival of 64 male chronic alcoholic cirrhotics with first-onset ascites discharged from a gastrointestinal convalescent service was examined over a 32-mo period of study. Of 54 patients discharged as improved, 23 (43%) remained abstinent for a mean time of 14.0 mo and 15 (28%) resumed heavy drinking (greater than 2 g/kg/day). Twelve of 15 heavy drinkers died in a mean time of 7.2 mo, while all but one abstainer were alive. Differences in survival were statistically significantly different (p less than 0.001) when examined by the life-table method. Survival of 16 "moderate or binge" drinkers was not significantly different from abstainers. However, the number of rehospitalizations for liver disease was increased in this group. The study indicates that continued heavy drinking is associated with poor survival of alcoholic cirrhotics.

Altered invertebrate nerve function after chronic exposure to low concentrations of alcohol.

Previous studies of direct alcohol toxicity on nerve tissue have been carried out using acute, extremely high doses of alcohol. Chronic administration of 20 mM ethanol to the mollusc Aplysia californica was achieved by adding ethanol to surrounding seawater. Although the animals appeared healthy, isolated ganglion cells from treated animals had significantly decreased mean action potential amplitudes and prolonged mean action potential durations compared to controls. These findings suggest that chronic exposure to a low concentration of ethanol comparable to that producing drunkeness in humans may have a direct toxic effect on invertebrate nerve tissue.