Ordering decision and clinic cost variation among resident physicians.

Physicians vary considerably in the services they order for their patients. We examined ordering variation among 47 resident physicians during 4,991 continuity clinic visits with patients who had specific, chronic medical problems. We ranked the physicians by their average charge per visit and grouped them into three equal categories. High-charge physicians averaged $164 per visit, medium-charge $124 and low-charge $97. In comparing the frequencies with which physicians in each group ordered a wide array of specific laboratory tests, x-ray studies, medications and miscellaneous items, we found that ordering variation among the physician groups was not confined to certain decisions or categories of services. High-charge physicians ordered a little more of nearly every item or service. Although the magnitude of ordering variation for each item was small, the sum over many items was great, suggesting that cost-containment efforts may have to focus on the "little ticket" decision-making style of expensive physicians.

Comparison of family medicine and internal medicine: charges for continuing ambulatory care.

The authors compared charges for ambulatory and continuing patient care prescribed by residents in internal medicine and family medicine. An analysis of covariance showed that the charges per encounter in internal medicine were $38.83 greater than charges in family medicine after accounting for differences such as patient age, diagnosis, and severity of condition. However, family practitioners scheduled patient encounters more frequently. The median number of days between encounters was 30 for family medicine and 60 for internal medicine. The duration of medical care for each patient (up to 18 months was possible) and the summation of encounter charges over that duration of medical care were evaluated. Because only two out of eight duration-of-medical-care categories were significantly less in family medicine, the differences in charges between the specialties essentially disappeared. Comparative studies which consider only charges per encounter potentially have a large bias.

The volume of the sella turcica in children: new standards.

Measurement of the sella turcica is valuable in the assessment of a variety of pituitary and other conditions. The volume, a more reliable measurement than sellar area, has been difficult to interpret for lack of adequate standards. This study presents mean and 10th, 50th, and 90th percentiles for sellar volume in normal children aged 6-16 years on the basis of measurements in 960 sets of skull radiographs made for orthodontic purposes. Sellar volumes are plotted against chronologic age, and against skeletal age for the 62% of measurements for which a simultaneous bone age determination had been made. As expected, the sellar volume increases with age: for example, mean volume for a boy 5 years 9 months to 6 years 8 months is 228 mm3, for a boy 15 years 9 months to 16 years 8 months is 640 mm3. For most age groups, sellar volume in males is greater than in females. Tenth and ninetieth percentiles for sellar volume are widely separated, giving a wide range of normal. Nevertheless they should be useful in assessing sellar volume in clinical situations.

Evaluation of educational methods in a comprehensive cost-containment project in ambulatory care.

The cost of medical care in the United States is a matter of great concern to many health policy makers and physicians as well as to the seekers of care. At the University of New Mexico, a comprehensive cost-containment education program was devised and put into effect with residents from three primary care disciplines. In addition to documenting the effectiveness of the educational package in reducing patients charges, we asked house staff to state which parts of the package were of most use. Wall posters displaying charges for commonly ordered tests, procedures, and prescription items and the distribution of sample bills for patients seen by the individual resident were rated most highly. A test of knowledge of charges to patients did not show resident improvement after education. Cost-containment education can be effective in reducing patient charges, even if physicians do not internalize the actual charge data. We recommend the inclusion of cost-containment education in all primary care training programs, as these physicians play such an important role in the generation of patient charges.

Are physicians educable? Teaching medical students about school health.

Third-year medical students on their pediatric rotation at the University of New Mexico (UNM) are assigned to spend two mornings with school nurses at the students' choice of schools. Each student is given a list of goals and questions relating to those goals to guide his/her experience. Following the two sessions, each student answers a questionnaire testing understanding of aspects of the school nurse's work and interrelationships between school nurses and physicians. Of the first 67 students responding to the questionnaire, 66 found the program valuable and worthy of continuation. The medical students' understanding of the capabilities and limitations of the nurses whose work they observed appeared excellent. Two-thirds of the students perceive poor communication with physicians as a major frustration for the nurses. Their appreciation of this need, plus their ability to recognize the many capabilities of school nurses, should result in better interaction between the two professions.

Predicting the need for primary care specialists: the example of a southwestern state.

Because of a need to project the requirements for the training of primary care practitioners in the state of New Mexico, we reviewed available means of determining health manpower needs. Combining several of these methods, we constructed a three-tiered model, taking into account different patterns of care-seeking in areas of various population densities. These methods may be applicable in other states like New Mexico where densely populated cities contrast with sparsely settled rural areas. All such methods, however, are confounded by the state of balance of many factors, including immigration and emigration of physicians, use of nonphysician providers, and patient movement across boundaries for care. This report contributes to the growing literature on health manpower needs by recognizing and attempting to account for differences between urban and rural patterns of care-seeking.

Antihistamines and alpha-adrenergic agents in treatment of otitis media.

Studies are not available to support the common use of alpha-adrenergic agents and/or antihistamines in the treatment of acute otitis media. A total of 378 patients with acute otitis were entered in a double-blind study comparing treatment results with antibiotics and either placebo, pseudoephedrine, triprolidine, or a combination of these; 196 patients returned. Age and return rate did not differ among groups. Cure rates and duration of fever were the same for each group. The cost and possible side effects of these agents, added to their lack of beneficial effect in otitis, should interdict their use.

School health experience before and after completion of pediatric training.

A questionnaire regarding school health training and current school-based activities was completed by 116 of 141 young pediatricians practicing in four southwestern states. Responses indicated that few (22.4%) were exposed to school health during their residencies, although most (65.5%) are now providing some school health services. Those who had had school health training during residency are much more likely to be providing services than those who did not. Likewise, during their residencies, few received instruction in methods of health education, though many, led again by those who had appropriate residency experience, now participate in school health education programs. Residency programs should provide training in school health to improve the physician's comfort and efficiency in the roles he is presently asked to play, and to increase his involvement in this critically important area of pediatrics.