Angiotensin blockade therapy and survival in pancreatic cancer: a population study.

BACKGROUND: Pancreatic cancer (PC) is one of the most aggressive and challenging cancer types to effectively treat, ranking as the fourth-leading cause of cancer death in the United States. We investigated if exposures to angiotensin II receptor blockers (ARBs) or angiotensin I converting enzyme (ACE) inhibitors after PC diagnosis are associated with survival. METHODS: PC patients were identified by ICD-9 diagnosis and procedure codes among the 3.7 million adults living in the Emilia-Romagna Region from their administrative health care database containing patient data on demographics, hospital discharges, all-cause mortality, and outpatient pharmacy prescriptions. Cox modeling estimated covariate-adjusted mortality hazard ratios for time-dependent ARB and ACE inhibitor exposures after PC diagnosis. RESULTS: 8,158 incident PC patients were identified between 2003 and 2011, among whom 20% had pancreas resection surgery, 36% were diagnosed with metastatic disease, and 7,027 (86%) died by December 2012. Compared to otherwise similar patients, those exposed to ARBs after PC diagnosis experienced 20% lower mortality risk (HR=0.80; 95% CI: 0.72, 0.89). Those exposed to ACE inhibitors during the first three years of survival after PC diagnosis experienced 13% lower mortality risk (HR=0.87; 95% CI: 0.80, 0.94) which attenuated after surviving three years (HR=1.14; 95% CI: 0.90, 1.45). CONCLUSIONS: The results of this large population study suggest that exposures to ARBs and ACE inhibitors after PC diagnosis are significantly associated with improved survival. ARBs and ACE inhibitors could be important considerations for treating PC patients, particularly those with the worst prognosis and most limited treatment options. Considering that these common FDA approved drugs are inexpensive to payers and present minimal increased risk of adverse events to patients, there is an urgent need for randomized clinical trials, large simple randomized trials, or pragmatic clinical trials to formally and broadly evaluate the effects of ARBs and ACE inhibitors on survival in PC patients.

Metformin exposure and survival in head and neck cancer: A large population-based cohort study.

WHAT IS KNOWN AND OBJECTIVE: Observational clinical studies of metformin for prevention and treatment of several cancer types have reported mixed findings. Although preclinical studies have suggested metformin may reduce head and neck cancer (HNC) proliferation, clinical evidence is limited. The objective of this large population-based study was to evaluate the relationship between metformin exposure following HNC diagnosis and all-cause mortality. METHODS: We conducted a retrospective cohort study using the Italian Emilia-Romagna Regional administrative healthcare database, which includes demographic, hospital and outpatient prescription information for ~4.5 million residents. Included patients were followed from the first hospital discharge (index) during the study period (01/2003-12/2012) with a diagnosis of HNC. Metformin exposure and select covariates were operationalized in a time-dependent manner during follow-up. Cox proportional hazards models estimated the covariate-adjusted time-dependent association between metformin exposure and all-cause mortality. RESULTS AND DISCUSSION: Among 7872 patients diagnosed with HNC, 708 (9.0%) were exposed to metformin after HNC diagnosis, and 3626 (46.1%) died during follow-up (median follow-up: 35.2 months). In the covariate-adjusted model, the all-cause mortality rate appeared lower (HR: 0.81, 95% CI: 0.61-1.09) among metformin exposed patients during the 2 years post-diagnosis, while the all-cause mortality rate appeared higher (HR: 1.20, 95% CI: 0.94-1.53) among exposed patients after 2 years post-diagnosis. Metformin was protective among patients ≤60 years of age (HR for the period of 0-2 years post-diagnosis: 0.22, 95% CI 0.09-0.56; HR for the period ≥2 years post-diagnosis: 0.56, 95% CI 0.26-1.22) but not in those >60 years. WHAT IS NEW AND CONCLUSION: In this population-based study of metformin in HNC, we found a modest protective association between metformin exposure and all-cause mortality in the 2-year post-diagnosis period. Age appeared to modify the association between metformin and HNC survival.

Effectiveness of palliative care services: A population-based study of end-of-life care for cancer patients.

BACKGROUND: Multiple studies demonstrate substantial utilization of acute hospital care and, potentially excessive, intensive medical and surgical treatments at the end-of-life. AIM: To evaluate the relationship between the use of home and facility-based hospice palliative care for patients dying with cancer and service utilization at the end of life. DESIGN: Retrospective, population-level study using administrative databases. The effect of palliative care was analyzed between coarsened exact matched cohorts and evaluated through a conditional logistic regression model. SETTING/PARTICIPANTS: The study was conducted on the cohort of 34,357 patients, resident in Emilia-Romagna Region, Italy, admitted to hospital with a diagnosis of metastatic or poor-prognosis cancer during the 6 months before death between January 2013 and December 2015. RESULTS: Patients who received palliative care experienced significantly lower rates of all indicators of aggressive care such as hospital admission (odds ratio (OR) = 0.05, 95% confidence interval (CI): 0.04-0.06), emergency department visits (OR = 0.23, 95% CI: 0.21-0.25), intensive care unit stays (OR = 0.29, 95% CI: 0.26-0.32), major operating room procedures (OR = 0.22, 95% CI: 0.21-0.24), and lower in-hospital death (OR = 0.11, 95% CI: 0.10-0.11). This cohort had significantly higher rates of opiate prescriptions (OR = 1.27, 95% CI: 1.21-1.33) ( p < 0.01 for all comparisons). CONCLUSION: Use of palliative care at the end of life for cancer patients is associated with a reduction of the use of high-cost, intensive services. Future research is necessary to evaluate the impact of increasing use of palliative care services on other health outcomes. Administrative databases linked at the patient level are a useful data source for assessment of care at the end of life.

Predicting risk of hospitalisation: a retrospective population-based analysis in a paediatric population in Emilia-Romagna, Italy.

OBJECTIVES: Develop predictive models for a paediatric population that provide information for paediatricians and health authorities to identify children at risk of hospitalisation for conditions that may be impacted through improved patient care. DESIGN: Retrospective healthcare utilisation analysis with multivariable logistic regression models. DATA: Demographic information linked with utilisation of health services in the years 2006-2014 was used to predict risk of hospitalisation or death in 2015 using a longitudinal administrative database of 527 458 children aged 1-13 years residing in the Regione Emilia-Romagna (RER), Italy, in 2014. OUTCOME MEASURES: Models designed to predict risk of hospitalisation or death in 2015 for problems that are potentially avoidable were developed and evaluated using the C-statistic, for calibration to assess performance across levels of predicted risk, and in terms of their sensitivity, specificity and positive predictive value. RESULTS: Of the 527 458 children residing in RER in 2014, 6391 children (1.21%) were hospitalised for selected conditions or died in 2015. 49 486 children (9.4%) of the population were classified in the 'At Higher Risk' group using a threshold of predicted risk >2.5%. The observed risk of hospitalisation (5%) for the 'At Higher Risk' group was more than four times higher than the overall population. We observed a C-statistic of 0.78 indicating good model performance. The model was well calibrated across categories of predicted risk. CONCLUSIONS: It is feasible to develop a population-based model using a longitudinal administrative database that identifies the risk of hospitalisation for a paediatric population. The results of this model, along with profiles of children identified as high risk, are being provided to the paediatricians and other healthcare professionals providing care to this population to aid in planning for care management and interventions that may reduce their patients' likelihood of a preventable, high-cost hospitalisation.

Variation in hospital utilization at the end of life for patients with cancer in the Emilia-Romagna region of Italy.

INTRODUCTION: Despite the preference of many patients to die at home, high proportions of patients with advanced cancer undergo major procedures, receive intensive care, and die in the hospital. The goal of this study is to examine variation in hospital utilization and site of death for patients dying with poor-prognosis cancer in the Regione Emilia-Romagna (RER), Italy. METHODS: We conducted a retrospective, population-level study using administrative data. Patients were included if they died in 2012 and had at least one hospital admission for metastatic or poor-prognosis cancer within 180 days of death. Variations in the use of the hospital, intensive care, and procedures performed were evaluated. RESULTS: 11,470 patients died with metastatic or poor-prognosis cancer in 2012. Seventy-eight percent of patients were hospitalized in the last month of life while 50.7% of patients died in the hospital. Results varied by local health authority from 38.3% to 69.3%. Of patients who had an ICU stay, 55.1% in the community hospitals and 59.8% in the teaching hospitals were admitted to the ICU on the day of death or the day before death. 7.5% of patients underwent a major procedure in the last 30 days of life. CONCLUSIONS: The overall high rate, and substantial variation, in hospital care at the end of life offers the RER the opportunity to evaluate if increasing availability of palliative care, along with provider and patient education, could reduce utilization of high-cost hospital care and increase patient and family satisfaction.

Assessing adverse events of postprostatectomy radiation therapy for prostate cancer: evaluation of outcomes in the Regione Emilia-Romagna, Italy.

PURPOSE: Although the likelihood of radiation-related adverse events influences treatment decisions regarding radiation therapy after prostatectomy for eligible patients, the data available to inform decisions are limited. This study was designed to evaluate the genitourinary, gastrointestinal, and sexual adverse events associated with postprostatectomy radiation therapy and to assess the influence of radiation timing on the risk of adverse events. METHODS: The Regione Emilia-Romagna Italian Longitudinal Health Care Utilization Database was queried to identify a cohort of men who received radical prostatectomy for prostate cancer during 2003 to 2009, including patients who received postprostatectomy radiation therapy. Patients with prior radiation therapy were excluded. Outcome measures were genitourinary, gastrointestinal, and sexual adverse events after prostatectomy. Rates of adverse events were compared between the cohorts who did and did not receive postoperative radiation therapy. Multivariable Cox proportional hazards models were developed for each class of adverse events, including models with radiation therapy as a time-varying covariate. RESULTS: A total of 9876 men were included in the analyses: 2176 (22%) who received radiation therapy and 7700 (78%) treated with prostatectomy alone. In multivariable Cox proportional hazards models, the additional exposure to radiation therapy after prostatectomy was associated with increased rates of gastrointestinal (rate ratio [RR] 1.81; 95% confidence interval [CI] 1.44-2.27; P<.001) and urinary nonincontinence events (RR 1.83; 95% CI 1.83-2.80; P<.001) but not urinary incontinence events or erectile dysfunction. The addition of the time from prostatectomy to radiation therapy interaction term was not significant for any of the adverse event outcomes (P>.1 for all outcomes). CONCLUSION: Radiation therapy after prostatectomy is associated with an increase in gastrointestinal and genitourinary adverse events. However, the timing of radiation therapy did not influence the risk of radiation therapy-associated adverse events in this cohort, which contradicts the commonly held clinical tenet that delaying radiation therapy reduces the risk of adverse events.

Predicting risk of hospitalisation or death: a retrospective population-based analysis.

OBJECTIVES: Develop predictive models using an administrative healthcare database that provide information for Patient-Centred Medical Homes to proactively identify patients at risk of hospitalisation for conditions that may be impacted through improved patient care. DESIGN: Retrospective healthcare utilisation analysis with multivariate logistic regression models. DATA: A population-based longitudinal database of residents served by the Emilia-Romagna, Italy, health service in the years 2004-2012 including demographic information and utilisation of health services by 3,726,380 people aged ≥18 years. OUTCOME MEASURES: Models designed to predict risk of hospitalisation or death in 2012 for problems that are potentially avoidable were developed and evaluated using the area under the receiver operating curve C-statistic, in terms of their sensitivity, specificity and positive predictive value, and for calibration to assess performance across levels of predicted risk. RESULTS: Among the 3,726,380 adult residents of Emilia-Romagna at the end of 2011, 449,163 (12.1%) were hospitalised in 2012; 4.2% were hospitalised for the selected conditions or died in 2012 (3.6% hospitalised, 1.3% died). The C-statistic for predicting 2012 outcomes was 0.856. The model was well calibrated across categories of predicted risk. For those patients in the highest predicted risk decile group, the average predicted risk was 23.9% and the actual prevalence of hospitalisation or death was 24.2%. CONCLUSIONS: We have developed a population-based model using a longitudinal administrative database that identifies the risk of hospitalisation for residents of the Emilia-Romagna region with a level of performance as high as, or higher than, similar models. The results of this model, along with profiles of patients identified as high risk are being provided to the physicians and other healthcare professionals associated with the Patient Centred Medical Homes to aid in planning for care management and interventions that may reduce their patients' likelihood of a preventable, high-cost hospitalisation.

A predictive model of hospitalization risk among disabled medicaid enrollees.

OBJECTIVES: To identify Medicaid patients, based on 1 year of administrative data, who were at high risk of admission to a hospital in the next year, and who were most likely to benefit from outreach and targeted interventions. STUDY DESIGN: Observational cohort study for predictive modeling. METHODS: Claims, enrollment, and eligibility data for 2007 from a state Medicaid program were used to provide the independent variables for a logistic regression model to predict inpatient stays in 2008 for fully covered, continuously enrolled, disabled members. The model was developed using a 50% random sample from the state and was validated against the other 50%. Further validation was carried out by applying the parameters from the model to data from a second state's disabled Medicaid population. RESULTS: The strongest predictors in the model developed from the first 50% sample were over age 65 years, inpatient stay(s) in 2007, and higher Charlson Comorbidity Index scores. The areas under the receiver operating characteristic curve for the model based on the 50% state sample and its application to the 2 other samples ranged from 0.79 to 0.81. Models developed independently for all 3 samples were as high as 0.86. The results show a consistent trend of more accurate prediction of hospitalization with increasing risk score. CONCLUSIONS: This is a fairly robust method for targeting Medicaid members with a high probability of future avoidable hospitalizations for possible case management or other interventions. Comparison with a second state's Medicaid program provides additional evidence for the usefulness of the model.

The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy.

PURPOSE: To test the hypothesis that scores of a validated measure of physician empathy are associated with clinical outcomes for patients with diabetes mellitus. METHOD: This retrospective correlational study included 20,961 patients with type 1 or type 2 diabetes mellitus from a population of 284,298 adult patients in the Local Health Authority, Parma, Italy, enrolled with one of 242 primary care physicians for the entire year of 2009. Participating physicians' Jefferson Scale of Empathy scores were compared with occurrence of acute metabolic complications (hyperosmolar state, diabetic ketoacidosis, coma) in diabetes patients hospitalized in 2009. RESULTS: Patients of physicians with high empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications (4.0, 7.1, and 6.5 per 1,000 patients, respectively, P < .05). Logistic regression analysis showed physicians' empathy scores were associated with acute metabolic complications: odds ratio (OR) = 0.59 (95% confidence interval [CI], 0.37-0.95, contrasting physicians with high and low empathy scores). Patients' age (≥69 years) also contributed to the prediction of acute metabolic complications: OR = 1.7 (95% CI, 1.2-1.4). Physicians' gender and age, patients' gender, type of practice (solo, association), geographical location of practice (mountain, hills, plain), and length of time the patient had been enrolled with the physician were not associated with acute metabolic complications. CONCLUSIONS: These results suggest that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence.

A brief instrument to measure patients' overall satisfaction with primary care physicians.

BACKGROUND AND OBJECTIVES: A brief and psychometrically sound scale to measure patients' overall satisfaction with their primary care physicians would be useful in studies where a longer instrument is impractical. The purpose of this study was to develop and examine the psychometrics of a brief instrument to measure patients' overall satisfaction with their primary care physicians. METHODS: Research participants included 535 outpatients (between 18--75 years old, 66% female) who completed a mailed survey that included 10 items for measuring overall satisfaction with their primary care physician who was named on the survey. Patients were also asked about their perceptions of physician empathy, preventive tests recommended by the physician (colonoscopy, mammogram, and prostate-specific antigen (PSA) for age and gender appropriate patients) and demographic information. RESULTS: Factor analysis of the patient satisfaction items resulted in one prominent component. Corrected item-total score correlations of the patient satisfaction scale ranged from 0.85 to 0.96; correlation between patient satisfaction scores and patient perception of physician empathy was 0.93, and correlation with recommending the physician to family and friends was 0.92. Criterion-related validity coefficients were mostly in the 0.80s and 0.90s. Patient satisfaction scores were significantly higher for those whose physicians recommended preventive tests (colonoscopy, mammogram, and PSA-compliance rates >.80). Cronbach's coefficient alpha for patient satisfaction scale was 0.98. CONCLUSIONS: Empirical evidence supported the validity and reliability of a brief patient satisfaction scale that has utility in the assessments of educational programs aimed at improving patient satisfaction, medical services, and patient outcomes in primary care settings.

Empathic and sympathetic orientations toward patient care: conceptualization, measurement, and psychometrics.

PURPOSE: To develop instruments for measuring empathic and sympathetic orientations in patient care and to provide evidence in support of their psychometrics. METHOD: Third-year medical students at Jefferson Medical College responded to four clinical vignettes in 2010. For each vignette, students indicated the extent of their agreement with an empathic response (conveying their understanding of patients' concerns) and with a sympathetic response (sharing patients' feelings). The authors calculated, based on students' responses to the clinical vignettes, two measures of empathic and sympathetic orientation. Students also completed the Jefferson Scale of Empathy (JSE) and the Interpersonal Reactivity Index (IRI). RESULTS: Of the 258 students in the class, 201 (78%) responded to all four vignettes and completed the JSE and IRI. The authors confirmed construct validity of the measures of empathic and sympathetic orientation through factor analysis. The empathic orientation was significantly associated with the measure of empathy (as measured by the JSE) but not with measures of sympathy (as measured by specific scales of the IRI). Conversely, sympathetic orientation was significantly associated with measures of sympathy. Thus, these results support the validity of the empathic and sympathetic orientation measures as assessed by four clinical vignettes. Coefficient alphas for the two measures were, respectively, 0.79 and 0.84. CONCLUSIONS: The validated measures of empathic and sympathetic orientation provide research opportunities to enhance the understanding of the contributions of empathy and sympathy to physicians' competence and patient outcomes.

Physicians' empathy and clinical outcomes for diabetic patients.

PURPOSE: To test the hypothesis that physicians' empathy is associated with positive clinical outcomes for diabetic patients. METHOD: A correlational study design was used in a university-affiliated outpatient setting. Participants were 891 diabetic patients, treated between July 2006 and June 2009, by 29 family physicians. Results of the most recent hemoglobin A1c and LDL-C tests were extracted from the patients' electronic records. The results of hemoglobin A1c tests were categorized into good control (<7.0%) and poor control (>9.0%). Similarly, the results of the LDL-C tests were grouped into good control (<100) and poor control (>130). The physicians, who completed the Jefferson Scale of Empathy in 2009, were grouped into high, moderate, and low empathy scorers. Associations between physicians' level of empathy scores and patient outcomes were examined. RESULTS: Patients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%, P < .001). Similarly, the proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than physicians with low scores (44%, P < .001). Logistic regression analyses indicated that physicians' empathy had a unique contribution to the prediction of optimal clinical outcomes after controlling for physicians' and patients' gender and age, and patients' health insurance. CONCLUSIONS: The hypothesis of a positive relationship between physicians' empathy and patients' clinical outcomes was confirmed, suggesting that physicians' empathy is an important factor associated with clinical competence and patient outcomes.

Prescription drug use during pregnancy: a population-based study in Regione Emilia-Romagna, Italy.

PURPOSE: Drug utilization studies in pregnant women are crucial to inform pharmacovigilance efforts in human teratogenicity. The purpose of this study was to estimate the prevalence of prescription drug use among pregnant women in Regione Emilia-Romagna (RER), Italy. METHODS: We conducted a retrospective prevalence study using data from the RER health care database. Outpatient prescription drug data were reconciled for RER residents who delivered a baby in a hospital between January 1, 2004 and December 31, 2004. Drug data were stratified by trimester of use, pregnancy risk categorization, and anatomical classification. RESULTS: Among the 33,343 deliveries identified in 2004, 70% of women were exposed to at least one prescription medication during pregnancy and 48% were exposed to at least one prescription medication after excluding vitamin and mineral products. Many of the most commonly used medications were anti-infectives, such as amoxicillin, fosfomycin, and ampicillin. Nearly 1% of women were exposed to drugs contraindicated (i.e., category X) in pregnancy, including 189 women (0.6%) who received these drugs during the first trimester. Several statin medications were among the most common contraindicated drug exposures. CONCLUSION: A large proportion of women who gave birth in RER in 2004 were exposed to prescription medications. Approximately 1 in 100 women were exposed to contraindicated drugs. The most commonly identified drug exposures can help focus pharmacoepidemiologic efforts in drug-induced birth defects.

Components of postgraduate competence: analyses of thirty years of longitudinal data.

CONTEXT: The conceptualisation and measurement of competence in patient care are critical to the design of medical education programmes and outcome assessment. OBJECTIVE: We aimed to examine the major components and correlates of postgraduate competence in patient care. METHODS: A 24-item rating form with additional questions about resident doctors' performance and future residency offers was used. Study participants comprised 4560 subjects who graduated from Jefferson Medical College between 1975 and 2004. They pursued their graduate medical education in 508 hospitals. We used a longitudinal study design in which the rating form was completed by programme directors to evaluate residents at the end of the first postgraduate year. Factor analysis was used to identify the underlying components of postgraduate ratings. Multiple regression, t-test and correlational analyses were used to study the validity of the components that emerged. RESULTS: Two major components emerged, which we labelled 'Knowledge and Clinical Capabilities' and 'Professionalism', and which addressed the science and art of medicine, respectively. Performance measures during medical school, scores on medical licensing examinations, and global assessment of Medical Knowledge, Clinical Judgement and Data-gathering Skills showed higher correlations with scores on the Knowledge and Clinical Capabilities component. Global assessments of Professional Attitudes and ratings of Empathic Behaviour showed higher correlations with scores on the Professionalism component. Offers of continued residency and evaluations of desirable qualities were associated with both components. CONCLUSIONS: Psychometric support for measuring the components of Knowledge and Clinical Capabilities, and Professionalism provides an instrument to empirically evaluate educational outcomes to medical educators who are in search of such a tool.

Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study.

BACKGROUND: In the US, a growing body of epidemiological studies has documented widespread potentially inappropriate medication prescribing among the elderly in outpatient settings. However, only limited information exists in Europe. OBJECTIVE: To evaluate the prevalence of potentially inappropriate medication prescribing among elderly outpatients in Emilia Romagna, Italy and to investigate factors associated with potentially inappropriate medication prescribing in that setting. METHODS: Retrospective cohort study using the Emilia Romagna outpatient prescription claims database from 1 January 2001 to 31 December 2001 linked with information (age, sex and other variables) available from a demographic file of approximately 1 million Emilia Romagna residents aged >or=65 years. The cohort comprised 849 425 elderly patients who had at least one drug prescription during the study period. The prevalence of potentially inappropriate medication prescribing, as defined by the 2002 Beers' criteria, was measured together with predictors associated with potentially inappropriate medication prescribing. RESULTS: A total of 152 641 (18%) elderly Emilia Romagna outpatients had one or more occurrences of potentially inappropriate medication prescribing. Of these, 11.5% received prescriptions for two medications of concern and 1.7% for three or more. Doxazosin (prescribed to 23% of subjects) was the most frequently occurring potentially inappropriate prescribed medication, followed by ketorolac (20.5%), ticlopidine (18.3%) and amiodarone (12.6%). Factors associated with greater likelihood of potentially inappropriate medication prescribing were older age, overall number of drugs prescribed and greater number of chronic conditions. The odds of receiving potentially inappropriate prescribed medications were lower for females, subjects living in more urban areas and subjects with a higher income level. CONCLUSIONS: This study provides strong evidence that potentially inappropriate medication prescribing for elderly outpatients is a substantial problem in Emilia Romagna. Focusing on the prevalence of potentially inappropriate medication prescribing and associated predictors can help in the development of educational programmes targeting outpatient practitioners to influence prescribing behaviour and, therefore, reduce potentially inappropriate medication prescribing.

Medical education and health services research: the linkage.

The medical community is coming under increased scrutiny. Challenges to the integrity of the healthcare system have been raised due to reports about the prevalence of medical errors. A heightened level of vigilance is required. Equally important is the need to isolate and correct the source of any problem, perceived or real. We are faced with challenging questions. Is the selection of students and residents appropriate? Are their education and evaluation valid? These questions must be answered at least in part by understanding the climate in which the services to the patients are rendered. Otherwise deficiencies noted in practice may be inappropriately attributed to the educational process. This article addresses the importance, implications and impact of the link between medical education and health services research. The goal of medical education is to prepare physicians to meet the challenges of practice by fulfilling their roles of clinician, educator and resource manager. Health services research can be linked to any of these physician roles. An understanding of health services is necessary to assess how well this goal is being met in the context of the changing healthcare system. A partnership between medical education and health services research is essential for academic health centers and health services institutions in assessing issues of health manpower and for the public good. Academic health centers have an important role in this partnership providing an infrastructure and expertise for both education and health services research.

Modeling risk-adjusted capitation rates for Umbria, Italy.

We studied the potential effect of refining per capita financing in Italy by risk adjustment using severity of illness as well as age and gender. Data were drawn from hospital, pharmaceutical, and demographic files for the entire population of the Umbrian region of Italy in 1997 and 1998. Hospitalization data from 1997 were used to classify patients into severity of illness categories which were hypothesized to be at risk for higher health services costs in 1998. Data on costs in 1998 were developed from hospital and pharmaceutical administrative data. Coefficients from 1997 models were used to develop predicted 1998 costs. Predicted costs in 1998 were compared to observed costs. Disease Staging models identified 155 unique clinical risk adjustment categories. These categories included 5.3% of the Umbrian population in 1997, who accounted for 21.6% of costs in the next year. In prediction models of future year costs using Umbrian data, R(2) values for Disease Staging models were 0.16, compared to values of 0.07 for a risk adjustment model used by Medicare. By identifying groups within the overall population who were more severely ill and who used more resources, these models can be used to assist health care planners estimate health care resources such as facilities, manpower, and programs.

Evaluations of medical students' clinical experiences in a family medicine clerkship: differences in patient encounters by disease severity in different clerkship sites.

BACKGROUND AND OBJECTIVES: Evaluation of medical students'clinical encounters is an essential component of optimizing their educational experience. In this study, we collected data on the diagnoses and disease severity in student-patient encounters at different family medicine clerkship sites. METHODS: Participants were 582 third-year medical students who completed a total of 7,515 specially designed patient encounter cards in a 6-week family medicine clerkship atfive training sites over 3 years. RESULTS: Variation was found in the average number of encounters in different clerkship sites. The findings for three frequently encountered diseases (essential hypertension, diabetes mellitus, and upper respiratory infection) showed significant differences in the proportions of patients at different stages of the disease in different clerkship sites. CONCLUSIONS: Students at different clerkship sites experience different numbers of encounters with patients and significant variation in the illness severity of patients seen in those encounters.