Preventable hospitalizations in primary care shortage areas. An analysis of vulnerable Medicare beneficiaries.

BACKGROUND: Health care outcomes among vulnerable elderly populations (defined in this study as Medicare beneficiaries who rated their overall general health as "fair" or "poor") are a growing concern. Recent studies suggest that potentially preventable hospitalizations may be useful for identifying poor ambulatory health care outcomes among vulnerable populations. OBJECTIVES: To determine if Medicare beneficiaries in fair or poor health are at increased risk of experiencing a preventable hospitalization if they reside in primary care health professional shortage areas. DESIGN: A survey of Medicare beneficiaries from the 1991 Medicare Current Beneficiary Survey. PATIENTS: Medicare beneficiaries living in the community. RESULTS: Medicare beneficiaries in fair or poor health were 1.82 times more likely to experience a preventable hospitalization if they resided in a primary care shortage area (95% confidence interval, 1.18-2.81). After controlling for educational level, income, and supplemental insurance, Medicare beneficiaries in fair or poor health were 1.70 times more likely to experience a preventable hospitalization if they resided in a primary care shortage area (95% confidence interval, 1.09-2.65). CONCLUSIONS: Medicare beneficiaries in fair or poor health are more likely to experience a potentially preventable hospitalization if they live in a county designated as a primary care shortage area. Provision of Medicare coverage alone may not be enough to prevent poor ambulatory health care outcomes such as preventable hospitalizations. Improving health care outcomes for vulnerable elderly patients may require structural changes to the primary care ambulatory delivery system in the United States, especially in designated shortage areas.

Management of osteoarthritis of the knee by primary care physicians.

BACKGROUND: Most patients with osteoarthritis (OA) are treated by primary care physicians (in this article, primary care physicians are family physicians and general internists). OBJECTIVE: To describe and compare the self-reported practice patterns of family physicians and general internists for the evaluation and management of severe OA of the knee, including factors that might influence referral for total knee replacement. DESIGN, SETTING, AND PARTICIPANTS: A survey was developed and mailed to randomly selected community family physicians and general internists practicing in Indiana. MAIN OUTCOME MEASURE: Self-reported physician practice patterns regarding OA of the knee. RESULTS: Physical examination was the most common method of evaluating OA of the knee. Family physicians were more likely to examine for crepitation, joint stability, and quadriceps muscle strength than were general internists (P<.05). Patients with OA of the knee treated by family physicians were more likely to receive nonsteroidal anti-inflammatory drugs or oral corticosteroids and were less likely to receive aspirin, acetaminophen, or narcotics compared with patients treated by general internists. Six patient characteristics were rated as positive factors favoring a referral for possible total knee replacement, 8 characteristics were rated as negative, and 5 were rated as not a factor in the decision about referral. CONCLUSIONS: Results from this study suggest that additional research is needed to determine the evaluative techniques for OA of the knee that provide the most useful information for management decisions, the management techniques that maximize patient outcomes, and the criteria that should be used to select patients who would benefit most from referral for possible total knee replacement.

Factors related to potentially preventable hospitalizations among the elderly.

OBJECTIVES: The authors examine whether the odds of having a hospitalization associated with an ambulatory care sensitive condition can be explained by observed differences in a Medicare beneficiary's predisposing, enabling, and need characteristics. METHODS: A multivariate cross-sectional analysis of Medicare's administrative inpatient claims data and the Medicare Current Beneficiary Survey was conducted on a nationally representative sample of Medicare beneficiaries. Each Medicare beneficiary's hospital utilization was classified into one of three categories: (1) no hospital admissions; (2) hospitalized, but no hospitalizations for a potentially preventable condition; and (3) at least one potentially preventable hospitalization. RESULTS: The results suggest that being older, black, or living either in a core standard metropolitan statistical area (SMSA) county or a rural county significantly increases the odds of a preventable hospitalization, whereas having attended college, or having only Medicare insurance coverage reduces the odds of a preventable hospitalization. Further, those individuals who assess their health status as poor, have had coronary heart disease, a myocardial infarction, or diabetes, and required assistance with two or more of the six basic activities of daily living are at a greater risk of a preventable hospitalization. CONCLUSIONS: Policy efforts aimed at reducing the number of preventable hospitalizations among the elderly should address the complex health care delivery needs of those Medicare beneficiaries who have special health care needs because they are very old, black, live in core SMSA or rural counties, have poor overall health status, and have physical limitations. Efforts to reduce the number of Medicare beneficiaries who experience a preventable hospitalization may be cost-effective as these beneficiaries may account for up to 17.4% of Medicare's reimbursement for inpatient, outpatient, and physician services in our data set.

Indiana family physician attitudes and practices concerning smoking cessation.

Most physicians are aware of the health benefits of smoking cessation and agree they have a responsibility to help smokers quit. Many physicians, however, do not regularly address smoking cessation with their patients. Questionnaires were sent to 2,095 family practice physicians in Indiana. Information obtained included: demographic data; office-based smoking cessation practices; counseling; and physicians' perceptions of intervention outcomes. Most physicians (86%) asked new patients if they smoked, and 23% questioned patients about their exposure to passive smoke. Younger physicians, female physicians and urban physicians were more likely to ask new patients if they smoked. A formal smoking cessation program was used by 28% of the responding physicians. Among those not using a program, 7% reported plans to implement one in the coming year, 40% were not planning to implement one, and 53% were unsure. Physician and practice characteristics were not correlated with the use of smoking cessation programs. Only 11% of physicians considered their smoking cessation counseling skills to be excellent; 27% indicated the need for improvement in skills. One-half (52%) believed their counseling efforts were effective; almost half (45%) believed that current reimbursement policies limited their involvement in smoking cessation interventions. Most respondents have not instituted smoking cessation programs in their practices. It is likely that a combination of strategies, including both undergraduate, graduate and continuing medical education programs and reform in reimbursement practices for cessation programs, will be required to achieve significant increases in long-term smoking abstinence rates.

Small area variation analysis: a tool for primary care research.

Small area variation analysis is a research tool used by health services researchers to describe how rates of health care use and events vary over well-defined geographic areas. Significant variation has been shown to exist in the rates of hospitalization for chronic obstructive lung disease, pneumonia, hypertension, and in surgical procedures, such as hysterectomy, cholecystectomy, and tonsillectomy. Potential sources of variation include differences in underlying morbidity, access to care, physician judgment, quality of care delivered, patient demand for services, and random variation. Small area variation studies have been used to determine if significant variation exists across geographic areas and to describe relationships between the observed variation and potential causal factors. Methodologic concerns include the definition of small areas, defining the at-risk population within each small area, sample size, case mix adjustments, and stability of rates over time. The use of small area analysis in primary care will require definition of appropriate small areas for ambulatory care, description of the variation in ambulatory events across small areas, development of appropriate measures for ambulatory case mix, and development of appropriate tools to measure the outcomes of ambulatory care.

Patient preference for health status screening instruments.

The Dartmouth Primary Care Cooperative Information Project (COOP) charts and mini-Duke-UNC Health Profile (DUHP) instruments were developed to screen patients' health status in clinical settings. The purpose of this study is to determine patient preferences for use of these instruments in a family practice setting. A sample of 203 consecutive, consenting patients presenting to a university-based family practice clinic was administered both instruments. Patients then completed a questionnaire which asked which instrument was preferred and why. Overall, neither instrument was significantly preferred by patients. Patient perceived accuracy for the COOP was significantly positively related to age and negatively related to quality of life. Patient ease, rather than perceived accuracy, dominated the preference relationship, yet neither instrument was found to be easier to use by the elderly or those in poorer health. This study reveals that patients prefer instruments which are easier to use, but that neither the COOP nor the mini-DUHP was found to be significantly easier to use by all patients. However, the COOP was perceived to be more accurate for a subset of patients, the elderly with poor quality of life beyond the realm of health.

Primary care physicians and avoidable hospitalizations.

BACKGROUND: The rate of admission for avoidable hospital conditions (AHCs) has been proposed as a measure of the ability of a population to access health care. The purpose of this study was to determine the relationship between the availability of primary care physicians and the rate of avoidable hospitalizations. METHODS: Statewide hospital discharge data for general acute care hospitals in Pennsylvania were used to determine age- and sex-adjusted AHC rates in the 26 health service areas (HSAs) in Pennsylvania. The number and type of primary care physician as well as the per capita income for each HSA were obtained from the Area Resource File. Correlations of number and type of physician with AHC rates were obtained. RESULTS: Only the number of family and general practice physicians (FPs/GPs) per population was significantly correlated with adult and pediatric AHC rates. As the number of FPs/GPs in each HSA increased, the AHC rate decreased. The significant relationship between FPs/GPs and the AHC rate remained after controlling for the effect of per capita income. No significant correlation was found between either the number of general internists and the adult AHC rate or the number of general pediatricians and the pediatric AHC rate. CONCLUSIONS: The availability of FPs/GPs is related to lower rates of hospitalization for certain conditions. Family physicians may provide more effective first-contact access to health care than is provided by either general internists or pediatricians in Pennsylvania. Future studies should address whether care by family physicians is more cost-effective as a result of this reduction in avoidable hospitalizations.

Hypertension management: relationship between visit interval and control.

OBJECTIVE: Hypertension is one of the most common diagnoses resulting in an office visit to the physician. We examined the relationship between the variation in the interval between follow-up visits for hypertensive patients and the control of blood pressure. METHODS: The sample consisted of 113 patients who made 399 visits. Data included current medical problems, medications, type of health insurance, and socioeconomic status for each patient. RESULTS: The mean number of days between visits was 70.6 with a standard deviation of 76.3. No significant relationship was found between visit interval and severity of hypertension (p = 0.14). Sample size made it possible to detect a 20% difference with a likelihood of 0.80 at a significance level of 0.05. CONCLUSIONS: Our findings are limited by our focus on patient behavior rather than physician recommendation concerning the interval between visits, and by the distinct possibility that many of the visits were made for reasons other than follow-up of hypertension.

A combined family practice and occupational medicine residency program.

Family physicians deliver a significant proportion of occupational medicine services in this country. A shortage of physicians specifically trained in occupational and environmental medicine (OEM) has been well documented. A 1991 report from the Institute of Medicine recommends an alternative approach to certification of OEM physicians by creating a streamlined graduate training program that would result in dual certification in a primary care specialty and OEM. For the past three years, the University of Oklahoma has offered such a combined track program, comprising four years of training in family practice and occupational medicine. This article describes the development and structure of the combined program.

Physicians' recognition of depression.

Depression is a common but underrecognized disorder in family practice. The purpose of this study was to determine the relationship between physician attitudes toward psychosocial aspects of care and psychiatric knowledge and recognition of depression in a family practice residency clinic. Adult patients (n = 582) presenting to 16 family practice residents were screened for depression using the short form of the Beck Depression Inventory. A regression model was created with the rate of recognition of depression for each physician as the dependent variable. Independent variables included in the model were resident scores on the Physician Belief Scale and the psychiatric subsection of the in-training exam scores, patient familiarity, and whether the attending physician was consulted. Orientation toward psychosocial aspects of medical care was found to be significantly related to recognition of patients at risk for depression. In-training examination psychiatric subsection scores were unrelated to a resident's clinical recognition of depression risk. This study suggests that physician attitude is a significant factor in successful recognition of depression by family practice residents.

Infection of fetal scalp electrode monitoring sites.

Complications caused by placement of a fetal scalp electrode include trauma, hemorrhage and infection. Infections are usually localized and self-limited, but they can occasionally lead to serious complications, such as osteomyelitis, sepsis and death. The recommended treatment for a scalp abscess is incision and drainage, followed by appropriate antibiotic therapy. If a serious infection is suspected, the infant should be hospitalized, blood cultures obtained and intravenous antibiotic therapy initiated.

Recognition of depression in patients who smoke.

BACKGROUND: Depression is a common illness in family practice and is frequently missed by busy practitioners. Recent studies have suggested a relationship between smoking and depression in the general population. The purpose of this study is to determine whether a patient's smoking is related to the physician's recognition of a patient's depression. If so, smoking may serve as a cue used by physicians to recognize depression in their clinical decision-making process. METHODS: Adult patients presenting to the University of Oklahoma Family Practice Residency Clinic were screened for depression using the short form of the Beck Depression Inventory (BDI). After each patient visit, upper level residents or fellows completed response cards on which they recorded their assessment of the likelihood of a depression, their familiarity with the patient, and whether they had any knowledge of a depression history. RESULTS: The prevalence of depression as measured by the BDI among smokers (n = 232) and nonsmokers (n = 472) was 24.1% and 15.3%, respectively, a significant difference (P less than .001). Physicians identified depression at a significantly higher rate (75.0%) among depressed smokers than among depressed nonsmokers (48.6%) (P less than .0001). Smokers were 2.06 times as likely to be labeled depressed when controlling for the presence of a current depression, physician knowledge of a depression history, and physician familiarity with the patient (P less than .0001, 95% CI = 1.44,2.94). CONCLUSIONS: Smoking may serve as a cue for the clinician in the recognition of depression. Further research is needed to determine how smoking or a related factor may be used by physicians to correctly identify depression.