Medical students' experience with psychiatric diagnoses in a family medicine clerkship.

BACKGROUND: Many medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses encountered by the students. PURPOSE: This study examines patients encountered with psychiatric diagnoses using quantitative data collected by students in a family practice clerkship. METHODS: Over a 2-year period, 445 students completed 3,320 patient encounter forms for patients with a psychiatric diagnosis, noting their comfort level and responsibilities. RESULTS: The patients' diagnoses reflect those seen in a typical family practice. Of the 71,869 presenting diagnoses, 3,548 were for a psychiatric condition, most commonly depression (37.1%) and neuroses (28.0%). Students reported a high level of comfort in diagnosing and treating patients with a psychiatric disorder. The students routinely discussed these cases with their preceptors. CONCLUSIONS: By using a relatively simple computerized database, many curricular issues can be identified. For example, analysis of the database shows that the clerkship provides students with substantial practice in taking patient histories and performing initial patient examinations in patients presenting with a psychiatric problem. However, students infrequently provided patient education and counseling to patients with psychiatric disorders. Specific psychiatric diagnoses reflecting limited experience and lower levels of perceived competence include attention deficit disorder and senile and presenile organic psychotic disorders.

ENT experience in a family medicine clerkship: is there enough?

BACKGROUND: Curriculum planning is an essential process at any institution of learning. Currently, at Indiana University, a 1-week required otorhinolaryngology clerkship is being considered for removal from the curriculum, and this exposure is planned for integration into other primary care clerkships. A data collection system for patient encounters was created to obtain objective quantitative data about ear, nose, and throat conditions in the family medicine clerkship. METHODS: A total of 445 students filled out 56,151 patient encounter forms that contained the diagnoses, patient age, student comfort levels, and student responsibilities. RESULTS: Of the 56,151 encounters, 22.9% involved a condition involving an ear, nose, or throat (ENT) diagnosis, and the overall top-10 diagnoses reflect a typical family practice. Few students reported being given the opportunity to perform procedures. CONCLUSIONS: It appears that students are receiving sufficient practice in taking patient histories and performing initial patient physicals for ENT cases and that they see a sufficient number of ENT cases. However, students had more limited opportunity to perform and/or assist with ENT procedures or to be involved with patient education and ENT counseling. The number of ENT cases in the third-year clerkship is sufficient, and the experience is mostly more than adequate. Our study indicates that ENT training is a significant part of the family medicine clerkship, and curriculum integration is possible, though concerns about procedural skills will need to be addressed.

Gender and preceptors' feedback to students.

To determine whether evaluation comments differed based on preceptors' and students' genders, preceptors' evaluations of medical students were analyzed. Preceptors tended to comment on the same themes in the same proportions, regardless of gender. However, women preceptors commented about "Personality/Maturity" and "Personality/Character" more frequently for men students than they did for women students. Conversely, women preceptors commented about "Clinical Skills-Negative" more frequently for women students than for men.

Cost-effectiveness comparison of five interventions to increase mammography screening.

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, compliance with recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of five combinations of physician recommendation and telephone or in-person individualized counseling strategies for increasing compliance with mammography. METHODS: There were 808 participants who were randomly assigned to one of six groups. A logistic regression model with compliance as the dependent variable and group as the independent variable was used to test for significant differences and a ratio of cost to improvement in mammogram compliance evaluated the cost-effectiveness. RESULTS: Three of the interventions (in-person, telephone plus letter, and in-person plus letter) had significantly better compliance rates compared with the control, physician letter, or telephone alone. However, when considering costs, only one emerged as the superior strategy. The cost-effectiveness ratios for the five interventions show that telephone-plus-letter is the most cost-effective strategy, achieving a 35.6% mammography compliance at a marginal cost of $0.78 per 1% increase in women screened. CONCLUSIONS: A tailored phone prompt and physician reminder is an effective and economical intervention to increase mammography. Future research should confirm this finding and address its applicability to practice.

Cost of hospitalizations for heart failure: sodium retention versus other decompensating factors.

OBJECTIVE: To determine the cost of heart failure-related hospital admissions and to compare the cost of admissions for sodium retention with the cost of admissions for other decompensating factors. DESIGN: Retrospective, non-experimental, cost analysis. SETTING: Midwestern university-affiliated, tertiary care, medical center. SAMPLE: Two hundred seven heart failure-related admissions, 117 (57%) of which were for sodium retention leading to volume overload. OUTCOME MEASURES: Cost of hospitalization. PROCEDURE: Data obtained from the patient and financial records of patients hospitalized for heart failure in 1992 were analyzed using the ratio of cost-to-charge accounting procedure. RESULTS: The total cost was $2,442,720 for the 207 heart failure-related admissions; the average cost was $12,400 per admission. Approximately half of the cost of the hospitalizations was expended in the 4 cost centers comprising routine and critical care services, which incorporate room charges and nursing care. Another one third of the cost was for supplies, medications, and laboratory tests. Admissions as a result of sodium retention had lower costs than admissions as a result of other factors. CONCLUSION: The cost of hospitalization for heart failure is high. Routine services, supplies, medications, and laboratory tests used by these patients contribute to the high cost of care. Improved outpatient management strategies are necessary to reduce hospital admissions as a result of sodium retention.

Assessing prenatal care in a family practice residency clinic.

BACKGROUND AND OBJECTIVES: This study demonstrates how one family practice residency clinic characterized obstetric clinic patients and assessed obstetric care using birth certificate data (demographic characteristics and risk factors) and birth outcome indicators. METHODS: We compared clinical characteristics and birth outcomes for 901 patients who were delivered by family physicians from the family practice residency clinic with a matched and unmatched group of patients who were delivered by other physicians in the county during 1990-1993. RESULTS: The study clinic patients were at higher risk and had lower use of prenatal care. However, the outcomes of the study clinic patients were significantly better (fewer labor and delivery complications, procedures, Cesarean deliveries, abnormal conditions of newborn, low birth weight deliveries, and preterm birth) or no different from the comparison group of non-clinic patients. CONCLUSIONS: The analysis of birth certificate data provided a favorable assessment of prenatal care provided by a family practice residency clinic. This type of analysis permits comparisons of birth outcomes with other local or regional providers, statewide providers, and the year 2000 national objectives established by the National Center for Health Statistics.

Do pseudoephedrine or phenylpropanolamine improve maximum oxygen uptake and time to exhaustion?

OBJECTIVE: To study the effects of over-the-counter dosages of the pure alpha 1-agonists pseudoephedrine (PSE) and phenylpropanolamine (PPA) on selected parameters of exercise performance, and to establish a range of corresponding drug levels in the urine of the athletes who use these drugs. DESIGN: Placebo-controlled, randomized, double-blinded, multiple-dose trial. SETTING: The National Institute of Fitness and Sport, the Department of Family Medicine, Indiana University, and the Sports Medicine Lab, Department of Pathology, Indiana University, Indianapolis, Indiana. PARTICIPANTS: A convenience sample of 20 male cyclists, aged 18-35, from the local cycling community. Inclusion criteria required cycling at least 50 miles a week, no chronic medical problems, and not taking any medications. Subjects were recruited by local ads and word of mouth. INTERVENTION: Patients were randomized to one of two groups of 10 subjects. Each subject in both groups performed three separate bicycle ergometer tests after ingestion of varying dosages of alpha 1-agonists. One group performed tests after receiving placebo, 0.33 mg/kg PPA, and 0.66 mg/kg PPA, whereas the other group received placebo, 1 mg/kg PSE, and 2 mg/kg PSE. A minimum 1-week washout period was required between tests. Urine for drug testing was collected 1 h before, immediately afterward, and the next morning after testing. Drug testing was performed by gas GC/MCD at a facility approved by the International Olympic Committee. MAIN OUTCOME MEASURES: Maximum oxygen uptake (VO2max), time to exhaustion, urine drug levels of PSE and PPA, peak blood pressures (BPs), peak pulse, and Borg scale (rating of perceived exertion or RPE). MAIN RESULTS: In the PPA group, the 0.33-mg/kg dose resulted in insignificant changes in peak systolic BP (+5.4 mm Hg, p = 0.260), peak diastolic BP (-1.6 mm Hg, p = 0.622), peak pulse (-2.2 beats/min, p = 0.12), peak Borg (RPE = -0.10 (p = 0.823), time to exhaustion (-16.9 s, p = 0.287), and VO2max (+0.50 ml/kg/min, p = 0.71). No significant change was noted in any study variable at the 0.66-mg/kg PPA dose, and some effects were dissimilar to the lower PPA dose effects. Peak systolic BP increased 2.8 mm Hg (p = 0.617), diastolic BP decreased 1.6 mm Hg (p = 0.634), peak pulse increased 1.4 beats/min (p = 0.504), peak Borg RPE decreased 0.80 (p = 0.210), time to exhaustion decreased 2.6 s (p = 0.861), and VO2max decreased 2.92 ml/kg/min (p = 0.14). In the 1-mg/kg PSE group, there was a significant increase in peak systolic BP (+10.6 mm Hg, p = 0.029). No significant changes occurred in peak diastolic BP (+2.4 mm Hg, p = 0.333), peak pulse (+2.2 beats/min, p = 0.306), peak RPE (+0.2, p = 0.62), time to exhaustion (+21.4 s, p = 0.289), and VO2max (+2.29 ml/kg/min, p = 0.31). In the 2-mg/kg PSE dose trial, there were insignificant changes in peak systolic BP of +2.4 mm Hg (p = 0.559), +3.8 mm Hg in peak diastolic BP (p = 0.106), +1.6 beats/min in peak pulse (p = 0.586), -0.1 in peak Borg RPE scales (p = 0.76), -10.4 s in time to exhaustion (p = 0.41), and +1.79 ml/kg/min in VO2max (p = 0.43). Urine drug levels in those subjects receiving 1 mg/kg PSE ranged from 7-55 micrograms/ml before performance and 30-128 micrograms/ ml after performance to 7-35 micrograms/ml the next morning. Levels in those receiving 2 mg/kg ranged from 5-160 micrograms/ml before performance and 44-200 micrograms/ml after performance to 8-44 micrograms/ ml the next day. In the PPA 0.33-mg/kg dose trials, the levels ranged 1-36 micrograms/ml before performance and 9-50 micrograms/ml after performance to < 1-14 micrograms/ml the next morning. In the PPA 0.66-mg/kg dose trials, the levels were 4-52 micrograms/ml before performance, 8-80 micrograms/ml after performance, and 6-74 micrograms/ml the next day. CONCLUSIONS: We found no significant differences between trials in maximum oxygen uptake (VO2max), peak or progression of Borg Scale (RPE), maximum systolic and diastolic BPs, peak pulse, or t

Physician factors affecting patient willingness to comply with exercise recommendations.

OBJECTIVE: To evaluate how physician factors such as weight, exercise habits, and humanistic traits could influence patient willingness to comply with exercise recommendations. DESIGN: Survey questionnaire. SETTING: University-based Family Medicine Clinic. PATIENTS: 411 consecutive established patients of the Family Medicine Clinic. MAIN OUTCOME MEASURES: Selected Physician characteristics that patients believed would increase their willingness to comply with exercise recommendations. Results were compared with patient demographics to determine possible effects of physician characteristics on patients acceptance of exercise recommendations. RESULTS: Patients with higher education levels could be positively influenced by a physician being of appropriate weight, a regular exerciser, and a nonsmoker, and enlisting use of other experts, negotiating an exercise program, providing exercise counseling, and being their primary provider. Patients with higher income levels could be positively related to a physician's being of appropriate weight, and a nonsmoker, negotiating an exercise program, and enlisting use of other experts. Female patients could be positively influenced by physicians being well groomed, well dressed, accessible, and good listeners. Patients who regularly exercise could be positively influenced by a physician's appropriate weight and exercise regimen. CONCLUSIONS: Physicians may have a positive impact on patient willingness to comply by prescribing exercise and providing education and detailed guidance for all candidates. The study also showed that physicians' negotiating exercise programs and being good "exercise" role models is very important.

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.

A cost analysis of a nurse-managed, voluntary community health clinic.

Nurse-managed, voluntary community health centers are thought to represent cost-effective means of providing healthcare to the medically indigent. A cost analysis of a community healthcare clinic indicates that the cost of a clinic visit may be more expensive than the cost of a community physician visit when all costs (real and donated) are included. Increasing the number of patients seen per hour may be necessary to achieve more cost-effective delivery.

The use of a break-even analysis: financial analysis of a fast-track program.

OBJECTIVE: To calculate the financial break-even point and illustrate how changes in third-party reimbursement and eligibility could affect a program's fiscal standing. METHODS: Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast-track program during June 1993. The fast-track program is located within the confines of the emergency medicine and trauma center at a 1,050-bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break-even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect. RESULTS: Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs. CONCLUSIONS: Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third-party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break-even volumes.

Trends in the frequency of cesarean delivery. A 21-year experience, 1970-1990.

Cesarean delivery rates in the United States increased from about 5% in 1965 to 24.7% in 1988, with the majority attributed to four indications: dystocia, fetal distress, previous cesarean delivery and breech presentation. This study calculated one hospital's cesarean delivery rate over a 21-year period to examine the trends in the rate and in their clinical indications. From 1974 to 1979, dystocia was responsible for 39.1% of the 151.2% overall increase in cesarean deliveries at the study hospital, followed by repeat cesarean deliveries (30.1%), fetal distress (8.7%) and breech presentation (3.5%). The percentage of all repeat cesarean deliveries increased, from 6.2 in 1981 to 8.0 in 1990, while the percentage of previous cesarean patients having another cesarean delivery declined from 96.6 in 1981 to 85.5 in 1990. Although there has been a reduction in the proportion of women having repeat cesarean delivery, the number of previous cesarean patients presenting for another delivery has been increasing. The cesarean experience at individual hospitals needs to be examined to provide a better understanding of the reasons for changes in their cesarean delivery rates.

Children with special health care needs program: urban/rural comparisons.

The purposes of this study were to: (1) describe both the urban and rural clients who received services from the Indiana Children with Special Health Care Needs program (CSHCN) including both demographic and clinical characteristics; (2) conduct a health care needs assessment of the CSHCN program clients in both urban and rural areas; and (3) measure the perceived quality and adequacy of the CSHCN program services. A survey instrument was developed and mailed to all 6,459 families who participated in the Indiana CSHCN program from July 1, 1990 to June 30, 1991. Of the 2,722 questionnaires used in the analysis, 1,624 clients (59.7%) resided in urban counties and 1,098 (40.3%) resided in rural counties. The most frequently noted conditions for program eligibility were asthma, ear infections, hearing impairments, heart defects, and convulsions and seizures. Asthma had greater prevalence among the urban clients while cleft lip/palate, epilepsy, and heart defects were more common among the rural clients. The majority of program clients perceived their medical needs as being met. However, significant numbers of clients perceived unmet needs for mental health services, support groups, information about community services, resources to pay for uncovered medical expenses, and respite care. Of the 23 listed services, five were reported at significantly lower rates by rural clients as not being met: regular medical care, recreation, child care/day care, parent support group services, and speech therapy. Quality of medical services was generally perceived as being "excellent or good," while services related to information about community programs, child's rights in school, resources available to pay for uncovered medical expenses, as well as communication between the treatment center and the child's school were more often rated as "fair or poor." A smaller proportion of rural clients rated physician care and availability of staff nurses as fair or poor. A larger percentage of the rural group reported that access to treatment center location was fair or poor, compared to the urban group. Overall, the evaluation of the Indiana CSHCN program has shown that the non-medical care component seems to be in need of change, especially in the area of information and communication. Attention needs to be focused on providing more family support such as respite or child care and support groups, better information and communications, and improved availability of mental health services to better enable the CSHCN program to meet its objectives.

The incidence of adynamic ileus in postcesarean patients. Patient-controlled analgesia versus intramuscular analgesia.

With the current clinical popularity of patient-controlled analgesia pumps (PCAP) in postoperative pain management, it is prudent to be aware of the possible risk of adynamic ileus formation from intravenous narcotic administration. We hypothesized that prolonged PCAP exposure could delay bowel motility and increase post-operative morbidity. After stringent exclusionary parameters were met, we retrospectively analyzed 170 postcesarean patients who received PCAP medication and compared data with 171 postcesarean patients who received traditional intramuscular (IM) administration. The degree of adynamic ileus formation of moderate and severe intensity was higher in PCAP users (21.8%) vs. IM users (13.5%), P = .02. There was no significant difference in the average cumulative amount of analgesic administered during the first 24 postoperative hours for PCAP (442.2 mg) vs. IM (397.7 mg), reflecting that the mode of narcotic delivery is responsible for ileus formation rather than the dosage. Type of postoperative diet and speed of diet advancement were also factored into the analysis and did not statistically influence the results. We conclude that PCAP usage may increase the morbidity risk for adynamic ileus formation, and that usage should be accompanied with close monitoring of bowel motility.

The learning curve and the cost of heart transplantation.

The effect of learning on hospital outcomes such as mortality or adverse events (the so-called "practice makes perfect" hypothesis) has been studied by numerous investigators. The effect of learning on hospital cost, however, has received much less attention. This article reports the results of a multiple regression model demonstrating a nonlinear, decreasing trend in operative and postoperative hospital costs over time in a consecutive series of 71 heart transplant patients, all treated in the same institution. The cost trend is shown to persist even after controlling for various preoperative demographic and clinical risk factors and the specific experience of individual surgeons. Using a reference case, the model predicts a cost of $81,297 for the first heart transplant procedure performed at the hospital. If this same patient had been the tenth case rather than the first, with the hospital having benefited from the experience gained in nine previous cases, the model predicts the cost would now be only $48,431, or approximately 60 percent of the cost of the first case. Had this patient been the twenty-fifth case, the predicted cost would be $35,352 (43 percent of the original cost), and had this been the fiftieth case, the cost would be $25,458 (31 percent of the original cost). The longitudinal study design used in this analysis greatly reduces the likelihood that the observed cost reduction is due to economies of scale rather than learning. The results have implications for a policy of regionalization as a tactic for containing hospital cost. Whereas others have pointed to a volume-cost relationship as an argument for the regionalization of expensive and complex hospital procedures, the present data isolate a learning-cost relationship as a separate argument for regionalization.

An analysis of reimbursement for outpatient medical care in an urban hospital emergency department.

The investigators examined the demographic and clinical factors associated with the collection experience in a series of 786 patients who were treated in an urban hospital emergency department (ED) but not admitted to the hospital. They found that 57% of the total net charge of $150,489 had been paid within 180 days. This rate can be compared with an average inpatient collection rate of 85% at 180 days. Seven factors were found to account for the collection rate variation, making up 38.4% of the total variation. Age, gender, primary diagnosis, season of visit, time of arrival, and residence were not found to be main contributors. Insufficient collection rates may be an indication that EDs increasingly are becoming a financial risk to hospitals. The hospital's collection experience will become more important as an indicator of financial risk if the costs of operating EDs continue to escalate and collection rates do not improve. Both the costs of providing a service and the amount of the charge actually collected are valid concerns to those operating EDs.

Uncompensated hospital care for pregnancy and childbirth cases.

BACKGROUND: The large number of medically indigent patients in the United States is a major concern to policymakers and may be due to recent increases in the number of uninsured people. The purpose of this study was to identify the factors that affect the amount of unpaid hospital charges for services provided to pregnant women. METHODS: Individual and hospital data were collected on a representative set of 235 pregnancy and childbirth patients with unpaid hospital charges from 28 hospitals in the state of Indiana. RESULTS: Most of these patients did not have insurance coverage (63.8%), yet the majority were employed in the public or private sector (72.3%). Over half (55.5%) of the total uncompensated care amount for this group was from the $1000 to 2499 debt category. The median charge for these patients was $1468, of which the typical hospital was able to collect only 25.5%. CONCLUSIONS: The findings support the belief that any national effort to expand the availability of health insurance coverage to women through increased employment will not totally eliminate the uncompensated care problem. The findings also indicate that rural hospitals face the uncompensated care problem mainly because a significant portion of rural patients are without adequate health insurance coverage.

A determination of institutional and patient factors affecting uncompensated hospital care.

For this study, a sample of 985 patients classified as "charity" and "bad debt" cases in 1986 were identified from 28 Indiana hospitals. In a multiple regression model, insurance coverage, total hospital charge, pregnancy-related diagnoses, marital status, employment status, discharge status, urban location, and total hospital revenue were significant factors in predicting unpaid hospital bills, when controlling other demographic characteristics. Sixty percent had some form of insurance and were responsible for 40 percent of the uncompensated amount, justifying the need to examine the adequacy of patient insurance coverage. However, providing insurance coverage will not entirely eliminate the problem of uncompensated care; hospitals also need to increase collection efforts for all unpaid bills.

Financial analysis of an inner-city helicopter service: charges versus collections for patients transferred from another acute care facility.

Emergency helicopter services provided by trauma centers are now being perceived as contributing to the financial burden of the hospital because of recent changes in trauma reimbursement under the Medicare Prospective Payment System (PPS) and because of the general perception that collection rates are lower among trauma patients. The use of helicopters to transfer patients from one acute care facility to another may also be concentrating the patients with low collection rates at the receiving hospital. We examined retrospectively the demographic and clinical factors associated with the collection experience in a series of 288 trauma patients transferred by helicopter from another acute care facility to an inner-city hospital. Factors affecting payment at 180 and 360 days included patient age, insurance class, discharge status, and size of the hospital charge. As long as reimbursement continues to be cost-based for nonMedicare patients, collection rates remain an important consideration in determining the financial viability of using helicopters to transfer patients.