[Varices along the segment of the internal saphenous vein]. / Varices sur le trajet de la veine saphène interne.

Four hundred and twenty two patients, i.e. 607 legs, were examined by 7.5 Herz continuous mode Doppler in order to determine the value of treatment of long saphenous insufficiency. History, subjective symptoms and physical finding were compared with the aim of determining the incidence of absence of deep valves. Pain, tiredness and swelling were found 550 times, accompanied by deep insufficiency in 266 cases. There was a history of thrombosis in 35 cases. There were subjective symptoms only in 30 and absence of deep valves in 14. Results of clinical examination: 554 cases of saphenous insufficiency were confirmed 425 times by Doppler examination, i.e. 72 per cent of legs which had been treated by stripping and clinical examination nevertheless showed 81 cases of superficial insufficiency. This leads to the conclusion that history is no longer valid in the diagnosis of an old thrombosis. Clinical examination is very reliable, giving results identical of superior to those of Doppler studies. Saphenous varicosities are accompanied by functional disturbances which can be explained by the frequent absence of valves in the deep system.

Academic group practice. The physicians' view.

In order to evaluate physician response to the reorganization of a traditional medical clinic into a group practice model, a randomized controlled trial was conducted using equivalent groups of patients and physicians. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, nurse practitioner, staff nurse, and receptionist. A panel of 50 medical residents was interviewed prior to the reorganization and 1 year later. Residents in the experimental groups perceived improvements in the ancillary staff, placed a higher value on informal discussion of patient management problems, and were more satisfied with the outpatient experience. Moreover, residents in the group practices were more likely to voluntarily schedule additional clinic sessions to accommodate their patients. No change was noted in their career choices. We conclude that reorganization of a traditional medical clinic into a group practice model can result in increased physician satisfaction although it may not have a major impact on long-term career goals.

Effect of an academic group practice on patient show rates: a randomized controlled trial.

Ambulatory medical clinics at academic centers are reputed to be expensive, inefficient, and poorly regarded by the medical residents who staff them. In an effort to address these problems, some centers have reorganized their traditional clinics into group practices. These group practices are thought to be more effective for teaching and providing services than are the traditional clinics. This is a report on the results of a study in which the authors reorganized two of four firm clinics into group practices in order to test the influence of the organizational changes on the various aspects of ambulatory care. During this controlled prospective trial of the group practice model, higher show rates were observed for patients in the group practices than in the traditional clinics (70% vs 65%, P less than 0.0005). The possible reasons for the higher rates are discussed.

Academic group practice. The patient's perspective.

The effect upon patient satisfaction of a reorganization of a traditional medical clinic into a group practice model was examined in a controlled trial in which both patients and physicians were randomized. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, a nurse practitioner, and a receptionist. This reorganization resulted in a substantial decrease in charges and utilization for patients in the experimental group. A panel of 302 patients was interviewed prior to the reorganization and 1 year later. Patients in the experimental groups perceived improvements in access to their physicians as well as decreases in clinic waiting time and decreases in the lag time between requesting and obtaining an appointment. General health perceptions and other satisfaction measures were unchanged. The authors conclude that a group practice organization can result in decreased patient charges without substantially altering patient satisfaction.

Hospital admissions caused by iatrogenic disease.

Complications of medical therapy requiring hospitalization affect the costs and quality of medical care. We studied all admissions to the medical services of a public teaching hospital to characterize current incidence and cause of iatrogenic admissions. We studied 834 admissions resulting in 47 distinct iatrogenic events and 45 iatrogenic admissions (5.4%). Thirty-five cases were caused by medications, nine by procedures, one by radiotherapy, one by transfusional therapy, and one by nosocomial infection. Almost 50% of these admissions were avoidable. Though the incidence of iatrogenic admissions in this study is similar to that in previous reports, the profile of the responsible agents is different. We did not find relationships with age, number or type of diagnoses, or number of medications on admission. Study of other patient and physician characteristics may be more rewarding in reducing the number of iatrogenic complications.

Influence of simple computerized feedback on prescription charges in an ambulatory clinic. A randomized clinical trial.

Pharmaceuticals account for a significant portion of health care costs and are an important target for attempts at cost reductions. While many techniques have been shown effective, most are resource-intensive, have demonstrated fatigue after the intervention is ceased, and have been directed at specific items rather than total charges. The authors designed a computerized program to feed back prescription charges. The intervention is easy to execute, inexpensive, and can be maintained indefinitely. The intervention was performed in a randomized, prospective, controlled trial with the medical residents of a large county hospital. The goal was to reduce total prescribing charges and produce a meaningful financial result. The intervention reduced the mean charge for a prescription by 6.7% (P less than 0.025), but with a long latent period and minimal impact on resident knowledge of drug charges. Significant differences were seen only at the end of the study. The program was viewed positively by the residents. The low cost of the intervention yielded a benefit-to-cost ratio in excess of 50:1. Because of computerization and ongoing patient and resident randomization at the study hospital, added costs of this randomized trial in terms of computer time and research assistance were less than $1,000.

The cost implications of academic group practice. A randomized controlled trial.

We evaluated the reorganization of a general medical clinic into several group practices, using equivalent groups of patients and physicians in a randomized controlled trial. The group practice, unlike the traditional clinic, provided decentralized registration, clinic coverage five days a week, and telephone coverage at night and on weekends. Residents worked in small groups with an attending physician, nurse practitioner, and receptionist. All financial activity involving a sample of 2299 patients was followed during the 11-month intervention. The total hospital charges per patient were 26 percent lower for the patients seen in the group practice than for those seen in the traditional clinic (P = 0.003). This difference was primarily attributable to inpatient charges, which were 27 percent lower per patient hospitalized (P = 0.004). The mean length of stay was 8.3 days among group-practice patients and 10.5 days among traditional-clinic patients (P = 0.011). We conclude that organizational changes to improve outpatient access and to integrate inpatient and outpatient services can decrease medical charges.