Evidence for the Will Rogers phenomenon in migration of employees to managed care plans.

Employees have increasing opportunities to enroll in managed care plans, and employers tend to favor these plans because of their lower costs. However, lower costs may be the result of selection of healthier patients into managed care plans. This study measured differences in health care utilization across an indemnity plan and a managed care plan, and for all employees together. We found that apparent increases in utilization in both indemnity and managed care plans disappeared when the plans were viewed together, reflecting the migration of sicker patients from indemnity plans to managed care plans.

Relation between myocardial infarction, depression, hostility, and death.

OBJECTIVE: To examine the independent impact of major depression and hostility on mortality rate at 6 months and 12 months after discharge from the hospital in patients with a myocardial infarction. METHOD: Three hundred thirty-one patients were prospectively evaluated for depression with a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. The Cook Medley Hostility Scale data were analyzed by chi(2) procedures for nominal and categoric data, and Student t test was used for continuous data types. RESULTS: Depression was a significant predictor of death at 12 months (P =. 04) but not at 6 months (P =.08). Hostility was not found to be a predictor of death at 6 months or 12 months. CONCLUSIONS: Major depression in patients hospitalized after myocardial infarction is a significant univariable predictor of death at 12 months, although it was not a statistically significant predictor after adjusting for other variables. Hostility is not a predictor of death. Prospective studies are needed to determine the impact of aggressive treatment of depression on post-myocardial infarction survival.

How a community teaching hospital is changing to better serve its community.

In recent years increased attention has been focused on the importance of teaching hospitals' serving the health of their communities. A community teaching hospital may have a special impetus and some advantages because of its linkage to a defined geographic community and a traditional mission of providing clinical and other services to that community. The authors describe how their community teaching hospital, the health and education services network it belongs to, and the integrated delivery system of which it is a member work together to respond to the current challenge to provide care and education to local communities. In particular, they describe how since 1995 the hospital has used an approach (called Measurably Enhancing the Status of Health) to create and operate its new Department of Community Health and Health Studies and associated new programs to benefit the community. The new department combines innovative community outreach programs with an emphasis on the qualitative and quantitative evaluation of the these programs. There are also programs of medical education in the hospital and at the Pennsylvania State University College of Medicine, and other programs that have community educational components (e.g., a coalition to reduce the number of smokers; a center to reduce health risks and prevent disease). The authors and their hospital colleagues have found three concepts to be helpful as they reflect on what they have learned since 1995 and continue to refine their community outreach work: community, complexity, and collaboration/competition. They explain these concepts and suggest that other institutions in academic medicine may find them and the ideas and programs of their hospital useful as the seek ways to care for, educate, and measure the health status of their own communities.

Guidelines, practice policies, and parameters: the case for geriatrics.

OBJECTIVE: As the population ages, the care of older persons becomes more important. At the same time, practice guidelines that provide recommendations for appropriate care are being published in greater numbers. The purpose of this work is to determine the proportion of guidelines that contain specific information about older persons. DESIGN: Through a random sample of published guidelines listed in the AMA Directory of Practice Parameters, 1992 Edition, we determined the proportion of guidelines that contain specific age-related information. We also determined if, over time, there was a difference in the proportion of practice guidelines containing information about older persons. RESULTS: 45.9% (95% CI, range 33.4-58.4) of guidelines that could conceivably pertain to older persons contain no age information; 24.6% (95% CI, range 13.8-35.4) of guidelines contain information only about persons less than 65 years of age; 29.5% (95% CI, range 18.1-41.0) of guidelines contain specific information about older persons. Moreover, there were no secular trends in the proportion of guidelines pertaining to older persons. CONCLUSIONS: Only a minority of practice guidelines contain information about older persons. Possible causes and solutions to this shortfall are discussed.

The effect of cost-containment policies on rates of coronary revascularization in California.

BACKGROUND: Lower rates of use of resources have been reported for the treatment of hospitalized patients covered by Medicaid than for privately insured patients. Cost-containment policies may exacerbate such differences in the use of hospital resources. We studied patients with ischemic heart disease who received care at nonfederal hospitals in California in 1983 (the year a Medicaid cost-containment program was implemented), in 1985, or in 1988. Within this sample of patients, we compared the rates of coronary revascularization (coronary-artery bypass surgery or coronary angioplasty) among patients covered by Medicaid, patients with private insurance covering fee-for-service care, and patients enrolled in a health maintenance organization (HMO). METHODS: Logistic-regression models were used to determine adjusted odds ratios for the use of coronary revascularization procedures in patients with different types of insurance, with control for demographic, clinical, and hospital characteristics. The study samples were made up of 49,167 patients in 1983, 47,809 in 1985, and 44,631 in 1988. RESULTS: The frequency of revascularization increased in all three insurance groups from 1983 to 1988, but it did so much faster in the fee-for-service and HMO groups than in the Medicaid group. Patients with private fee-for-service insurance were 1.66 times as likely as Medicaid patients to undergo revascularization in 1983 (P < 0.01), 2.01 times as likely in 1985 (P < 0.01) and 2.33 times as likely in 1988 (P < 0.01). Patients enrolled in HMOs were 0.96 times as likely as Medicaid patients to undergo revascularization in 1983 (P < 0.05), 1.23 times as likely in 1985 (P < 0.01), and 1.53 times as likely in 1988 (P < 0.01). CONCLUSIONS: The frequency of coronary revascularization in California in 1983 was nearly twice as high for patients with private fee-for-service insurance as for patients enrolled in HMOs or for Medicaid recipients. The implementation that year of stringent cost-control measures by Medicaid may explain the slower increase in the frequency of revascularization over five year among Medicaid recipients as compared with patients in the fee-for-service and HMO groups. Different incentives in fee-for-service and HMO practice may explain the lower frequency of revascularization among patients enrolled in HMOs, although the rates of increase for these two groups were about the same from 1983 to 1988.

Maintaining confidentiality in a look-back investigation of patients treated by a HIV-infected dentist.

The spread of human immunodeficiency virus (HIV) from a Florida dentist with acquired immunodeficiency syndrome (AIDS) to several of his patients has generated considerable concern about the risk of HIV transmission during dental treatment. Accordingly, self-reporting of HIV infection and subsequent AIDS by a dentist at our medical center prompted notification and testing of patients at risk. Key features of the notification and testing process were (a) only patients who had undergone procedures deemed to pose appreciable risk of exposure to the dentist's blood were notified, (b) the identity of the dentist was shielded by not including in notification letters any identifying information other than the name of the medical center, and (c) patients' blood specimens were tested promptly for HIV antibodies and results were reported immediately to each patient to minimize the period of anxiety. HIV antibody testing was requested by 41 of the 88 patients to whom notification letters were sent, and all 41 were HIV negative after having undergone 395 procedures by the HIV-infected dentist. Review of the 88 patients' medical and dental records showed that at least 77 had received treatment by other health care providers at the medical center so that they would not be able to ascertain which provider had HIV infection. None of the patients who were notified by the medical center subsequently queried the dentist concerning possible HIV infection. Our experience demonstrates that look-back investigations can be conducted by institutions in a manner that substantially protects the identity of health care workers with HIV infection, minimizes the number of patients discomfitted, and avoids excessive utilization of personnel time. Even greater protection of the identity of health care workers with HIV infection presumably can be achieved when notification is undertaken by a public health agency.

Cutaneous cryptococcosis without evidence of systemic involvement.

As many as 15% of cases of systemic infection with Cryptococcus neoformans have cutaneous involvement. The existence of primary cutaneous disease is controversial. We report a patient with cutaneous cryptococcosis without evidence of visceral involvement at the time of diagnosis. She has been followed up for 5 years and remains free of systemic involvement. Cutaneous cryptococcosis does not always signify systemic disease.

Surgical outcome for resident and attending surgeons.

We asked whether surgical process and outcome differ for physicians in postgraduate training supervised by attending surgeons compared with attending surgeons alone. All appendectomies performed during a 2 year period in a 320 bed voluntary hospital where either the admitting diagnosis or the preoperative diagnosis suggested acute appendicitis were included in the study. Data were abstracted from medical records and pathology reports. One hundred fifty-four cases of primary appendectomy were reviewed. In 97 cases, 1 of 9 attending physicians was listed as chief surgeon; in 57 cases, 1 of 15 resident physicians was listed as chief surgeon. There were no significant differences between the two patient groups according to age and sex. There was no difference between attending resident physicians in accuracy of diagnosis. Despite a pathologically normal appendix, attending surgeons in six cases and residents in two cases listed a discharge diagnosis of appendicitis. The average length of stay was 8.8 days for attending surgeons' cases and 7.1 days for residents' cases (t = 1.09, p = 0.29). The postoperative complication rates were 24 percent for attendings' cases and 12 percent for residents' cases (chi-square = 2.31, p = 0.16). We conclude that there is no appreciable difference in either the process or the outcome of care for patients undergoing appendectomy whether the operation is performed by an attending physician or a resident physician supervised by an attending physician.

Diagnosis of diabetic eye disease.

The correct diagnosis of proliferation diabetic retinopathy is essential, because it is a treatable disease and missing the diagnosis can lead to the patient becoming blind. We examined the ability of internists and ophthalmologists to diagnose proliferative retinopathy under optimal conditions. Twenty-three physicians performed retinal examinations on ten diabetic patients and one normal patient with dilated pupils. Physician examiners were members of a university medical center and included 10 internists, 2 diabetologists, 4 senior medical residents, 4 general ophthalmologists, and 3 ophthalmologists who were subspecialists in retinal disease. Correct diagnosis was determined separately by the consensus of three ophthalmologists specializing in retinal disease, who reviewed seven-view stereo fundus photographs and medical charts. Of a possible 483 individual eye a examinations, 438 were completed. The overall error rate was 61%. The error rate for missing the diagnosis of proliferative retinopathy varied from 0% for retinal specialists to 49% for internists, diabetologists, and medical residents. We conclude that potentially serious mistakes in diagnosis are currently made by the physicians who care for most diabetic patients. Experience and specialized knowledge lessen that the error rate. Further education or greater use of referrals may be necessary to provide optimal patient care.

Surgical therapy of variant angina associated with nonobstructive coronary disease.

Patients with variant angina refractory to medical therapy pose a difficult management problem. We report two patients with variant angina who had focal spasm in coronary arteries with fixed obstructions of less than 20% of the luminal diameter. Ischemic episodes were accompanied by malignant ventricular arrhythmias and third degree atrioventricular block. Symptoms were refractory to intensive medical management with nitrates and calcium blocking agents in one patient and with nitrates in the other who was treated before calcium blockers were available. Surgery was done; a bypass graft was placed distal to the area of focal spasm and the native artery was ligated proximally. Both patients are asymptomatic 24 and 66 months after surgery and neither takes anginal medication regularly. The surgical procedure outlined should be considered only if therapy to control life threatening ischemic symptoms with nitrates and calcium blocking agents fails.

Diagnostic services utilization review at a university medical center.

The rational provision of diagnostic services is important in maintaining health care quality and controlling costs. Establishing a successful diagnostic services utilization review committee requires substantial commitment from the hospital and the medical staff.

The inclusion of capitation reimbursement in solo practice.

Capitation reimbursement has been an integral part of prepaid group practices in both medicine and dentistry, and claims have been made for its ability to influence the delivery of services favorably. Experts have suggested that if capitation is implemented, more preventive care will be provided, more diagnostic services will be provided, there will be better continuity of care, utilization of high-cost services will be reduced, and clinical outcome will be improved. This study focused on the dominant mode of practice in dentistry, the general, solo practitioner, to determine if these contentions held. A sample of 245 patients whose care was paid for by a capitation mechanism was matched to a sample of 245 similar patients whose care was paid for on a standard fee-for-service basis--all from three dentists' practices. All services in all years of care for each patient were analyzed. It was determined that the rate of restorations was lower, while rates of diagnostic testing and prophylaxis were higher for capitation patients. Continuity was also better under capitation, but rates of extractions were virtually identical for the two groups.

Capitation in dentistry: a quasi-experimental evaluation.

Two matched samples of 245 patients were drawn from solo dental practices which contained both capitation and fee-for-service components. All services rendered to patients during their entire time under care of the practice were recorded and analyzed. Results indicate different styles of care under the two payment mechanisms. An improved preventive style was associated with capitation, as well as fewer fillings. Outcome measured by a modification of the DMF (decayed-missing-filled) Index was also more favorable under capitation.