The knowledge base of certified internists. Relationships to training, practice type, and other physician characteristics.

A written examination was used to assess the knowledge base of 183 practicing certified internists. Analyses of the examination scores showed that performance on the initial American Board of Internal Medicine certification examination taken 7.6 years previously was the major factor predicting current knowledge base. By developing regression models, the unique contribution of different variables to prediction of current examination scores was determined. Prior American Board of Internal Medicine certification examination performance accounted for 70.9% of the explained variance, and demographic and practice variables were responsible for 17.8%. Among the demographic and practice variables studied, community size and subspecialty practice were the only variables that contributed significantly to the regression equations. Examination scores were highest for certified internists practicing in smaller communities. General internists received higher scores than subspecialists. Although statistically significant, the apparent adverse influence of subspecialty practice and larger community size on examination performance was modest. Further study is needed to determine if longer periods in practice might produce different relationships between variables such as these and examination performance.

Beta blockers and the primary prevention of nonfatal myocardial infarction in patients with high blood pressure.

A population-based, case-control study was conducted to determine whether beta blockers, used for the treatment of high blood pressure, prevent first events of coronary heart disease. All study subjects were health-maintenance organization enrollees with pharmacologically treated hypertension. Patients presented in 1982 to 1984 with new coronary heart disease, and control subjects were a probability sample of eligible hypertensive enrollees free of coronary heart disease. With the investigators blind to case-control status, the subjects' medical records were reviewed for other coronary risk factors, and the health-maintenance organization's computerized pharmacy database was used to ascertain the use of beta blockers. A larger proportion of controls than cases were using beta blockers. This difference was confined to the subgroup with nonfatal myocardial infarctions. For current use, the estimated relative risk for nonfatal myocardial infarction was 0.62 (95% confidence interval, 0.39 to 0.99). Among current users of beta blockers, higher doses conferred greater protection. Past use and total lifetime intake of beta blockers were only weakly associated with case-control status. The current use of beta blockers may prevent first events of nonfatal myocardial infarction in patients with high blood pressure.

Correlates and effect of non-response in a postpartum survey of obstetrical care quality.

This study investigated the differences between unprompted respondents, prompted respondents, and non-respondents to a postpartum postal survey, and determined the likely impact of non-response on the accuracy of calculations of patient assessments of obstetrical care quality. Birth certificate and hospital discharge data were obtained for 1664 live births at three hospitals in Washington State between 8/91-10/91 and linked with 1268 completed postpartum maternal postal surveys. Non-white race, public insurance payer, unmarried status, and smoking in pregnancy were independent risk factors for non-participation. Among participants, non-white race, unmarried status, and having an infant who was low birthweight, preterm, or discharged late were independent risk factors for prompted response. The inclusion of prompted respondents did not substantially alter the calculated proportion of women rating obstetrical care quality as low, and these figures were similar to proportions estimated for the entire intended cohort using a modification of Drane's method. A one-time mailing of an obstetrical care quality survey can provide information similar to that obtained with more extensive follow-up even though substantial differences may exist between unprompted and prompted respondents, and with adjustment for factors related to non-participation and timing of response, it may be possible to obtain accurate estimation of outcome prevalences for the entire intended cohort.

Quality of ambulatory care of the elderly: an analysis of five conditions.

Twelve hundred twenty-six (1,226) persons representative of the noninstitutionalized United States population aged 65-74 years were interviewed and examined as part of the 1971-1975 Health and Nutrition Examination Survey (HANES). Using information available in the HANES data base, standards for what could be considered minimally acceptable care were developed for five tracer conditions. Rates of "deficient" care were: angina, 46 percent; dyspnea on exertion, 78 per cent; hypertension, 26 per cent; hearing impairment, 61 per cent; depression, 80 per cent. Deficient care was analyzed by gender, race, income, locale, and self-rated health status. Only low income emerged as a consistent risk factor for deficient care, with the relative odds for deficient care for poor patients as compared with non-poor patients ranging from 2.7 to 5.6 (P less than 0.05) for four of five conditions. A subgroup analysis attempted to determine whether deficiencies were caused by limited access to physicians, underreporting of symptoms, or barriers that occurred after presenting complaints to a physician. The analysis revealed that for three of four symptomatic conditions, the poor and non-poor patients were equally likely to report their symptoms, whereas the poor were more likely to receive "deficient" care after presenting complaints to physicians. The ramifications of these findings as they pertain to the present situation are discussed.

Washington State's model of physician leadership in cardiac outcomes reporting.

BACKGROUND: In 1993, the cardiac surgery community in Washington State opposed an effort by the state Health Care Authority (HCA) to identify "centers of excellence" for selective contracting of coronary artery bypass grafting (CABG) procedures, and proposed an alternate model that would create a statewide cardiac outcomes registry under physician governance to be used by all institutions for internal quality improvement activities. METHODS: A prospective pilot data collection effort, which examined preoperative and postoperative patient-reported health status, served as the basis for evaluating the capacity of a physician-led organization to develop a collaborative atmosphere and facilitate universal hospital participation. RESULTS: A surgical steering group met on a regular basis and reached consensus on governance issues, protocols for standardized data collection, and policies regarding data dissemination. All 14 centers that performed bypass surgery in the state participated. Patients who were surveyed reported statistically significant improvements in physical, emotional, and anginal-specific health status after bypass surgery. Baseline patient characteristics and longitudinal outcomes were compared across institutions. CONCLUSIONS: Based on the feasibility of this collaborative outcomes reporting program, the HCA revised its policy regarding selective contracting and has helped to support an ongoing physician-led and -governed cardiac outcomes reporting system that is particularly notable for the subsequent integration of both CABG surgery and catheterization-based procedures into one standardized registry.

Analysis, assessment, and presentation of risk-adjusted statewide obstetrical care data: the StORQS II study in Washington State. Statewide Obstetrics Review and Quality System.

OBJECTIVE: To develop an effective, concise presentation of hospital-specific birth event and delivery-related complication rates, including significant deviations from expected rates calculated using risk-adjusted peer hospital data, for distribution to all Washington State hospitals with delivery services. DATA SOURCES: Complete data for calendar year 1993, including inpatient discharge records for mothers and newborns, birth certificates, and infant death records, for 74 hospitals from Washington state source files. STUDY DESIGN: Institutions were classified into four peer groups based on presence of neonatal intensive care units, number of births, and rural/urban location. Twenty-three clinical indicators of procedure (e.g., cesarean section) and complication rates were analyzed and presented. METHODS: For each indicator, observed and expected rates (adjusted within peer group for categorized baseline risk factors) were calculated and presented by institution. Effective graphic and numeric techniques for presenting significant deviations from expected rates were developed. Results were calculated in terms of numbers of events as well as rates. Approaches applicable to institutions with small numbers of deliveries were selected. PRINCIPAL FINDINGS: Exact confidence intervals (C.I.s) for event rates were superior to binomial or Poisson approximations for small hospitals. For calculating expected rates, indirect adjustment was used due to small numbers within risk factor categories. For all indicators, observed and expected rates along with 95 percent C.I.s for the true rate were presented graphically by institution for each peer group. Transforming C.I.s into "statistically acceptable ranges" allowed hospital personnel to assess their performance in terms of actual numbers of events as well as rates. CONCLUSIONS: Readily available statistical methods and straightforward descriptive approaches allow accurate presentation of outcomes for both large and small institutions.

The Health of the Public Program at the University of Washington: a new role for academic medical centers.

The University of Washington Health of the Public Program has convened a consortium composed of the region's academic medical center, the two largest managed care plans in Washington, and representatives of the state's major private and public purchasers of health care. The consortium's purpose is to test the feasibility of collaboratively collecting cross-system data, assessing variations in practice, and implementing site-specific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortium's initial efforts are described. In today's climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community-wide outcomes of care.

Organizational and financial influences on patterns of surgical care.

Rates of surgery for similar patient groups are lower in well-established prepaid group plan forms of HMO than in either independent practice association forms of HMO or in traditional fee-for-service care arrangements. The biologic outcomes of care are at least as good in prepaid group plan settings as in other settings. The implications of these conclusions for the future are discussed.

Comparison of diagnostic methods of family practice and internal medicine residents.

The diagnostic methods of third year residents in internal medicine (N=23) and family practice (N=22) were compared with respect to common ambulatory patient problems. Five written simulated patients were presented and the dependent variables were: initial and revised diagnostic hypotheses, physical examination items, and laboratory charges. The two groups considered the same number and type of diagnostic hypotheses. There were large differences in the selection of physical examination items (P less than .001), with the family practice group selecting fewer items. Laboratory charges were significantly greater for the internal medicine group with two patients (P less than .05), and the charges were nearly identical with two patients. A high degree of patient-specific behavior was demonstrated by both groups. These findings have implications for the future training of primary care physicians.

Teaching sigmoidoscopy to primary care physicians: a controlled study of continuing medical education.

A sigmoidoscopy skills preceptorship was developed for physicians to increase the rate of sigmoidoscopy by physicians in a health maintenance organization. The preceptorship was designed as a randomized, controlled study of continuing medical education. Baseline sigmoidoscopy rates of participating physicians were similar to those of nonparticipants, as were selected demographic and professional characteristics. Physicians randomized to receive sigmoidoscopy training significantly increased their rate of sigmoidoscopy when compared with controls. The proportion of barium enemas accompanied by sigmoidoscopy likewise increased. All physicians who participated improved when compared with nonparticipants. The sigmoidoscopy skills preceptorship appears to be a worthwhile endeavor in continuing medical education.

Hypertension. Management in a prepaid health care project.

Previous studies have shown that care for hypertension in clinical practice is not optimal. This study consists of a review of medical records of 101 hypertensive patients enrolled in a community prepaid health care project, in which all direct costs to patients are eliminated and in which patients are known to have geographical access to care. The results show that even under such conditions, there are deficiencies in what is done in the diagnosis and management of hypertension (process of care). Furthermore, recorded blood pressures in the medical records indicate that 34% of identified patients had diastolic pressures greater than 95 mm Hg at the time of last visit for hypertension.

Congenital limb reduction defects in the agricultural setting.

To ascertain whether parental involvement in agricultural work and residence in an agricultural setting are associated with the development of congenital limb reduction defects, we carried out a case-control study using California birth records from 1982, 1983, and 1984. Cases with limb reduction defects (N = 237) and randomly selected controls (N = 475) were compared regarding parental occupation and maternal county of residence. After adjustment for potential confounders in a multivariate analysis, the estimated relative risk (RR) of parenting a child with a limb reduction defect among parents involved in agricultural work was 0.9 (95 per cent confidence limits = 0.4, 1.7). The RR among mothers who resided in a county of high agricultural productivity as compared with minimal agricultural productivity was 1.7 (95% CL = 1.1, 2.7), while the RR associated with residence in a county with high pesticide use as compared with minimal pesticide use was 1.9 (95% CL = 1.2, 3.1). When we limited the cases to children with limb reduction defects who had at least one additional anomaly (n = 79) and compared them to the control births, the corresponding RRs were 1.6 (95% CL = 0.7, 3.6), for parental involvement in agricultural work, 2.4 (CL = 1.2, 4.7) for county agricultural productivity, and 3.1 (CL = 1.5, 6.5) for county pesticide use.

Hospital medical staff organization and quality of care: results for myocardial infarction and appendectomy.

This article examines the relationships among hospital structural characteristics, individual physician characteristics, medical staff organization characteristics and quality of care for two conditions: acute myocardial infarction and appendicitis. Using data obtained from the Commission on Professional and Hospital Activities (CPHA), approximately 50,000 acute myocardial infarction cases and 8,183 appendectomy cases collected from 96 hospitals in the East North Central Region of the country (Illinois, Indiana, Michigan, Ohio and Wisconsin) were examined. These data were merged with medical staff organization and related data on hospital characteristics obtained from the American Hospital Association. The results indicate that such medical staff organization factors as involvement of the medical staff president with the hospital governing board, overall physician participation in hospital decision making, frequency of medical staff committee meetings and percentage of active staff physicians on contract are positively associated with higher quality-of-care outcomes, independent of the effects of hospital and physician characteristics. Further, the medical staff organization factors appear to be somewhat more strongly associated with higher quality-of-care outcomes than the hospital and physician characteristics. For acute myocardial infarction, higher volume of patients treated per family practitioner and internist and presence of a coronary care unit were also associated with better outcomes. Given the restricted number of conditions studied, the geographically limited sample and the fact that specific variables were not consistently related to quality of care for both conditions, the results area viewed as preliminary. However, they are consistent with and extend other developing findings in this area. They also suggest that more attention needs to be given to the organization of the hospital medical staff and its articulation with the overall hospital decision-making structure and process in attempts to improve outcomes of hospitalization.

Potential effect of self-care algorithms on the number of physician visits.

To assess the potential effect of self-care algorithms on the number of physician visits, actual visits from the Seattle Virus Watch were compared retrospectively with those recommended by clinical algorithms for common illnesses from the book, Take Care of Yourself, by Vickery and Fries. From a total of 3929 illnesses, records indicating the presence of the index symptom for eight algorithms were identified, determining whether the criteria for seeing a physician were met and whether a physician visit was recorded. The number of visits observed was compared to the number of visits recommended by the algorithms. Strict adherence would have increased the number of visits over that observed for five, remained the same for two, and decreased for one of the algorithms. These results indicate that adherence to some commonly promulgated self-care algorithms may increase rather than decrease the number of physician visits.

Thyroid neoplasia in Marshall Islanders exposed to nuclear fallout.

We studied the risk of thyroid neoplasia in Marshall Islanders exposed to radioiodines in nuclear fallout from the 1954 BRAVO thermonuclear test. We screened 7266 Marshall Islanders for thyroid nodules; the islanders were from 14 atolls, including several southern atolls, which were the source of the best available unexposed comparison group. Using a retrospective cohort design, we determined the prevalence of thyroid nodularity in a subgroup of 2273 persons who were alive in 1954 and who therefore were potentially exposed to fallout from the BRAVO test. For those 12 atolls previously thought to be unexposed to fallout, the prevalence of thyroid nodules ranged from 0.9% to 10.6%. Using the distance of each atoll from the test site as a proxy for the radiation dose to the thyroid gland, a weighted linear regression showed an inverse linear relationship between distance and the age-adjusted prevalence of thyroid nodules. Distance was the strongest single predictor in logistic regression analysis. A new absolute risk estimate was calculated to be 1100 excess cases/Gy/y/1 X 10(6) persons (11.0 excess cases/rad/y/1 million persons), 33% higher than previous estimates. We conclude that an excess of thyroid nodules was not limited only to the two northern atolls but extended throughout the northern atolls; this suggests a linear dose-response relationship.

Trends in the utilization of mammography in Washington state and British Columbia: relation to stage of diagnosis and mortality.

To compare the utilization of an imaging technology in the United States and Canada and its effect on clinical outcomes, trends in the utilization of mammography among women aged 50 to 75 years from 1984 through 1988 in Washington State and British Columbia were examined. Also compared were trends in the stage at time of diagnosis of invasive breast cancer and mortality due to breast cancer in the two regions. Annual mammography use increased in both regions, but the proportion of women examined was consistently two to three times higher in Washington than in British Columbia (43% vs 16% in 1988). Although there was no difference in mortality trends, the proportion of women diagnosed with localized disease in Washington increased each year (from 52% to 64%, P less than .001), while in British Columbia it remained unchanged at approximately 56%. Results of this study suggest that differences in utilization were influenced by clinical policies, the degree to which these policies were promoted, reimbursement, and the organization of radiology services.

Medicaid prenatal care: a comparison of use and outcomes in fee-for-service and managed care.

BACKGROUND: To control rising costs, state Medicaid agencies are enrolling recipients in managed care health plans (MCPs). We performed this study to assess this policy's impact on accessibility and outcomes of Medicaid-funded prenatal care. METHODS: We performed a retrospective, controlled study with three cohorts: a study group of 1106 Medicaid recipients enrolled in three MCPs, a matched comparison group of 4830 recipients receiving care in the fee-for-service (FFS) system, and a second matched comparison group of 4434 non-Medicaid enrollees of the same MCPs. Data on prenatal care use and birth outcomes were obtained through linkage of claims and discharge files with birth certificate files. RESULTS: Medicaid recipients enrolled in MCPs used prenatal care similarly to those in the FFS system and showed equal or modestly improved birth-weight distributions. However, Medicaid MCP enrollees showed poorer use of prenatal care and birth outcomes compared with non-Medicaid enrollees of the same plans. CONCLUSIONS: Enrollment in MCPs has a neutral or small beneficial effect on the prenatal care received by the Medicaid population. However, providing financial access and modifying the system of care for this population did not result in parity with the general population.