Friend or foe? How primary care physicians perceive hospitalists.

BACKGROUND: Increased use of hospitalists is redefining the role of primary care physicians. Whether primary care physicians welcome this transition is unknown. We examined primary care physicians' perceptions of how hospitalists affect their practices, their patient relationships, and overall patient care. METHODS: A mailed survey of randomly selected general internists, general pediatricians, and family practitioners with experience with hospitalists practicing in California. MAIN OUTCOME MEASURES: Physicians' self-reports of hospitalists' effects on quality of patient care and on their own practices. RESULTS: Seven hundred eight physicians were eligible for this study, and there was a 74% response rate. Of the 524 physicians who responded, 34% were internists, 38% were family practitioners, and 29% were pediatricians. Of the 524 respondents, 335 (64%) had hospitalists available to them and 120 (23%) were required to use hospitalists for all admissions. Physicians perceived hospitalists as increasing (41%) or not changing (44%) the overall quality of care and perceived their practice style differences as neutral or beneficial. Twenty-eight percent of primary care physicians believed that the quality of the physician-patient relationship decreased; 69% reported that hospitalists did not affect their income; 53% believed that hospitalists decreased their workload; and 50% believed that hospitalists increased practice satisfaction. In a multivariate model predicting physician perceptions, internists, physicians who attributed loss of income to hospitalists, and physicians in mandatory hospitalist systems viewed hospitalists less favorably. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of hospitalists' effect on patients and on their own practice satisfaction, especially in voluntary hospitalist systems that decrease the workload of primary care physicians and do not threaten their income. Primary care physicians, particularly internists, are less accepting of mandatory hospitalist systems. Arch Intern Med. 2000;160:2902-2908

HIV seroconversion in intravenous drug users in San Francisco, 1985-1990.

OBJECTIVE: To examine the HIV seroconversion rate, risk factors for seroconversion, and changes in risk behavior over time in intravenous drug users (IVDU) in San Francisco, 1985-1990. DESIGN: Observational study. SETTING: All methadone maintenance and 21-day methadone detoxification programs in San Francisco. PARTICIPANTS: A total of 2351 heterosexual IVDU, of whom 681 were seronegative at first visit and seen at least twice ('repeaters'). MAIN OUTCOME MEASURES: HIV seroconversion rates, risk factors for seroconversion, and changes in behavior. RESULTS: The HIV seroconversion rate in repeaters was 1.9% per person-year (ppy) of follow-up [2.1% in women versus 1.7% in men (not significant); 4% in African Americans versus 1% in whites (P = 0.006); 3.9% ppy in the first third of the study, 1.2% in the second (P = 0.007), and 1.9% in the last (not significant)]. Risk factors for seroconversion were five or more sexual partners per year [hazard ratio (HR) = 2.6; P = 0.02], use of shooting gallery ever (HR = 2.9; P = 0.02), and less than 1 year (lifetime) in methadone maintenance (HR = 2.7; P = 0.02). Self-reported intravenous cocaine use fell from 33 to 15% over 5 years, shooting gallery use fell from 19 to 6%, and the proportion with five or more sexual partners fell from 25 to 10%. Bleach use rose to 75% of needle-sharers. CONCLUSIONS: The 1985-1990 HIV seroconversion rate in IVDU (1.9% ppy) was comparable to that in San Francisco cohorts of homosexual men (1.4% ppy). A decline in HIV seroconversion coincided with changes in risk behavior. Stable attendance of methadone maintenance was highly protective: the seroconversion rate in subjects with 1 year or more in methadone was 12% ppy.

Differences in laboratory values in HIV infection by sex, race, and risk group.

OBJECTIVES: To determine differences in CD4+ and CD8+ lymphocyte values, beta 2-microglobulin (beta 2M), and HIV p24 antigenemia by sex and race among HIV-seropositive and HIV-seronegative injecting drug users (IDU), and to compare these values with those in homosexual men of equivalent status. DESIGN: Baseline values from a cohort of 206 HIV-seropositive and 173 HIV-seronegative IDU were compared with values from a cohort of 288 HIV-seropositive homosexual men and 176 HIV-seronegative controls, who were prospectively followed at 6-month intervals, to examine differences in laboratory values in HIV-infected individuals by sex, race, and risk group. METHODS: Among HIV-seropositives, we compared white and black IDU only (n = 167), and white male IDU (n = 38) with white homosexual men (n = 256). Laboratory values from the cohort of homosexual men at 24, 36 and 48 months of follow-up were compared with IDU values. RESULTS: HIV-infected female IDU had significantly higher CD4+ lymphocyte counts (P < 0.03) and percentages of CD4+ lymphocytes (P < 0.004) than male IDU, resulting in higher CD4:CD8 ratios (P < 0.002). White IDU had significantly higher serum beta 2M levels than black IDU (P < 0.02). Black female IDU were much less likely to be HIV p24-antigenemic (1%) than all other groups (P < 0.005). Compared with homosexual men, male IDU had significantly elevated beta 2M levels (0.58 mg/l higher). When controlled for CD4+ lymphocyte values as a surrogate for length of time HIV-infected, beta 2M and HIV p24 antigenemia differences persisted. CONCLUSIONS: These differences should be considered when HIV p24 antigen, CD4+ lymphocyte counts and beta 2M levels are used as surrogate markers in clinical trials and management of HIV disease.

Does HIV reporting by name deter testing? MESH Study Group.

OBJECTIVE: Name-based HIV reporting is controversial in the United States because of concerns that it may deter high-risk persons from being tested. We sought to determine whether persons at risk of HIV infection knew their state's HIV reporting policy and whether they had delayed or avoided testing because of it. DESIGN: A cross-sectional anonymous survey. METHODS: We interviewed 2404 participants in one of three high-risk groups: men who have sex with men (MSM), heterosexuals attending a sexually transmitted disease (STD) clinic, and street-recruited injection drug users (IDU). Participants were asked standardized questions about their knowledge of reporting policies and reasons for having delayed or avoided testing. We recruited in eight US states: four with name-based reporting and four without; all offered anonymous testing at certain sites. RESULTS: Fewer than 25% correctly identified their state's HIV reporting policy. Over 50% stated they did not know whether their state used name-based reporting. Of the total, 480 participants (20%) had never been tested. Of these, 17% from states with name-based reporting selected concern about reporting as a reason for not testing compared with 14% from states without name-based reporting (P = 0.5). Comparing previously tested participants from states with name-based reporting to those from states without, concern about HIV reporting was given as a reason for delaying testing by 26% compared with 13% of IDU (P < 0.001), and for 26% compared with 19% of MSM (P = 0.06). CONCLUSION: Most participants did not know their state's HIV reporting policy. Name-based reporting policies were not associated with avoiding HIV testing because of worry about reporting, although they may have contributed to delays in testing among some IDU.

Relationships of plasma estradiol, testosterone, and sex hormone-binding globulin with lipoproteins, apolipoproteins, and high density lipoprotein subfractions in men.

Plasma estradiol, testosterone, and sex hormone-binding globulin (SHBG) were studied in relation to plasma lipoproteins, high density lipoprotein (HDL) subfractions, and apolipoproteins in 73 healthy but sedentary middle-aged men. Among potentially confounding variables, a strong positive association was found between estradiol levels and cigarette use, while testosterone and SHBG correlated negatively with percent body fat and alcohol intake. After adjustment for smoking, percent body fat, and alcohol, plasma estradiol levels correlated negatively with total cholesterol and low density lipoprotein cholesterol, and testosterone levels correlated positively with apolipoprotein B, while SHBG levels correlated positively with HDL2 mass and apolipoprotein A-I. SHBG was also strongly associated with the waist to hip girth ratio (WHR). Adjustment for WHR eliminated the significant associations of SHBG with triglycerides, HDL2 mass, and apolipoprotein A-I. SHBG levels and WHR may reflect tissue sensitivity and the impact of exposure to fluctuating levels of sex hormones for a period of days, or longer. These variables may provide more insight into the role of sex hormones in lipoprotein metabolism than do single samples of circulating hormones. It is also suggested that long term effects of sex hormones on adipose tissue distribution may at least partially underlie sex-related differences in lipoprotein metabolism.

Relationship of dietary fat, protein, cholesterol, and fiber intake to atherogenic lipoproteins in men.

Nutritional components (g/1000 kcal) obtained from 3-day diet records are compared to triglyceride, total cholesterol, low-density (LDL), intermediate-density (IDL), and very low-density (VLDL) lipoprotein concentrations of 77 free-living men. Polyunsaturated-fatty acid consumption correlated negatively with concentrations of triglycerides, total cholesterol, LDL- and VLDL-cholesterol, and total-lipoprotein mass of smaller-LDL particles (Sf0 0-7), IDL (Sf0 12-20), and VLDL (Sf0 20-400) in serum and plasma. Animal-protein consumption correlated positively and plant-protein consumption correlated negatively with triglycerides, smaller-LDL mass, VLDL-cholesterol, and VLDL-mass levels. Serum concentrations of smaller-LDL particles were also positively correlated with dietary-cholesterol intake and negatively correlated with crude-fiber consumption. Thus, diet-lipoprotein relationships observed cross-culturally and experimentally are further supported when detailed dietary measurements from 3-day diet records and lipoprotein measurements from repeated blood samplings are correlated in free-living men.

HIV-related oral manifestations in two cohorts of women in San Francisco.

The goals of this study were to compare the prevalence of oral lesions in women infected with human immunodeficiency virus (HIV) and HIV-negative women, and to determine the association of oral lesions with route of HIV transmission and with level of immunosuppression in infected women. As part of a prospective 4-year study, oral examinations and blood tests were performed, at 6-month intervals, on 176 HIV-infected women and on 117 HIV-negative women at risk for HIV infection. We evaluated participants for the following oral conditions: hairy leukoplakia, candidiasis, ulcers, warts, non-Hodgkin's lymphoma, Kaposi's sarcoma, and parotid enlargement. As previously reported in men, the prevalence of oral lesions was significantly higher among HIV-infected (22%) than HIV-negative women (3%) [odds ratio (OR) = 8.2; 95% confidence interval (CI) 2.8, 23.5], particularly candidiasis (14%) and hairy leukoplakia (10%). Among HIV-infected women with CD4 cell count nadir > or = 200 cells/microliters, the prevalence of hairy leukoplakia was higher among those infected heterosexually than among injection drug users (OR = 5.5; 95% CI: 1.5; 19). The OR for the association between oral lesions and CD4 cell count nadir (< 200 vs. > 500 cells/microliters) was 8.9 (95% CI: 2.6, 30), indicating a strong positive association with level of immunosuppression.

Does weight loss cause the exercise-induced increase in plasma high density lipoproteins?

Studies showing an increase in plasma concentration of high density lipoprotein cholesterol (HDL-C) with moderate exercise have usually rejected the role of body weight change in the HDL-C raising process, ostensibly because the amount of weight lost has been negligible. To investigate HDL-C changes more thoroughly, we followed initially sedentary middle-aged men randomly assigned to either a moderate running (n = 36) or a sedentary control (n = 28) group for one year. Among runners, one-year changes in plasma HDL-C concentrations correlated strongly with their body weight changes (r = - 0.53, P less than 0.001). Curve-fitting procedures and regression analysis suggested that processes associated with weight change produce much of the plasma HDL-C changes induced by moderate exercise and that changes in HDL-C concentration predominantly reflect changes in the reputedly anti-atherogenic HDL2 sub-component. Further, the interaction between weight change and plasma HDL-C concentration was significantly different (P less than 0.001) in exercisers and controls suggesting that the metabolic consequences of exercise-induced weight change are different from the consequences of weight change in the sedentary state.

Relationship of exercise, oral contraceptive use, and body fat to concentrations of plasma lipids and lipoprotein cholesterol in young women.

To investigate the relationship of exercise and oral contraceptive use to plasma lipids and lipoproteins, a cross-sectional study was designed to compare lipid levels in 96 exercising and non-exercising women who used or did not use oral contraceptives. Exercisers had significantly lower plasma triglyceride concentrations and low-density/high-density lipoprotein ratios than non-exercisers after adjustment for differences in pill type distribution between groups. Women using progestin-dominant pills had significantly lower plasma triglyceride and high-density lipoprotein concentrations and significantly higher low-density/high-density lipoprotein ratios compared with women using estrogen/progestin-balanced pills. As body fat was significantly associated with both pill type and physical activity, it is unclear how much of these lipoprotein differences were due to body fat, exercise, or pill use. Regular physical activity together with reduced body fat partially compensated for plasma lipoprotein differences associated with oral contraceptive use.

The effects of weight loss by exercise or by dieting on plasma high-density lipoprotein (HDL) levels in men with low, intermediate, and normal-to-high HDL at baseline.

To assess whether baseline plasma high-density lipoprotein (HDL) cholesterol levels affected the HDL response to weight loss, we examined lipoprotein changes in overweight men aged 30 to 59 years who were randomized to lose weight by exercise training (primarily running, n = 46) or by caloric restriction (ie, dieting, n = 42) or to remain sedentary, nondieting controls (n = 42) in a 1-year study. In exercisers, absolute increases in HDL (mg/dL) were greatest in men with normal-to-high baseline HDL and least in men with low baseline HDL. Specifically, when divided into groups of low (< or = 37 mg/dL), intermediate (38 to 47 mg/dL), and normal-to-high HDL cholesterol (> or = 48 mg/dL) at baseline, the exercisers increased HDL cholesterol by 2.3 +/- 1.9, 4.9 +/- 1.1, and 7.0 +/- 1.3 mg/dL, respectively; HDL2 cholesterol by 0.8 +/- 1.6, 2.3 +/- 1.2, and 5.1 +/- 1.3 mg/dL; and HDL2 mass by 2.8 +/- 5.1, 9.5 +/- 8.9, and 31.7 +/- 11.0 mg/dL. Relative increases in HDL cholesterol were more similar in the low (7.1% +/- 6.1%), intermediate (12.4% +/- 3.9%), and normal-to-high men (13.2% +/- 4.0%). Regression analyses were performed to assess whether baseline HDL cholesterol was related to the amount of absolute HDL change per unit of weight loss. In exercisers, the increase in HDL3 cholesterol concentrations was significantly greater in men with low HDL than in those with normal-to-high HDL at entry (2.0 +/- 0.8 v 0.2 +/- 0.8 mg/dL per kg/m2 lost).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of weight-loss by exercise and by diet on apolipoproteins A-I and A-II and the particle-size distribution of high-density lipoproteins in men.

We studied separately the effects of weight-loss by dieting or by running on apolipoprotein (apo) A-I, apo A-II, and high-density lipoprotein (HDL) subfractions in sedentary, moderately overweight men assigned at random into three groups: exercise without calorie restriction, calorie restriction without exercise, and control. The absorbance of protein-stained polyacrylamide gradient gels was used as an index of mass concentrations for five HDL subclasses that have been identified by their particle sizes: HDL3c (7.2 to 7.8 nm), HDL3b (7.8 to 8.2 nm), HDL3a (8.2 to 8.8 nm), HDL2a (8.8 to 9.7 nm), and HDL2b (9.7 to 12.9 nm). During the 1-year trial, the exercisers ran (mean +/- SD) 15.6 +/- 9.1 km/wk, and the dieters reported eating 340 +/- 71 fewer calories per day than at baseline. Total body weight and fat weight were both reduced significantly more in dieters (-7.2 +/- 4.1 and -6.2 +/- 4.1 kg, respectively) and in exercisers (-4.0 +/- 3.9 and -4.6 +/- 3.5 kg) than in controls (0.6 +/- 3.7 and -0.7 +/- 2.7 kg). As compared with mean changes in controls, exercisers and dieters each decreased HDL3b and increased HDL2b. Exercisers also significantly increased plasma apo A-I concentrations. Analysis of covariance was used to statistically adjust the mean lipoprotein changes for the effects of weight-loss. The adjustment eliminated the significant reductions in HDL3b and the significant increases in HDL2b in exercisers and dieters, and it eliminated the significant increase in apo A-I in exercisers. When adjusted, the dieters' mean changes in HDL2b had significantly decreased relative to those of both exercisers and controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of low-fat diet, calorie restriction, and running on lipoprotein subfraction concentrations in moderately overweight men.

We studied the effects of exercise (primarily running), calorie restriction (dieting), and a low-fat, high-carbohydrate diet on changes in lipoprotein subfractions in moderately overweight men in a randomized controlled clinical trial. After 1 year, complete data were obtained for 39 men assigned to lose weight through dieting without exercise, 37 men assigned to lose weight through dieting with exercise (primarily running), and 40 nondieting sedentary controls. We instructed both diet groups to consume no more than 30% total fat, 10% saturated fat, and 300 mg/d of cholesterol, and at least 55% carbohydrates, and the controls were instructed to maintain their usual food choices. Analytic ultracentrifugation was used to measure changes in plasma lipoprotein mass concentrations. In addition, the absorbance of protein-stained polyacrylamide gradient gels was used as an index of concentrations for five high-density lipoprotein (HDL) subclasses that have been identified by their particle sizes, ie, HDL3c (7.2 to 7.8 nm), HDL3b (7.8 to 8.2 nm), HDL3a (8.2 to 8.8 nm), HDL2a (8.8 to 9.7 nm), and HDL2b (9.7 to 12 nm). Relative to controls, weight decreased significantly in men who dieted with exercise (net difference +/- SE, -3.3 +/- 0.4 kg/m2) and in men who dieted without exercise (-2.0 +/- 0.4 kg/m2). Dieting with exercise significantly decreased very-low-density lipoprotein (VLDL)-mass concentrations and significantly increased plasma HDL2-mass, HDL3a, HDL2a, and HDL2b relative to both control and dieting without exercise. There were no significant changes in lipoprotein mass and HDL protein for dieters who did not run.(ABSTRACT TRUNCATED AT 250 WORDS)

The associations of high-density lipoprotein subclasses with insulin and glucose levels, physical activity, resting heart rate, and regional adiposity in men with coronary artery disease: the Stanford Coronary Risk Intervention Project baseline survey.

We used nondenaturing polyacrylamide gradient gel electrophoresis to examine the associations of high-density lipoprotein (HDL) subclasses with adiposity, physical activity, resting heart rate (an indicator of sympathetic drive), and plasma insulin and glucose levels in 97 men with angiographically documented coronary artery disease. These men neither smoked nor used medications known to affect lipoproteins. The absorbency of protein stain was used as an index of mass concentrations at intervals of 0.01 nm within five HDL subclasses: HDL3c (7.2 to 7.8 nm), HDL3b (7.8 to 8.2 nm), HDL3a (8.2 to 8.8 nm), HDL2a (8.8 to 9.7 nm), and HDL2b (9.7 to 12 nm). HDL peak diameter was determined from the predominant peak of the HDL particle distribution when plotted against particle diameter. Four men who were non-insulin-dependent diabetics as defined by a fasting glucose exceeding 140 mg/dL had significantly higher plasma HDL3b levels and significantly smaller HDL peak diameters than nondiabetic men, and were therefore excluded from further analyses. In the remaining 93 nondiabetic men, plasma HDL3b levels correlated positively with indices of truncal obesity (waist to hip ratio and subscapular skinfold), whereas plasma HDL2b levels correlated negatively with indices of total adiposity (body mass index [BMI]) and truncal obesity (subscapular and abdominal skinfold). Fasting plasma insulin levels correlated negatively with HDL3a, HDL2a, and HDL2b. Obesity significantly affected the relationships of resting heart rate with insulin and HDL subclasses.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipoprotein subfractions of runners and sedentary men.

Serum concentrations of lipoprotein mass by flotation rate were measured in 12 long-distance runners and 64 sedentary men by analytic ultracentrifugation. The runners had significantly lower serum mass concentrations of the smaller, denser low-density lipoprotein particles of flotation rates Sf 0-7 (including the LDL-II, LDL-III, and LDL-IV subspecies), very-low-density lipoprotein (VLDL) particles of Sf 20-400, and high-density lipoprotein (HDL) particles of flotation rates F1.20 0-1.5 (predominantly the HDL3 subspecies), and higher serum mass concentrations of HDL particles with flotation rates between F1.20 2.0-9.0 (including HDL2a and HDL2b and less dense particles belonging to HDL3) than did sedentary men. Lipoprotein lipase activity was higher, and hepatic lipase activity was lower in runners than in the sedentary men. Thus, the effects of endurance exercise training to lower LDL may be specific to the smaller, denser LDL particle region. Similarities in the lipoprotein mass profiles of the runners and the low-risk profiles of sedentary, middle-aged women suggest the effects of common metabolic factors possibly leading to reduced risk of coronary artery disease.

Anal and cervical human papillomavirus infection and risk of anal and cervical epithelial abnormalities in human immunodeficiency virus-infected women.

OBJECTIVE: To determine the prevalence of anal and cervical infection with human papillomavirus (HPV) and cytologic abnormalities and to examine the relation among HPV infection, cytologic abnormalities, and human immunodeficiency virus (HIV) serostatus. METHODS: Anal and cervical Papanicolaou tests, HPV dot blot tests, and polymerase chain reaction (PCR) tests for HPV were performed concurrently in a cross-sectional study of 114 women enrolled in a community-based study of HIV infection. RESULTS: Cervical HPV infection was associated with HIV serostatus by both dot blot (odds ratio [OR] 4.2, 95% confidence interval [CI] 1-25) and PCR (OR 8.9, 95% CI 3.2-27). Anal HPV infection was twice as frequent as cervical and also was associated with HIV by dot blot (OR 2.5, 95% CI 0.9-7) and PCR (OR 2.6, 95% CI 1.03-6.8). Eleven percent (11 of 96) of cervical cytologies were abnormal and were associated with HIV (OR 6.1, 95% CI 1.2-60.5). Fourteen percent (15 of 109) of anal cytologies were abnormal and were associated with HIV (OR 3.4, 95% CI 0.9-15.5). Among HIV-seropositive women, epithelial abnormalities were associated with lower mean CD4+ cell counts when HPV DNA was detected by dot blot at either the cervix (P = .04) or anus (P = .009). Independent predictors for cervical epithelial abnormalities were HPV DNA positivity by dot blot (OR 32.1, 95% CI 2.9-353.9) and positive HIV serostatus with CD4+ cell count below 250 cells/mm3 (OR 126.8, 95% CI 7.5-2132.6). CONCLUSIONS: Human papillomavirus-associated epithelial abnormalities are associated with immune suppression among HIV-infected women. Anal HPV infection and disease is at least as common as cervical infection and disease among HIV-seropositive women.

Physician supply and access to care in urban communities.

This paper uses an analysis of survey data from urban Californians to determine whether patients' reports of access to care were associated with physician supply. On unadjusted analyses, higher levels of physician supply were associated with better access to care. However, this association was no longer apparent after adjusting for underlying population characteristics such as insurance status, income, and race/ethnicity. Poorer access to care in communities with lower physician supply appeared to be explained mainly by lack of health insurance and other population characteristics rather than by physician supply. We conclude that a more geographically equitable distribution of physicians in urban areas is unlikely to compensate for an inegalitarian system of health insurance.

Medicaid managed care's impact on safety-net clinics in California.

A growing percentage of Medicaid patients are receiving medical care within a managed care system. This policy change has raised concerns about whether safety-net providers can maintain their share of Medi-Cal (California Medicaid) patients. From 1995 to 1997 several of California's counties implemented mandatory Medi-Cal managed care. The majority of California's safety-net primary care clinics experienced a decline in the percentage of their patients insured by Medi-Cal. However, after the overall decline in the number of Medi-Cal beneficiaries was controlled for, the increased penetration of Medi-Cal managed care in a county was not independently associated with a decline in clinics' share of Medi-Cal patients. Despite this fact, it may become increasingly difficult for clinics to maintain their current level of services with declining Medi-Cal enrollment and other anticipated reforms in their funding.

Independent practice association physician groups in California.

We surveyed independent practice association (IPA) physician groups in California about their approaches to staffing, physician payment, and governance. Most IPAs desired more primary care physicians but not more specialists. Capitation was the major mode of remuneration for primary care physicians in 77 percent of IPAs, and for specialists in 30 percent of IPAs. Most IPAs also used financial incentives related to use of referral or ancillary services. Boards of directors were dominated by physicians, but governance tended to be centralized rather than highly democratic. We found that IPAs mirror many of the broader trends in physician staffing and physician payment that exist in managed care organizations.

Measuring the need for medical care in an ethnically diverse population.

OBJECTIVE: To examine measures of need for health care and their relationship to utilization of health services in different racial and ethnic groups in California. DATA SOURCE: Telephone interviews obtained by random-digit dialing and conducted between April 1993 and July 1993 in California, with 7,264 adults (ages 18-64): 601 African Americans, 246 Asians, 917 Latinos interviewed in English; 1,045 Latinos interviewed in Spanish; and 4,437 non-Latino whites. STUDY DESIGN: A cross-sectional survey was conducted from a stratified, probability telephone sample. DATA COLLECTION: Interviews collected self-reported indicators of need for health care: self-rated health, activity limitation, major chronic conditions, need for ongoing treatment, bed days, and prescription medication. The outcome was self-reported number of physician visits in the previous three months. PRINCIPAL FINDINGS: Compared to whites, one or more of the other ethnic groups varied significantly (p < .05) on each of the six need-for-care measures after adjustment for health insurance, age, sex, and income. Latinos interviewed in Spanish reported lower percentages and means on five of the need measures but the highest percentage with fair or poor health (32 percent versus 7 percent in whites). Models regressing each need measure on the number of outpatient visits found significant interactions of ethnic group with need compared to whites. After adjustment for insurance and demographics, the estimated mean number of visits in those with the indicator of need was consistently lower in Latinos interviewed in Spanish, but the differences among the other ethnic groups varied depending on the measure used. CONCLUSION: No single valid estimate of the relationship between need for health care and outpatient visits was found for any of the six indicators across ethnic groups. Applying need adjustment to the use of health care services without regard for ethnic variability may lead to biased conclusions about utilization.

Charges for obstetric liability insurance and discontinuation of obstetric practice in New York.

BACKGROUND: The study objective was to determine whether New York physicians facing higher charges for obstetric liability insurance coverage are more likely to discontinue obstetric practice than physicians experiencing lower levels of increases in liability insurance charges. METHODS: We performed a physician-level analysis of factors predicting discontinuation of hospital-based obstetric practice by 1989 for physicians active in obstetrics in 1980. We examined both physicians who became completely clinically inactive in New York between 1980 and 1989, and physicians who remained clinically active but restricted their hospital practice to areas other than obstetrics. Multiple logistic regression models were used to analyze predictors of discontinuation of obstetrics, including regional malpractice insurance charges, physician characteristics, and practice characteristics. RESULTS: Although increases in malpractice insurance charges differed considerably among regions within New York State, there was no association between level of increase of charges for liability insurance and discontinuation of obstetric practice. A greater number of years since medical licensure was associated both with complete discontinuation of hospital practice in New York and selective discontinuation of obstetrical practice. Compared with obstetrician-gynecologists, family physicians were less likely to become completely clinically inactive. Among physicians who remained clinically active in hospital care, however, family physicians were less likely than obstetrician-gynecologists to continue to include obstetrics in their practice. CONCLUSIONS: There is no relationship between the level of increase in liability insurance premiums and the likelihood of discontinuing obstetric practice in New York. Discontinuation of obstetric practice appears to mainly reflect trends in the physician's life cycle of practice activity and in the scope of family and general practice.