Practice variation in physician referral for allogeneic hematopoietic cell transplantation.

Hematological malignancy patients not referred by their primary hematologist/medical oncologist suffer disparate access to allogeneic hematopoietic cell transplantation (HCT). However, investigation into physician, system and patient factors relevant to this decision making is lacking. We surveyed a national randomized sample of practicing hematologists/medical oncologists identified through the AMA (American Medical Association) masterfile. A modified Dillman approach was utilized to encourage survey response. From 1200 surveyed, a total of 113 physicians responded. In all, 68% were male, 62% identified as White/non-Hispanic, 79% practiced in non-academic settings and 80% reported spending 75-100% of their professional effort in clinical care. Using clinical vignettes, we detected significantly increased odds for HCT non-referral according to age (age 60 vs 30, odds ratio (OR) 8.3, 95% confidence interval (CI): 5.9-11.7, P<0.0001), insurance coverage (no coverage vs coverage, OR 6.9, 95% CI: 5.2-9.1, P<0.0001) and race (African-American vs Caucasian, OR 2.4, 95% CI: 1.9-2.9, P<0.0001). Physician (perception of HCT risks), system (insurance coverage) and patient (age, social support and co-morbid illness) factors were strongly endorsed by respondents as important determinants of their HCT referral practices. These data speak to important factors relevant to HCT referral practices, and highlight several opportunities for education and intervention to reduce current disparities.

Vice president Al Gore's health care agenda and the utilization of medical services: An empirical analysis.

OBJECTIVE: To estimate the impact of Vice President Al Gore's healthcare agenda on the utilization of physician and hospital services among 4 uninsured target populations: parents of publicly insured children; near elderly adults, ages 55-64; employed adults with disabilities; and adults employed in small firms or self-employed. METHODS: From the 1993 National Health Interview Survey, we select 4 representative samples of uninsured adults, ages 18-64, corresponding to the target groups described in Gore's healthcare agenda. For each adult in these samples, we estimate the change in medical service utilization caused by becoming insured using results from Craig and Ko.[1] The weighted average of these estimates represents the expected change in medical service utilization attributable to insurance. RESULTS: The increase in the utilization caused by insurance depends on the target group and the service in question. The increase in utilization of physician visits is 16% among parents of publicly insured children, 37% among the near elderly, 8% among the employed, disabled adults, and 21% among the self-employed. This effect is small compared with the increase in surgical procedures (31%, 110%, 316%, and 101%, respectively). However, given the size of the US healthcare system, this amounts to about a 0.5% increase in the production of medical services. Even if a universal coverage plan were instated in place of Gore's incremental coverage plan, production would increase by about 2%. CONCLUSIONS: Points 2 through 5 of Vice President Al Gore's healthcare agenda have an impact on the utilization of medical care by the 4 target populations. However, this impact varies by service and population, and its system-wide impact on the production of care is minor.

The assessment of platelet derived growth factor concentration in post myocardial infarction and stable angina patients.

Platelet derived growth factor (PDGF) has been implicated in the pathogenesis of atherosclerosis. PDGF is released by aggregating platelets and monocytes which gather around sites of arterial injury. In the study reported here the concentration of plasma PDGF was measured in post myocardial infarction (MI) patients (n = 28), angina patients (n = 25), and control subjects (n = 27). Venous blood samples were taken and the concentration of PDGF determined by an enzyme linked immunosorbent assay (ELISA). Plasma PDGF concentrations were significantly higher in the post MI group compared to both the control and angina groups (P < or = 0.05). The increase in PDGF concentration may be due to increased activation of platelets or monocytes since these two cells are major sources of plasma PDGF. High concentrations of PDGF in the circulation could further accelerate the progression of the disease.