Dyspepsia consulters and patterns of management: a population-based study.

BACKGROUND: Although dyspepsia is common, management patterns in the United States are unknown. AIM: To determine the pattern of dyspepsia evaluation and treatment over 20 years in a population-based cohort, and test the hypothesis that the management was influenced by dyspepsia subgroup and gender. METHODS: The validated Bowel Disease Questionnaire was mailed to a random sample of Olmsted County, Minnesota residents (1988-1990). Of the 835 survey respondents, 213 subjects were identified as having dyspepsia according to Rome I Criteria. The medical chart of each dyspeptic subject who had not denied research authorization (n = 206) was reviewed to identify all episodes of care for dyspepsia symptoms 10 years before and 10 years after the date the Bowel Disease Questionnaire was completed. Of these 206 subjects (mean age 47 years, 48% female), 34% had ulcer-like dyspepsia, 32% had dysmotility-like dyspepsia, and 37% had reflux-like dyspepsia. RESULTS: Nearly half (n = 98, 48%) had episodes of care for dyspepsia symptoms over 20 years. Of these 98 subjects, 49% had upper gastrointestinal endoscopy, 4% motility studies and 12% were tested for Helicobacter pylori. At the first visit of the episode of care closest to Bowel Disease Questionnaire completion, 72% were seen in primary care, 16% in emergency medicine and 2% in gastroenterology. In addition, 13% were referred to gastroenterology clinic within this episode. During the study period, 70% were given an 'acid' diagnosis, 7% a 'motility' diagnosis and 54% a 'functional' diagnosis; 78% received acid suppression agents (28% proton pump inhibitors), 18% psychotropic agents and 7% prokinetic agents. No significant association was found between gender and test usage, specialty referral or type of treatment, although women were three times less likely to receive proton pump inhibitors (odds ratio 3.3, 95% CI: 1.2-9.1). Symptom severity, frequency and pattern were risk factors for health care seeking in dyspepsia. CONCLUSIONS: Delivery of care for dyspepsia was similar among dyspepsia subgroups and in men and women.

The patient's perspective of irritable bowel syndrome.

OBJECTIVE: The researchers wanted to understand how irritable bowel syndrome (IBS) affects patients' lives and their interactions with physicians and the health care system. STUDY DESIGN: A qualitative study was performed using focus groups of people with physician-diagnosed IBS. Immersion/crystallization was used to identify overriding themes. POPULATION: Adult volunteers with a previous physician diagnosis of IBS were included. OUTCOMES MEASURED: The outcomes were patient-reported symptoms, episode triggers, treatments, lifestyle changes, and interactions with their physicians that were related to IBS, and overriding themes identified from the focus groups. RESULTS: The subjects described IBS as a chronic episodic illness that affects their daily lives. Interaction with the medical community seldom clarified understanding of the condition or improved its management. Three overriding themes emerged from the groups: a sense of frustration, a sense of isolation, and a search for a niche in the health/sick role continuum. Frustration was evident in the perceived inability to control symptoms, prevent episodes, identify episode triggers, and obtain medical validation of the condition. The constant anticipation of the next IBS episode, the need for immediate access to toilet facilities, and the nature of the bowel symptoms often required withdrawal from social activities and resultant isolation. CONCLUSIONS: IBS is perceived as a chronic condition resulting in frustration and social isolation, and physicians are perceived to be providing inadequate medical information or support to patients with IBS.

Do rural and urban children have comparable asthma care utilization?

This study compares asthma-related health care visits and drug therapy for rural and nonrural Kentucky children with Medicaid health insurance in 1995. The 8,634 children with asthma had a mean age of 5.7 years. Ninety-two percent made at least one asthma office visit, and 13 percent were hospitalized. The urban and rural patterns of care for childhood asthma varied in some potentially important ways. Urban children were twice as likely as rural children to see an asthma specialist (5 percent vs. 2.5 percent, P < 0.05), 2.7 times as likely to receive asthma care in an emergency department (19 percent vs. 7 percent, P < 0.01) and 1.4 times as likely to receive oral steroids (16 percent vs. 12 percent, P = 0.04). If given inhaled anti-inflammatory medication, rural children were more likely to receive inhaled steroids while urban children were more likely to receive cromoglycates.

Ovarian carcinoma: care and survival in a community-based population.

BACKGROUND: Previous studies of the management and costs of ovarian cancer have been based on data from oncology practices. Such studies may exclude patients who are not candidates for treatment and may not account for costs incurred during diagnosis or primary treatment. OBJECTIVE: The purpose of this study was to describe the epidemiology, management, and costs of care of ovarian cancer in a geographically defined population to better reflect the total spectrum of the disease and its care. METHODS: We conducted a retrospective review of the medical records of all residents of Olmsted County, Minnesota, who received a first diagnosis of epithelial ovarian carcinoma (including postmortem diagnoses) between 1985 and 1997. RESULTS: Of the 107 women with a new diagnosis of ovarian cacinoma, 42 (39%) had stage I or II tumors at the time of diagnosis. The mean age of the patients at the time of diagnosis was 64.7 years, and 20% were nulliparous. The diagnostic assessment for ovarian carcinoma was initiated by a family physician or internist in 50% of cases and by an obstetrician or gynecologist in 16% of cases. One hundred two patients (95%) underwent surgical treatment, and 80 (75%) received primary chemotherapy. The 5-year survival rate was 88% in those with stage I or II tumors and 17% in those with stage III or IV tumors. The mean charges for secondary care were higher than those for primary care ($36,110 vs $32,367; P < 0.05) in those receiving both types of therapy. Fifty percent of those dying of ovarian cancer received hospice care for a mean of 39.0 days before death. CONCLUSIONS: Most assessments leading to a diagnosis of ovarian carcinoma were initiated by primary care physicians. In this community-based population, early-stage and low-grade tumors were common (> or = 30%) and were associated with lower costs of care and higher 5-year survival rates. Total treatment costs for those requiring secondary therapy were approximately twice the costs for those requiring primary treatment only, with approximately 50% of costs associated with inpatient care.

Change in diagnosis among orthopedists compared to non-orthopedists in the management of acute knee injuries.

OBJECTIVE: Uncertainty regarding diagnosis is associated with lower patient satisfaction and can lead to delays in definitive treatment and to inappropriate use of resources. We sought to compare change in diagnosis among orthopedists and non-orthopedists caring for a community based cohort of individuals with incident acute knee injuries. METHODS: We conducted a longitudinal investigation of a population based cohort of Olmsted County residents with their first episode of acute knee injury occurring between January 1, 1993, and December 31, 1995. We reviewed the entire (inpatient and outpatient) medical records for these patients and collected extensive clinical data on all diagnoses made (including possible and probable) and the specialty of the attending physician(s) making them. Diagnoses were categorized as: (1) meniscus injury, cruciate injury, or osteochondral fracture; (2) ligament injury, patellar instability, patellar injury; or (3) sprain, strain, injury (unspecified). Diagnostic switches were defined as changes from one diagnostic category to another, or the addition or subtraction of a diagnostic category. We then examined the quality of the documented evidence supporting meniscal, ligamentous, and cruciate diagnoses (at initial evaluation) by comparing the clinical evidence to the recommendations outlined by the American Academy of Orthopaedic Surgeons clinical algorithm on acute knee injury. Analyses were conducted comparing (1) the number of diagnostic switches and (2) the quality of the documented evidence among those cases initially cared for by orthopedists and those cared for by non-orthopedists, using logistic regression analysis adjusting for age, sex, and injury severity. The influence of these variables on costs of care was also examined. RESULTS: There were 664 patients (361 men and 303 women) in our study population, with an average age of 36.0 years (minimum 17, maximum 87). Of these, 324 were excluded because they only had one clinical encounter for their acute knee injury. Of the remaining 340, 59 (17.4%) were initially cared for by an orthopedist and 211 (62.1%) were cared for by an orthopedist at some time during their care. Diagnostic switches were significantly less frequent in the group who were cared for by orthopedists (55% vs 74%, p < 0.001). This result persisted after adjusting for age, sex, and severity (p = 0.003). The proportion of cases whose diagnoses were supported by evidence was significantly higher among the group whose first attending physician was an orthopedist (63.0% vs 37.6%, p = 0.002). Both change in diagnosis (p < 0.001) and physician specialty (p < 0.001) were statistically significant predictors of costs of care. CONCLUSION: Compared to non-orthopedic care, orthopedic care for acute knee injury was associated with fewer changes in diagnosis, and diagnoses made by orthopedists were more likely to be supported by evidence. However, even after adjusting for severity, orthopedic care remained significantly more costly than non-orthopedic care.

Barriers to immunization in a relatively affluent community.

BACKGROUND: Although Healthy People 2000 calls for the complete immunization of at least 90% of children by age 20 months, few communities can claim such success. We wanted to determine the parent-reported barriers associated with underimmunization of infants in a relatively affluent midwestern population. METHODS: We undertook a case-control study of a population-based sample of parents and guardians of children who were either fully immunized or underimmunized at 20 months of age in Olmsted County, Minn. RESULTS: In this study, 596 of 1,216 parents (46%) of both immunized and underimmunized children participated. Of these participants, 281 (47%) reported barriers to immunizations, but only 15 (3%) reported major barriers. Whereas the most commonly reported barriers were barriers of inconvenience (waiting too long, inconvenient office hours), only delays caused by a sick child, fear of reactions, trouble remembering an appointment, not knowing when the next shot was due, and transportation problems were significantly associated with underimmunization when controlling for demographic factors. Fear of reactions, sick child delays, and not knowing when the next shot was due had the highest attributable risk for underimmunization. Taken together, parent-reported barriers and demographic factors explained less than 30% of the underimmunization status of children. Parents' most common recommendations for improving immunization status were the use of a recall or reminder system and a single unified schedule for immunizations. CONCLUSIONS: In this relatively affluent community, barriers to immunization were commonly reported but few (fear of reactions, sick child delays, and not knowing when the next shot was due) were associated with underimmunization. The types of barriers reported were similar to those reported in other communities, but unlike many populations studied, cost was not reported as an important barrier.

The estimated cost of school scoliosis screening.

STUDY DESIGN: This is a population-based, longitudinal retrospective study of one community's school-based scoliosis screening program. OBJECTIVE: To report the estimated costs of mass school-based screening for scoliosis. SUMMARY OF BACKGROUND DATA: School scoliosis screening has been reported to cost from as little as $0. 06 to as much as $194 per child. The lower estimate considered only the cost to the school, and the higher estimate defined all children with curves of 5 degrees or more as cases. METHODS: School scoliosis screening results were linked with the medical and chiropractic care records of all referred children to identify outcomes and scoliosis-related health service utilization from Grade 5 through graduation or age 19 years. Costs are presented per child screened, per child with a spinal curve of 20 degrees or more, and per child treated for scoliosis and are based on scoliosis-related health care utilization and school costs. RESULTS: Ninety-two (4.1%) of 2197 children screened were referred for further evaluation of possible scoliosis, and 68 (74%) of those had documented evaluation for possible scoliosis. Five of the 92 children referred were treated for scoliosis by age 19. Sixty-six scoliosis-related primary care visits, 79 scoliosis-related orthopedist visits, and 79 full spine radiographs followed referral but preceded treatment. Case-finding costs for screening were $24.66 per child screened (n = 2197), $3, 386.25 per child with a curve of 20 degrees or more (n = 16) and $10, 836.00 per child treated for scoliosis (n = 5). CONCLUSION: School scoliosis screening is significantly more costly than has previously been reported.

The rural health care workforce implications of practice guideline implementation.

BACKGROUND: Rural health care workforce forecasting has not included adjustments for predictable changes in practice patterns, such as the introduction of practice guidelines. PURPOSE: To estimate the impact of a practice guideline for a single health condition on the needs of a rural health professional workforce. METHODS: The current care of a cohort of rural Medicare recipients with diabetes mellitus was compared with the care recommended by a diabetes practice guideline. The additional tests and visits that were needed to comply with the guideline were translated into additional hours of physician services and total physician full-time equivalents. RESULTS: The implementation of a practice guideline for Medicare recipients with diabetes in rural Minnesota would require over 30,000 additional hours of primary care physician services and over 5,000 additional hours of eye care professionals' time per year. This additional need represents a 1.3% to 2.4% increase in the number of primary care physicians and a 1.0% to 6.6% increase in the number of eye-care clinicians in a state in which the rural medical provider to population ratios already meet some recommended workforce projections. CONCLUSIONS: The implementation of practice guidelines could result in an increased need for rural health care physicians or other providers. That increase, caused by guideline implementation, should be accounted for in future rural health care workforce predictions.

Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on health care charges.

BACKGROUND: Asthma is a common and costly condition. Concomitant asthma and allergic rhinitis (AR) have been shown to increase the medication costs for people with asthma. No studies have compared medical care costs of those with and without concomitant AR. OBJECTIVES: We sought to determine the prevalence and incremental medical care costs of concomitant AR. METHODS: For each member of a population-based asthma cohort, we used all their medical charts within Olmsted County to record age at first diagnosis of asthma; the presence and age of any diagnosis of AR; and the total, ambulatory, and respiratory care-related costs of medical care. Costs were compared for age- and sex-specific strata of people with asthma who did and did not have AR. RESULTS: AR was most commonly diagnosed in people whose asthma was diagnosed before age 25 (prevalence of 59%) and uncommonly diagnosed in anyone after age 40 (prevalence <15%). Yearly medical care charges were on average 46% higher for those with asthma and concomitant AR than for persons with asthma alone, controlling for age and sex. We were unable to assess the impact of treatment of AR on medical care charges. CONCLUSIONS: Physicians should consider the diagnosis of AR (prevalence >50%) in all symptomatic children and young adults with asthma. Further evaluation is necessary to evaluate the ability of treatment to decrease the incremental costs of AR in persons with asthma.

Identifying persons with diabetes using Medicare claims data.

The objective of this study was to develop and validate a method for identifying Medicare beneficiaries with diabetes by using Medicare claims data. We used self-reports of diabetes status from participants in the Medicare Current Beneficiary Survey to determine disease status, and then we examined these participants' Medicare claims. Using self-reported diabetes status as the "gold standard," we determined the sensitivity, specificity, and reliability of claims data in identifying beneficiaries with diabetes. We found that to construct a method that is adequately sensitive (> or = 70%), highly specific (> or = 97.5%), and reliable (kappa > or = 0.80), researchers must combine information from different types of Medicare claims files, use 2 years of data to identify cases, and require at least 2 diagnoses of diabetes among claims involving ambulatory care. Since these criteria are met by more than one method, the choice of method should be governed by the goals of the research as well as more practical concerns.

Barriers to seeking care following school vision screening in Rochester, Minnesota.

School vision screening provides an effective way to identify children who require vision therapy, usually glasses. To benefit from screening, children with abnormal screening test results must receive follow-up eye care, but care may be delayed for months or years. This project used community focus groups in Rochester, Minn., to identify barriers that may delay seeking professional care following school vision screening. Major barriers identified included lack of community awareness about the frequency and potential effect of refractive errors in children, a parental perception of inadequate communication between schools and the parents and community, high cost of corrective lenses, limited availability of convenient eye care appointments, and adolescents reluctance to wear glasses. Program planners developed a community action plan to address the perceived barriers.

Barriers to prenatal care: factors associated with late initiation of care in a middle-class midwestern community.

BACKGROUND: Barriers to prenatal care have been extensively investigated in low-income and inner-city communities. Less attention has been directed to the study of prenatal care among middle- and upper-class pregnant women. This study describes perceived barriers and factors associated with late initiation of prenatal care in a predominantly middle- to upper-class midwestern community. METHODS: Consenting women in Olmsted County, Minnesota, who were attending a clinic for their first obstetric visit completed a self-administered questionnaire that queried the presence of factors making it difficult to receive prenatal care, perception about the importance of prenatal care, expectations at the first prenatal care visit, and sociodemographic factors. RESULTS: Of the 813 women aged 14 to 47 years, 692 (86%) had their first prenatal visit within the first trimester of pregnancy. Only 98 (12%) women reported external barriers to receiving prenatal care. These factors included difficulty in getting an appointment (46.9%), problems finding child care (26.5%), and lack of transportation (14.3%). In multivariable logistic regression analyses, late initiation of care was associated with patient perception of prenatal care as being less than very important (odds ratio [OR] = 4.1, 95% confidence interval [CI], 1.7-9.7); external barriers to prenatal care (OR = 2.9, 95% CI, 1.6-5.4); annual income < $17,000 (OR = 2.9, 95% CI, 1.5-5.7); and an unintended pregnancy (OR = 2.1, 95% CI, 1.3-3.5). Multiparous women and women older than 35 years were more likely to perceive prenatal care as less than very important (OR = 3.9, 95% CI, 2.5-14.6 and OR = 2.9, 95% CI, 1.2-6.8, respectively). CONCLUSIONS: These findings suggest that perceptions about the importance of prenatal care may play a greater role in the initiation of care among this group of women than is recognized. Women with more experience with pregnancy appear to place slightly less importance on prenatal care.

The impact of a simulated immunization registry on perceived childhood immunization status.

We developed a simulated immunization registry to assess the impact on the perceived immunization status in a population-based sample of 2-year-olds living in Olmsted County, MN, in 1995. We compiled records of all immunizations by abstracting immunization data from all medical care facilities in the county. The data collected from each facility were analyzed separately to provide the immunization rate as perceived by each facility. This perceived rate was compared to the rate obtained by combining all recorded immunizations from all facilities (simulated registry). Information on children not receiving any carefrom facilities in Olmsted County was compiled from birth certificate data and community school lists. Data from the simulated registry indicated that 69.1% of all children in Olmsted County with medical records were up-to-date on their immunizations by 20 months of age. By 24 months, this increased to 74.2%. The immunization rate of 24-month-old children recorded at individual healthcare facilities in Olmsted County ranged from 24.3% to 79.5%. The addition of data from the simulated registry increased the immunization rate at each site: a 27.7% relative increase in the site with the lowest recorded immunization rate, a 14.0% increase in the site with the intermediate immunization rate, and a 6.9% increase in the site with the highest internally perceived immunization rate. The registry also identified excess immunizations in 5% of the county's 2-year-olds. Each healthcare facility in this community gained an immediate benefit from the development of a simulated immunization registry. This immediate improvement in one quality-of-care measure (up-to-date immunization rate) should be factored into the cost/benefit assessment of immunization registries.

Community impact of childhood varicella infections.

OBJECTIVES: To assess age-specific incidence rates, health care utilization, and lost parental work associated with varicella infection in a population-based cohort of children, and to validate parent-reported health care utilization data. STUDY DESIGN: We conducted a telephone survey of a population-based cohort of 4557 households with children aged birth to 13 years. Medical chart abstraction was used to validate health care utilization information. RESULTS: We report varicella incidence rates in preschool children that are 2 to 2.5 times higher than previous studies. Rates of varicella-related serious complications, hospitalizations, parental work leave, and medication use are comparable with rates reported elsewhere. However, health provider visits occurred only 0.3 to 0.5 times as frequently as estimated in other studies. One hundred percent of reported hospitalizations and serious complications and 92% of provider visits were validated to be within the study time frame through medical chart audits. CONCLUSIONS: Parents are an accurate source of varicella-related health care utilization data. Parent-reported incidence data indicate that varicella infections are increasing in preschool children. This shift to infections in younger children may be related to the increased use of out-of-home care for infants and young children. Furthermore, the shift may after the community burden of varicella because of the observed increased parental work loss and decreased frequency of health care visits in the preschool children.

Rural enrollment in MinnesotaCare.

Many rural Americans remain underserved and uninsured. Attempts to initiate national health care reform and universal health insurance coverage have stalled. The impetus to continue reform and universal coverage efforts has shifted back to the state level. Minnesota's health reform efforts resulted in the 1992 MinnesotaCare legislation, which included a subsidized insurance program. As of October 21, 1995, a total of 91,140 people were enrolled in MinnesotaCare. Enrollees are found in every county in the state and represent approximately 2.1% of Minnesota's total population and 2.4% of the state's population under age 65. Estimates of Minnesotans who are uninsured and therefore potentially eligible for this subsidized insurance plan range from 6% to 13%. MinnesotaCare enrollment estimates vary from a high of 10.8% of Red Lake County's population who are under age 65 and report incomes over 100% of the poverty level to a low of 1.5% for similar residents of Nicollet County. Counties with the lowest percentage of MinnesotaCare enrollees are clustered in southern Minnesota, especially the southeastern counties. Those with the highest percentage of enrollees appear to cluster in central Minnesota. MinnesotaCare enrollment is negatively associated with the size of the county's minority population and population density.

The relative community burden of otitis media and varicella.

Otitis media is a common and costly condition of childhood, with a great potential for cost savings from an effective vaccine. We present a population-based survey of the family burden of otitis media and compare it with another common childhood illness, varicella, for which vaccine prevention is available and cost-effective. We report yearly rates of affected children, complications, medication use, hospitalizations, parental work absences, and use of special sick-child day care in a population of 4557 households containing 9047 children younger than 13 years of age. Of the 9047 children in the sample, 26.1% were affected by otitis media in the year of the study; 68% of children in the second year of life had at least one episode. About one third of families lost workdays due to otitis media in their children, with an overall average loss of about 3 hours per affected child. Compared with the community burden of varicella, otitis media involves a greater total burden in terms of the number of affected children, the number of episodes, physician visits, prescription drugs, hospitalizations, and surgical procedures. Work loss was 3.4 times greater per family with a varicella case, but the number of families affected by otitis media was 3.3 times greater than for varicella, so that the total amount of family work loss was about the same for both illnesses for the year. The community burden of otitis media should be studied in a population-based longitudinal manner that includes parental work loss as well as health care costs to accurately determine the potential cost-benefit of prevention programs.

Immunization compliance outside the health plans. A non-HMO report card.

PURPOSE: To assess the rate of completed immunizations by age 24 months in children cared for by a private medical practice. METHODS: A chart review of all children born between January 1, 1990, and June 30, 1992, and seen by a provider in this private medical practice at least once between ages 15 months and 24 months. RESULTS: Overall, 77% of children received four DTP immunizations, 78% received at least three OPV immunizations, and 82% at least one MMR by 24 months of age. Seventy-two percent received the recommended combination of one MMR, three OPV, and four DTP immunizations by age 2. Rates were about 5% to 10% higher in children delivered by physicians of the group practice where the study occurred. The presence of a serious medical problem did not statistically significantly change the rates of completed immunizations. The rate of missed opportunities was almost three times as high in those not completing the basic DTP, OPV, MMR immunization series by age 24 months. CONCLUSIONS: Rates of immunizations are high in this private group practice and comparable to those reported by HMOs that care exclusively for children with insurance. However, the rate of missed opportunities is also high, with three to four visits for each child who did not complete the basic immunization series by age 24 months. This private practice report card will be used to improve immunization practices in our medical group.

Factors associated with appointment keeping in a family practice residency clinic.

BACKGROUND: Failure to keep an appointment not only affects the patient's health care, but also has an impact on the effectiveness and productivity of the medical facility. This study explored patient demographic factors associated with appointment keeping. METHODS: In a Midwestern, urban family practice residency clinic serving 2500 patient visits each month, data were obtained from the computer scheduling system and chart audits for 4669 patients who kept or missed 7283 physician appointments between April and June 1991. Independent variables studied were age, race and ethnicity, type of health insurance, marital status, sex, patient status, day and time of appointment, medical reason for the visit, and geographic proximity to the clinic. RESULTS: The kept-appointment rate for this study was 73.9%. Appointment keeping was associated with age, race and ethnicity, type of health insurance, the day of the appointment, the medical reason for the visit, and geographic proximity to the clinic. Rates of appointment keeping were higher for patients who were older, who were Asian or white, who had private or managed care insurance, who had longer distances to travel to the clinic, and those who had appointments scheduled for the day on which they contacted the clinic. CONCLUSIONS: Several identifiable factors significantly affect whether a patient will keep a clinic appointment. Our findings should be considered in program changes in appointment scheduling and follow-up methods for noncompliant patients.