Impact of a Usual Source of Care on Health Care Use, Spending, and Quality Among Adults With Mental Health Conditions.

Physical comorbidities associated with mental health conditions contribute to high health care costs. This study examined the impact of having a usual source of care (USC) for physical health on health care utilization, spending, and quality for adults with a mental health condition using Medicaid administrative data. Having a USC decreased the probability of inpatient admissions and readmissions. It decreased expenditures on emergency department visits for physical health, 30-day readmissions, and behavioral health inpatient admissions. It also had a positive effect on several quality measures. Results underscore the importance of a USC for physical health and integrated care for adults with mental health conditions.

Factors that Affect Choice of Mental Health Provider and Receipt of Outpatient Mental Health Treatment.

According to the US Department of Health and Human Services, 91 million adults live in mental health professional shortage areas and 10 million individuals have serious mental illness (SMI). This study examines how the supply of psychiatrists, severity of mental illness, out-of-pocket costs, and health insurance type influence patients' decisions to receive treatment and the type of provider chosen. Analyses using 2012-2013 MarketScan Commercial Claims data showed that patients residing in an area with few psychiatrists per capita had a higher predicted probability of not receiving follow-up care (46.4%) compared with patients residing in an area with more psychiatrists per capita (42.5%), and those in low-psychiatrist-supply areas had a higher predicted probability of receiving prescription medication only (10.2 vs 7.6%). Patients with SMI were more likely than those without SMI to obtain treatment. A $25 increase in out-of-pocket costs had marginal impact on patients' treatment choices.

Effect of Having a Usual Source of Care on Health Care Outcomes Among Children With Serious Emotional Disturbance.

OBJECTIVE: To determine the influence of a usual source of care (USC) on health care utilization, expenditures, and quality for Medicaid-insured children and adolescents with a serious emotional disturbance (SED). METHODS: Administrative claims data for 2011-2012 were extracted from the Truven Health MarketScan Multi-State Medicaid Research Database for 286,585 children and adolescents with a primary diagnosis of SED. We used propensity score-adjusted multivariate regressions to determine whether having a USC had a significant effect on utilization and expenditures for high-cost services that are considered potentially avoidable with appropriate outpatient care: physical and behavioral health inpatient admissions, emergency department (ED) visits, and hospital readmissions. RESULTS: Propensity score-adjusted regressions indicated that children with a USC had fewer inpatient admissions related to behavioral health (adjusted odds ratio [AOR] = 0.87; 95% confidence interval [CI], 0.79-0.97) and physical health (AOR = 0.91; 95% CI, 0.89-0.93) and lower expenditures for behavioral health inpatient admissions, physical health ED visits, and readmissions. Having a USC also was associated with a higher likelihood of receiving quality health care for 4 physical health and 2 behavioral health measures. CONCLUSIONS: Having a USC improved the health care of Medicaid-insured children and adolescents with an SED. However, despite having insurance, approximately one-fourth of this patient population did not appear to have a USC. This information can be used in developing programs that encourage connections with comprehensive health care that provides coordination among various providers.

Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study.

OBJECTIVE: The objective of this study was to compare international trends in pre-eclampsia rates and in overall pregnancy hypertension rates (including gestational hypertension, pre-eclampsia and eclampsia). DESIGN: Population data (from birth and/or hospital records) on all women giving birth were available from Australia (two states), Canada (Alberta), Denmark, Norway, Scotland, Sweden and the USA (Massachusetts) for a minimum of 6 years from 1997 to 2007. All countries used the 10th revision of the International Classification of Diseases, except Massachusetts which used the 9th revision. There were no major changes to the diagnostic criteria or methods of data collection in any country during the study period. Population characteristics as well as rates of pregnancy hypertension and pre-eclampsia were compared. RESULTS: Absolute rates varied across the populations as follows: pregnancy hypertension (3.6% to 9.1%), pre-eclampsia (1.4% to 4.0%) and early-onset pre-eclampsia (0.3% to 0.7%). Pregnancy hypertension and/or pre-eclampsia rates declined over time in most populations. This was unexpected given that factors associated with pregnancy hypertension such as pre-pregnancy obesity and maternal age are generally increasing. However, there was also a downward shift in gestational age with fewer pregnancies reaching 40 weeks. CONCLUSION: The rate of pregnancy hypertension and pre-eclampsia decreased in northern Europe and Australia from 1997 to 2007, but increased in Massachusetts. The use of a different International Classification of Diseases coding version in Massachusetts may contribute to the difference in trend. Elective delivery prior to the due date is the most likely explanation for the decrease observed in Europe and Australia. Also, the use of interventions that reduce the risk of pregnancy hypertension and/or progression to pre-eclampsia (low-dose aspirin, calcium supplementation and early delivery for mild hypertension) may have contributed to the decline.

Sleep following alcohol intoxication in healthy, young adults: effects of sex and family history of alcoholism.

BACKGROUND: This study evaluated sex and family history of alcoholism as moderators of subjective ratings of sleepiness/sleep quality and polysomnography (PSG) following alcohol intoxication in healthy, young adults. METHODS: Ninety-three healthy adults [mean age 24.4 ± 2.7 years, 59 women, 29 subjects with a positive family history of alcoholism (FH+)] were recruited. After screening PSG, participants consumed alcohol (sex/weight adjusted dosing) to intoxication [peak breath alcohol concentration (BrAC) of 0.11 ± 0.01 g% for men and women] or matching placebo between 20:30 and 22:00 hours. Sleep was monitored using PSG between 23:00 and 07:00 hours. Participants completed the Stanford Sleepiness Scale and Karolinska Sleepiness Scale at bedtime and on awakening and a validated post-sleep questionnaire. RESULTS: Following alcohol, total sleep time, sleep efficiency, nighttime awakenings, and wake after sleep onset were more disrupted in women than men, with no differences by family history status. Alcohol reduced sleep onset latency, sleep efficiency, and rapid eye movement sleep while increasing wakefulness and slow wave sleep across the entire night compared with placebo. Alcohol also generally increased sleep consolidation in the first half of the night, but decreased it during the second half. Sleepiness ratings were higher following alcohol, particularly in women at bedtime. Morning sleep quality ratings were lower following alcohol than placebo. CONCLUSIONS: Alcohol intoxication increases subjective sleepiness and disrupts sleep objectively more in healthy women than in men, with no differences evident by family history of alcoholism status. Evaluating moderators of alcohol effects on sleep may provide insight into the role of sleep in problem drinking.

Tracking abnormal cervical cancer screening: evaluation of an EMR-based intervention.

INTRODUCTION: System level barriers have been associated with inadequate follow-up of abnormal cervical cytology. OBJECTIVE: The aim of this study was to develop and evaluate an electronic tracking system to improve follow-up of abnormal Pap tests. PROGRAM DESCRIPTION: We implemented an electronic medical record (EMR)-based Pap test tracking system at two clinical practices at an inner-city academic health center. The system generated a provider-specific monthly report of all abnormal Pap results, and provided a patient-specific Pap tracking table embedded in the EMR for each subject. EVALUATION: We compared abnormal Pap test follow-up rates for the 24 months pre-intervention with rates 12 months following its implementation (post-intervention). The evaluation followed all subjects for 12 months from the date of their abnormal Pap test, looking for diagnostic resolution. RESULTS: Subjects were young women (mean age = 30.5) of primarily white (42%) and African American (37%) descent, who spoke English (88%). Forty-eight percent were insured through publicly subsidized insurance. Controlling for type of abnormality and practice location, the adjusted mean time to resolution decreased significantly from 108 days (confidence interval, CI 105-112 days) in the pre-intervention period to 86 days (CI 81-91 days). CONCLUSION: Our study cannot demonstrate that with follow up, we directly avoided cases of invasive cervical cancer. However, we show that in an at-risk urban population, an automated, EMR-based tracking system reduced the time to resolution, and increased the number of women who achieved diagnostic resolution.

Predictors of timely follow-up after abnormal cancer screening among women seeking care at urban community health centers.

BACKGROUND: We sought to measure time and identify predictors of timely follow-up among a cohort of racially/ethnically diverse inner city women with breast and cervical cancer screening abnormalities. METHODS: Eligible women had an abnormality detected on a mammogram or Papanicolaou (Pap) test between January 2004 and December 2005 in 1 of 6 community health centers in Boston, Massachusetts. Retrospective chart review allowed us to measure time to diagnostic resolution. We used Cox proportional hazards models to develop predictive models for timely resolution (defined as definitive diagnostic services completed within 180 days from index abnormality). RESULTS: Among 523 women with mammography abnormalities and 474 women with Pap test abnormalities, >90% achieved diagnostic resolution within 12 months. Median time to resolution was longer for Pap test than for mammography abnormalities (85 vs 27 days). Site of care, rather than any sociodemographic characteristic of individuals, including race/ethnicity, was the only significant predictor of timely follow-up for both mammogram and Pap test abnormalities. CONCLUSIONS: Site-specific community-based interventions may be the most effective interventions to reduce cancer health disparities when addressing the needs of underserved populations.

Towards equitable access to medicines for the rural poor: analyses of insurance claims reveal rural pharmacy initiative triggers price competition in Kyrgyzstan.

BACKGROUND: A rural pharmacy initiative (RPI) designed to increase access to medicines in rural Kyrgyzstan created a network of 12 pharmacies using a revolving drug fund mechanism in 12 villages where no pharmacies previously existed. The objective of this study was to determine if the establishment of the RPI resulted in the unforeseen benefit of triggering medicine price competition in pre-existing (non-RPI) private pharmacies located in the region. METHODS: We conducted descriptive and multivariate analyses on medicine insurance claims data from Kyrgyzstan's Mandatory Health Insurance Fund for the Jumgal District of Naryn Province from October 2003 to December 2007. We compared average quarterly medicine prices in competitor pharmacies before and after the introduction of the rural pharmacy initiative in October 2004 to determine the RPI impact on price competition. RESULTS: Descriptive analyses suggest competitors reacted to RPI prices for 21 of 30 (70%) medicines. Competitor medicine prices from the quarter before RPI introduction to the end of the study period decreased for 17 of 30 (57%) medicines, increased for 4 of 30 (13%) medicines, and remained unchanged for 9 of 30 (30%) medicines. Among the 9 competitor medicines with unchanged prices, five initially decreased in price but later reverted back to baseline prices. Multivariate analyses on 19 medicines that met sample size criteria confirm these findings. Fourteen of these 19 (74%) competitor medicines changed significantly in price from the quarter before RPI introduction to the quarter after RPI introduction, with 9 of 19 (47%) decreasing in price and 5 of 19 (26%) increasing in price. CONCLUSIONS: The RPI served as a market driver, spurring competition in medicine prices in competitor pharmacies, even when they were located in different villages. Initiatives designed to increase equitable access to medicines in rural regions of developing and transitional countries should consider the potential to leverage medicine price competition as a means of achieving their goal. Evaluations of interventions to increase rural access to medicines should include impact assessment on both formal and informal pharmaceutical markets.

Treatment of tracheal tumors.

The evidence for the treatment of tracheal tumors rests on a small number of single-institution series, national surveys, and epidemiologic studies. From this evidence, the following observations have been made: tracheal tumors are rare and must be identified among a much larger number of metastatic malignant tracheal lesions; most tracheal tumors are malignant; most tracheal tumors in selected series are resectable; and survival after resection exceeds survival after nonoperative treatment, even if resection margins are close. A discussion of evaluation and treatment of these tumors in this review proceeds along a systematic series of questions.

Administrative claims analysis of utilization and costs of care in health plan members with atopic dermatitis who had prior use of a topical corticosteroid and who initiate therapy with pimecrolimus or tacrolimus.

BACKGROUND: In the United States, pimecrolimus cream and tacrolimus ointment are approved as second-line therapy for short-term and intermittent noncontinuous long-term treatment of atopic dermatitis (AD) in nonimmunocompromised patients aged 2 years or older who have failed to respond adequately to other topical prescription treatments (e.g., topical corticosteroids), or when those treatments are not advisable; pimecrolimus is indicated for mild to- moderate AD and tacrolimus for moderate-to-severe AD. Comparative data on the effects of pimecrolimus versus tacrolimus on AD-related health care utilization and costs among similar patients seen in typical clinical practice are currently unavailable. OBJECTIVE: To compare utilization and costs of AD-related medical care in health plan members with AD who had prior use of a topical corticosteroid and who subsequently initiate therapy with pimecrolimus cream or tacrolimus ointment. METHODS: This was an observational, retrospective study using an administrative claims database with dates of service from August 1, 2000, through October 31, 2003, and representing approximately 2.5 million members in health maintenance organizations, preferred provider organizations, and Medicare and Medicaid plans mostly located in the cities of Chicago, Kansas City, and Phoenix and in the states of Kentucky, Florida, and Texas. The study sample included all members with 1 or more pharmacy claims for a topical corticosteroid and a diagnosis of AD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 691.XX (excluding 691.0X), or 692.XX (excluding 692.0X-692.8X)] who subsequently had 1 or more pharmacy claims for pimecrolimus or tacrolimus. AD-related utilization and medical care costs (plan payments plus member cost share) over 12 months of follow-up were compared between the pimecrolimus and tacrolimus groups. Because information on disease severity was not available in the administrative claims data, propensity matching was used to control for differences between groups in baseline demographic and clinical characteristics and pretreatment utilization of AD-related medical care services. RESULTS: Before matching, compared with the tacrolimus group (n = 197), members in the pimecrolimus group (n = 197) were older (mean age of 38 vs. 32 years, P = 0.022), had fewer topical corticosteroid pharmacy claims (mean 2.08 vs. 3.01, P = 0.002), and had fewer grams of corticosteroids dispensed (mean 132 vs. 193, P = 0.029) in the 12 months prior to treatment. After matching, there were 157 members in each group with no statistically significant differences in pretreatment characteristics. During the 12-month follow-up period, the mean (median) number of pharmacy claims was 1.8 (1.0) for pimecrolimus versus 2.0 (1.0) for tacrolimus and the mean (median) grams of study medication were 102 (60) and 105 (60), respectively. Members in the pimecrolimus group received a lower average number of prescriptions for any topical corticosteroids (1.37 vs. 2.04, P = 0.021) and for high-potency topical corticosteroids (0.61 vs. 1.04, P = 0.023) and were less likely to initiate alternative therapy (5% vs. 17%, P <0.001) or receive antistaphylococcal antibiotics (16% vs. 27%, P = 0.014). Members in the pimecrolimus group had lower average (median) AD-related expenditures (75% to 78% attributable to AD drug cost) compared with matched tacrolimus members ($263 [$270] vs. $361 [$398], P = 0.012). CONCLUSIONS: In health plan members with AD who had previously received at least 1 topical corticosteroid prescription, the customary use of pimecrolimus or tacrolimus was 1 to 2 prescriptions in 12 months of followup and only a median of 60 grams of topical medication. The difference in AD-related utilization and costs between pimecrolimus and tacrolimus was small, less than $100 per year, but favored pimecrolimus. Further research using validated measures of disease severity to control for potential confounding is needed to confirm the results of this observational study.

Uncommon primary tracheal tumors.

BACKGROUND: Primary tracheal tumors other than adenoid cystic or squamous cell carcinoma are uncommon and have a heterogeneous histologic appearance. The experience regarding their treatment and long-term outcome is limited, and alternatives to segmental tracheal resection, including endoscopic treatment or radiation, continue to be explored. METHODS: A retrospective analysis was performed of uncommon tracheal tumors among 360 primary tracheal tumors seen over 40 years, excluding adenoid cystic and squamous cell carcinoma. RESULTS: Of 90 patients, 34 (38%) had benign tumors and 56 malignant: 11 carcinoid tumors, 14 mucoepidermoid carcinomas, 13 sarcomas, 15 nonsquamous bronchogenic carcinomas, 2 lymphomas, and 1 melanoma. Three patients had a second tracheal malignancy. Dyspnea was the most common symptom in benign tumors and hemoptysis in malignant tumors. Twelve patients did not undergo tracheal resection (13.3%) and 1 died before resection. Surgical therapy in 77 patients (85%) consisted of laryngectomy in 3, laryngotracheal resection in 9, tracheal resection in 46, and carinal resection in 19. Hospital mortality was 2.6% (2 of 77 patients) and major complications occurred in 16% (12 of 77 patients). Mean follow-up was 9.7 years. After resection, survival at 10 years was 94% for benign and 83% for carcinoid tumors, and at 5 years survival was 60% for bronchogenic carcinoma, 100% for mucoepidermoid tumors, and 78% for sarcomas. Patients with lymphomas and melanoma are alive more than 8 years after resection. Ten patients experienced recurrence (14%). CONCLUSIONS: Surgical resection of uncommon primary tracheal tumors alleviates airway obstruction, is curative in patients with benign or slow-growing malignant lesions, and prolongs survival in highly malignant lesions.

Data withholding in genetics and the other life sciences: prevalences and predictors.

PURPOSE: To better understand the variety and prevalence of data withholding in genetics and the other life sciences and to explore factors associated with these behaviors. METHOD: In 2000, a sample of 2,893 geneticists and other life scientists (OLS) at the 100 most research-intensive universities in the United States were surveyed concerning data withholding and sharing. The instrument was developed and pretested in 1999. The two primary outcome measures were withholding in verbal exchanges with colleagues about unpublished research (verbal withholding) and withholding as part of the publishing process (publishing withholding). The independent variables related to the personal characteristics, research characteristics of faculty, and previous experience with data withholding. RESULTS: A total of 1,849 faculty responded (64%): 1,240 geneticists and 600 OLS. Forty-four percent of geneticists and 32% of OLS reported participating in any one of 13 forms of data withholding in the three previous years. Publishing withholding (geneticists 35%, OLS 25%) was more frequent than verbal withholding (geneticists 23%, OLS 12%). In multivariate analyses, male gender, participation in relationships with industry, mentors' discouraging data sharing, receipt of formal instruction in data sharing, and negative past experience with sharing were significantly associated with either verbal or publishing withholding among either geneticists or OLS. CONCLUSIONS: Data withholding is common in biomedical science, takes multiple forms, is influenced by a variety of characteristics of investigators and their training, and varies by field of science. Encouraging openness during the formative experiences of young investigators may be critical to increased data sharing, but the effects of formal training do not appear straightforward.

Perceived preparedness to provide preventive counseling: reports of graduating primary care residents at academic health centers.

OBJECTIVE: To assess the perceived preparedness of residents in adult primary care specialties to counsel patients about preventive care and psychosocial issues. DESIGN: Cross-sectional national mail survey of residents (63% response rate). PARTICIPANTS: Nine hundred twenty-eight final-year primary care residents in Internal Medicine (IM), family practice (FP), and Obstetrics/Gynecology (OB/GYN) at 162 U.S. academic health centers. MEASUREMENTS: Residents self-rated preparedness to counsel patients about smoking, diet and exercise, substance abuse, domestic violence, and depression. RESULTS: Residents felt better prepared to counsel about smoking (62%) and diet and exercise (53%) than about depression (37%), substance abuse (36%), or domestic violence (21%). In most areas, females felt better prepared than males. Rates of counseling preparedness varied significantly by specialty after adjustment for gender, race, medical school location, and percent of training spent in ambulatory settings. FP residents felt better prepared than OB/GYN residents to counsel about smoking, diet and exercise, and depression, while OB/GYN residents felt better prepared to address domestic violence than IM or FP residents. IM residents' perceptions of preparedness were between the other 2 specialties. Proportion of training spent in ambulatory settings was not associated with residents' perceived preparedness. CONCLUSIONS: Physicians completing residencies in adult primary care did not feel very well prepared to counsel patients about preventive and psychosocial issues. Significant differences exist among specialties, even after adjusting for differences in time spent in ambulatory settings. Increasing residency time in ambulatory settings may not alone be sufficient to ensure that residents emerge with adequate counseling skills.

Laryngotracheoplastic resection for primary tumors of the proximal airway.

BACKGROUND: Primary tumors of the airway with proximity to vocal cords and recurrent laryngeal nerves can be resected with sparing of the larynx. Long-term data on survival and local recurrence after laryngotracheal resection are scarce. METHODS: We conducted a retrospective study of laryngotracheal resection and reconstruction for primary tumors of the airway since 1972. RESULTS: Twenty-five patients aged 15 to 77 years presented with adenoid cystic carcinomas (n = 9), squamous cell carcinomas (n = 6), and other airway tumors (n = 10). Subglottic resection consisted of anterior cricoid in 5 patients; posterior cricoid mucosa in 9 patients, with resection of the posterior cricoid plate in 3 patients; lateral resection in 7 patients; and combined anterior and posterior elements in 4 patients. Vascularized trachea was tailored to reconstruct the defect. Seven patients without hoarseness required resection of the recurrent laryngeal nerve, and 4 other patients with hoarseness did not. There were no operative deaths. Two (8.0%) patients who had received prior high-dose cervical radiation had anastomotic separation, one requiring laryngectomy. One patient needed permanent tracheostomy, and temporary (<2 months) airway tubes were used in 5 patients. Sixteen patients received postoperative radiation. Median follow-up was 101 months. Four (16%) patients died of disease. Overall survival at 5 and 10 years was 79% and 64%, respectively. No patient underwent laryngectomy for recurrence. CONCLUSION: Laryngotracheal resection and immediate reconstruction for subglottic tumors is achieved with good preservation of voice, low morbidity, and no compromise of long-term survival.

Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina.

BACKGROUND: Tracheal resection for primary carcinoma may extend survival. We evaluated survival after surgical resection or palliative therapy to identify prognostic factors. METHODS: We conducted a retrospective study of patients diagnosed with primary adenoid cystic carcinoma (ACC) or squamous cell carcinoma (SCC) of the trachea between 1962 and 2002. Laryngotracheal, tracheal, or carinal resection was performed when distant metastasis and invasion of adjacent mediastinal structures were absent and tumor length permitted. Radiotherapy was administered after operation (54 Gy), except in superficial tumors, or as palliation (60 Gy). RESULTS: Of 270 patients with ACC or SCC (135 each), 191 (71%) were resected. Seventy-nine were not resected due to tumor length (67%), regional extent (24%), distant metastasis (7%), or other reasons (2%). Overall operative mortality was 7.3% (14/191) and improved each decade from 21% to 3%. Tumor in airway margins was present in 40% (17/191) of resected patients (ACC 59% versus SCC 18%) and lymph node metastasis in 19.4% (37/191). Overall 5- and 10-year survival in resected ACC was 52% and 29% (unresectable 33% and 10%) and in resected SCC 39% and 18% (unresectable 7.3% and 4.9%). Multivariate analysis of long-term survival found statistically significant associations with complete resection (p < 0.05), negative airway margins (p < 0.05), and adenoid cystic histology (p < 0.001), but not with tumor length, lymph node status, or type of resection. CONCLUSIONS: Locoregional, not distant, disease determines resectability in primary tracheal carcinoma. Resection of trachea or carina is associated with long-term survival superior to palliative therapy, particularly for patients with complete resection, negative airway margins, and ACC.

Statewide evaluation of youth access ordinances in practice: effects of the implementation of community-level regulations in Massachusetts.

The objectives of the study described in this article were to test whether community-level youth access ordinances reduce adolescents' perceived access to tobacco, purchase attempts, and tobacco use. A telephone survey was performed of a random sample of 3,831 Massachusetts adolescents linked to a database of all town-level youth access ordinances in the state. Respondents' perceived ease of access to tobacco, attempts to purchase tobacco, and tobacco use (ever smoking and current [past 30-day] smoking) were assessed. The association of these outcomes with the characteristics of youth access ordinances in the respondents' town of residence (n = 314) was tested in multilevel analyses that included town-level clustering, controlled for multiple individual and environmental characteristics, including a measure of community-level anti-smoking sentiment. Community-level youth access ordinances were not associated with adolescents' perceived access to tobacco, purchase attempts, or tobacco use, with two exceptions: (1) banning free-standing displays was associated with a 40% reduction in perceived access to tobacco (OR = 0.6; 95% CI, 0.4-0.9) and (2) a vending machine ban was associated a 30% higher report of perceived access to tobacco (OR = 1.3; 95% CI, 1.1-1.5). This study found no consistent associations between community-level youth access ordinances and adolescents' perceived access to tobacco, purchase attempts, or smoking prevalence.

Limits to the safety net: teaching hospital faculty report on their patients' access to care.

Many major teaching hospitals might not be able to offer adequate access to specialty care for uninsured patients. This study found that medical school faculty were more likely to have difficulty obtaining specialty services for uninsured than for privately insured patients. These gaps in access were similar in magnitude for public and private institutions. Initial treatment of uninsured patients at academic health centers (AHCs) does not guarantee access to specialty and other referral services, which suggests that there are limits to relying on a health care safety net for uninsured patients. AHCs and affiliated group practices should examine policies that limit access for uninsured patients.

Preparedness of internal medicine and family practice residents for treating common conditions.

CONTEXT: Although both internal medicine (IM) and family practice (FP) physicians frequently provide care for the same common adult conditions, IM and FP residency programs differ in their training emphases. OBJECTIVE: To assess differences in IM and FP residents' self-perceived preparedness to diagnose and treat common adult medical conditions. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of a national survey administered in the spring of 1998 to residents in their final year of residency at US academic health centers. A total of 279 IM residents in 25 programs and 326 FP residents in 75 programs responded to the survey. MAIN OUTCOME MEASURES: Residents' self-rated preparedness to diagnose and treat 4 inpatient conditions (acute myocardial infarction, diabetic ketoacidosis, acute asthma, and acute renal failure) and 8 outpatient conditions (diabetes, hypertension, low back pain, vaginitis, headache, depression, upper respiratory tract infection, and hyperlipidemia), controlling for resident sex, race/ethnicity, US medical school graduate status, intent to subspecialize, and estimates of exposure to patients in inpatient and outpatient settings. RESULTS: Internal medicine residents were more likely to report being very prepared for all 4 inpatient conditions (P< or =.001), while FP residents were more likely to report being very prepared for 5 of 8 outpatient conditions (P< or =.05). Differences between IM and FP residents persisted in multivariate analyses for all inpatient conditions and some outpatient conditions. Exposure to patients in inpatient and outpatient settings varied by specialty and was significantly associated with resident self-report of preparedness for a majority of conditions investigated. CONCLUSIONS: Internal medicine and FP residents report differences in preparedness to manage common adult conditions. These differences were consistent with the emphasis on an inpatient setting for IM residents and on office-based care for FP residents.

Data withholding in academic genetics: evidence from a national survey.

CONTEXT: The free and open sharing of information, data, and materials regarding published research is vital to the replication of published results, the efficient advancement of science, and the education of students. Yet in daily practice, the ideal of free sharing is often breached. OBJECTIVE: To understand the nature, extent, and consequences of data withholding in academic genetics. DESIGN, SETTING, AND PARTICIPANTS: Mailed survey (March-July 2000) of geneticists and other life scientists in the 100 US universities that received the most funding from the National Institutes of Health in 1998. Of a potential 3000 respondents, 2893 were eligible and 1849 responded, yielding an overall response rate of 64%. We analyzed a subsample of 1240 self-identified geneticists and made a limited number of comparisons with 600 self-identified nongeneticists. MAIN OUTCOME MEASURES: Percentage of faculty who made requests for data that were denied; percentage of respondents who denied requests; influences on and consequences of withholding data; and changes over time in perceived willingness to share data. RESULTS: Forty-seven percent of geneticists who asked other faculty for additional information, data, or materials regarding published research reported that at least 1 of their requests had been denied in the preceding 3 years. Ten percent of all postpublication requests for additional information were denied. Because they were denied access to data, 28% of geneticists reported that they had been unable to confirm published research. Twelve percent said that in the previous 3 years, they had denied another academician's request for data concerning published results. Among geneticists who said they had intentionally withheld data regarding their published work, 80% reported that it required too much effort to produce the materials or information; 64%, that they were protecting the ability of a graduate student, postdoctoral fellow, or junior faculty member to publish; and 53%, that they were protecting their own ability to publish. Thirty-five percent of geneticists said that sharing had decreased during the last decade; 14%, that sharing had increased. Geneticists were as likely as other life scientists to deny others' requests (odds ratio [OR], 1.39; 95% confidence interval [CI], 0.81-2.40) and to have their own requests denied (OR, 0.97; 95% CI, 0.69-1.40). However, other life scientists were less likely to report that withholding had a negative impact on their own research as well as their field of research. CONCLUSIONS: Data withholding occurs in academic genetics and it affects essential scientific activities such as the ability to confirm published results. Lack of resources and issues of scientific priority may play an important role in scientists' decisions to withhold data, materials, and information from other academic geneticists.