Visit length in pediatric primary care: lessons from a pilot study.

As business drivers create pressure to see more patients in a given period, there is no reliable guidance regarding the optimal allocation of resources in ambulatory visits. Many pediatric primary clinics set appointment lengths in increments of "five minutes." Defining the appointment lengths for potentially longer visits by arbitrary increments (e.g., twice the time for an acute visit) is a common "experiential" scheme. However, how much additional time is really needed if the patient is new to practice or when the visit is arranged for preventive services is unknown. Identifying the misallocation of clinic resources is fundamental because misallocation reduces access for patients and increases practice costs. In this study, using a time-motion approach, we examined the characteristics of 372 visits in a pediatric primary care clinic.

Recurrent genomic gains in preinvasive lesions as a biomarker of risk for lung cancer.

Lung carcinoma development is accompanied by field changes that may have diagnostic significance. We have previously shown the importance of chromosomal aneusomy in lung cancer progression. Here, we tested whether genomic gains in six specific loci, TP63 on 3q28, EGFR on 7p12, MYC on 8q24, 5p15.2, and centromeric regions for chromosomes 3 (CEP3) and 6 (CEP6), may provide further value in the prediction of lung cancer. Bronchial biopsy specimens were obtained by LIFE bronchoscopy from 70 subjects (27 with prevalent lung cancers and 43 individuals without lung cancer). Twenty six biopsies were read as moderate dysplasia, 21 as severe dysplasia and 23 as carcinoma in situ (CIS). Four-micron paraffin sections were submitted to a 4-target FISH assay (LAVysion, Abbott Molecular) and reprobed for TP63 and CEP 3 sequences. Spot counts were obtained in 30-50 nuclei per specimen for each probe. Increased gene copy number in 4 of the 6 probes was associated with increased risk of being diagnosed with lung cancer both in unadjusted analyses (odds ratio = 11, p<0.05) and adjusted for histology grade (odds ratio = 17, p<0.05). The most informative 4 probes were TP63, MYC, CEP3 and CEP6. The combination of these 4 probes offered a sensitivity of 82% for lung cancer and a specificity of 58%. These results indicate that specific cytogenetic alterations present in preinvasive lung lesions are closely associated with the diagnosis of lung cancer and may therefore have value in assessing lung cancer risk.

Expected value prioritization of prompts and reminders.

Computer-based prompting and reminder systems have been shown to be highly effective in increasing rates of preventive services delivery. However, there are many more recommended preventive services than can be practically included in a typical clinic visit. Therefore prioritization of preventive services prompts is necessary. We describe two approaches to prioritizing preventive services prompts based on expected value decision making. One method involves a static, global prioritization across all preventive services and has been used in a production system for almost 7 years. The second method uses influence diagrams to prioritize prompts dynamically, based on individual patient data. The latter approach is still under development. Both methods are labor intensive and require a combination of epidemiologic data and expert judgment. Compromises in strictly normative process were necessary to achieve user satisfaction.