Primary cesarean section rates in uninsured, Medicaid and insured populations of predominantly rural northern New England.

Many studies in the United States during the past two decades have reported consistently lower cesarean section rates in women of lower socioeconomic status as defined by census tract, insurance status, or maternal level of educational attainment. This study sought to determine whether cesarean section rates in predominantly rural northern New England are lower for lower, compared with higher socioeconomic groups, as they are reported nationally and in more urban areas. Age-adjusted, primary cesarean section rates for privately insured, Medicaid and uninsured women were calculated using 1990 to 1992 uniform hospital discharge data for Maine, New Hampshire and Vermont. Age-adjusted cesarean section rates for insured women (15.71 percent) were significantly higher than those for Medicaid (14.35 percent) and uninsured (12.85 percent) women. These differences in the cesarean section rate between the insured and poorer populations in northern New England are much less than those reported elsewhere in the country.

Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis.

BACKGROUND: Population-based variations in rates of operations for the treatment of lumbar disc herniation and spinal stenosis are well known. This variability may occur in part because of differences in the threshold at which physicians recommend an operation, reflecting uncertainty about the optimum use of an operative procedure. To the best of our knowledge, no previous reports have indicated whether differences in population-based rates of operative treatment are associated with patient outcomes. METHODS: The Maine Lumbar Spine Study is an ongoing prospective study of 655 patients who had a herniated lumbar disc or spinal stenosis. The patients were enrolled by their physicians, who provided baseline demographic and treatment-related data. The patients completed baseline and follow-up questionnaires that focused on symptoms, function, satisfaction, and quality of life. Small-area variation analysis was used to develop three distinct so-called spine service areas in Maine. The outcomes (usually at four years; minimum, two years) were compared among these areas, in which a total of 250 patients had been managed operatively and had answered questionnaires. RESULTS: Population-based rates of operative treatment derived from statewide data that had been collected over five years in the state of Maine ranged from 38 percent below to 72 percent above the average rate in the state (a greater than fourfold difference). The outcomes for the patients who had been managed by surgeons in the lowest-rate area were superior to those for the patients in the two higher-rate areas. Seventy-nine percent (fifty-seven) of seventy-two patients in the lowest-rate area had marked or complete relief of pain in the lower extremity compared with 60 percent (eighteen) of thirty patients in the highest-rate area. The improvements in the Roland disability score (p < or = 0.01), quality of life (p < or = 0.01), and satisfaction (p < or = 0.05) were significantly greater among the patients in the lowest-rate area. The patients in the higher-rate areas generally had less severe symptoms and findings at baseline than those in the lowest-rate area did. CONCLUSIONS: Higher population-based rates of elective spinal operations may be associated with inferior outcomes. This variability is possibly related to differences in physicians' preferences with regard to recommending an operation and in their criteria for the selection of patients. Physicians cannot assume that their outcomes will be the same as those of others, and therefore they need to evaluate their own results.

Maine Carpal Tunnel Study: small area variations.

As is the case for all elective procedures, small area variations occur in rates of surgery for carpal tunnel syndrome. A 1993 analysis of Maine data demonstrates that carpal tunnel release rates across population-based service areas varied 3.5-fold, from 0.82 to 2.87 per thousand. Four areas had rates significantly higher and 2 were significantly lower than the state average of 1.44 per thousand. Among many potential factors influencing variations, physician practice patterns appear to be the major contributor.

Changing physician behavior: the Maine Medical Assessment Foundation.

Methods to produce change in physician practice patterns are of increasing importance to payers and regulators as well as to physicians themselves. Because some of the strategies being adopted occur without physician input and participation, they have aroused concern in the medical community. We describe the methods used and results achieved by the Maine Medical Assessment Foundation, a nonprofit education and research organization, that has been active in practice pattern analysis since the late 1970s. The foundation has successfully engaged clinicians in a program of systematic assessment of medical care provided to residents of Maine. Significant change in practice patterns has been documented. Physicians have become active participants in the process of voluntary self-assessment, education, and quality improvement.

Do physicians do what they say? The inclination to test and its association with coronary angiography rates.

OBJECTIVE: Efforts to evaluate variations in cardiac procedures have focused on patient factors and differences in health care delivery systems. We wanted to assess how physicians' inclination to test patients with coronary artery disease influences utilization patterns. SETTING AND SUBJECTS: Physicians and the populations of Maine, New Hampshire, and Vermont. DESIGN: We conducted a survey of 263 family practitioners, internists, and cardiologists residing in 57 hospital service areas in Maine, New Hampshire, and Vermont. Using patient scenarios, we assessed the clinicians' inclinations to test during the evaluation of patients with coronary artery disease. Self-reported testing intensities were used to create three indices: a Catheterization Index, an Imaging Exercise Tolerance Test (ETT) Index, and Nonimaging ETT Index. Using administrative data, age- and gender-adjusted population-based coronary angiography rates were calculated. Physicians were assigned to low (2.9/1,000), average (4.2/1,000), and high (5.8/1,000) coronary angiography rate areas, based on where they practice. Analysis of variance techniques were used to assess the relation of the index scores to the population-based coronary angiography rates and to physician specialties. RESULTS: There was a positive relationship between the population-based coronary angiography rates and the self-reported scores of the Catheterization Index (p < .005) and the Imaging ETT Index (p = .01), but none was found for the Non-imaging ETT Index (p = .10). These relationships were evident in subanalyses of cardiologists and internists, but not of family practitioners. CONCLUSIONS: Self-reported testing intensity by physicians is related to the population-based rates of coronary angiography. This relationship cuts across specialties, suggesting that there is a "medical signature" for the evaluation of patients with coronary artery disease.

Dealing with geographic variations in the use of hospitals. The experience of the Maine Medical Assessment Foundation Orthopaedic Study Group.

Orthopaedists and other physicians in Maine organized the Maine Medical Assessment Foundation to deal with the problem of variations in the rates of hospitalization for orthopaedic conditions. Five musculoskeletal injuries and five orthopaedic procedures were selected for study. The variation in decision-making by orthopaedists was least for fractures of the ankle and fractures of the hip and was greatest for fractures of the forearm, derangement of the knee, and lumbosacral sprain. The rates in an area tended to be consistently high or low for the same treatments. The major reasons for the variations appeared to be related to lack of agreement about optimum treatment. Feedback of data to physicians on variations in patterns of practice reduced the variations.

Informed inquiry into practice variations: the Maine Medical Assessment Foundation.

This paper reports on the development of a successful physician organized and driven medical assessment program, the Maine Medical Assessment Foundation. Responding to the issues and challenges presented by practice pattern variation in the state of Maine, eight physician specialty study groups have been developed in the state over the past ten years. Working in a confidential, educational, non-regulatory format, study groups have had remarkable success in providing feedback of epidemiologic data on area variations to practitioners. This process has succeeded in modifying practice patterns, resulting in marked improvements in quality of care and decreases in apparently excessive utilization of health care resources. Simultaneously, physicians have become supporters of the process of small area analysis and they have joined in community based outcomes research projects. This successful program can be a model for other areas.

Estimating hospital costs by diagnosis for population-based analysis.

Knowledge of cost or charge for a discharge with a specified diagnosis to a given hospital is a prerequisite for population-based analysis of acute hospital utilization. As this information is not usually available directly for all discharges of residents of a geographical area, estimates are required. We compared alternative estimates derived from the data being assembled in many states--from hospital discharge data systems and routine cost and statistical reports. The independent variables were the name of the hospital, its total inpatient costs, and the diagnosis and length of stay for each discharge. We verified our estimates with data from Maine, for which charges were also available for many discharges. The estimate that used all three of the variables from the discharge data bank was most accurate. It explained 77.3 percent of the variability in hospital average charges per case for eight representative diagnoses. A simpler estimate, not requiring knowledge of diagnosis, proved almost as accurate. This estimate, defined as the product of cost per day for a hospital times length of stay for a case, explained 76.1 percent of the variability in individual charges per case, and 91.9 percent of the variability in average cost per case. Thus, per capita expenditures on hospital care for any diagnosis, and for inpatient care in total, can be estimated reliably by combining information from discharge data banks with routinely reported hospital per diem costs.