Cost and Utilization: Hospitalized Patients on a Family Medicine Service.

OBJECTIVES: The cost of hospitalizations contributes to the rising expense of medical care in the United States. Providing health insurance to uninsured Americans is a strategy to reduce these costs, but only if costs for uninsured patients are disproportionately high. This study examined hospitalization use patterns for uninsured patients compared with those with Medicaid and commercial insurance. METHODS: We performed a retrospective chart review to analyze inpatient admissions to a family medicine teaching service in a 290-bed, for-profit community hospital during a 2-year period based on insurance status of the patient. Outcome variables investigated were length of stay, emergency department visits, and readmission rates to the hospital and/or emergency department. Secondary outcome variables were mean charges. RESULTS: A total of 1102 admissions to a family medicine teaching service were evaluated. Length of stay, readmission rates to the hospital and the emergency department after hospital discharge, and average length of stay compared with diagnosis-related groups were significantly higher in the Medicaid population than for insured and uninsured individuals. Variable costs also were significantly higher. CONCLUSIONS: Insurance status was found to be a significant factor in hospital charges and utilization data, with Medicaid patients having the highest costs. This suggests that moving uninsured patients to Medicaid may not significantly reduce hospitalization costs.

Discrepancies in cardiovascular disease risk calculation affect aspirin use recommendations in patients with diabetes.

OBJECTIVES: Aspirin is recommended for cardiovascular disease (CVD) prevention in patients who are at high risk for CVD. The objective of this study was to compare agreement between two American Diabetes Association-endorsed CVD risk calculators in identifying candidates for aspirin therapy. METHODS: Adult patients with diabetes mellitus (n = 238) were studied for 1 year in a family medicine clinic. Risk scores were calculated based on the United Kingdom Prospective Diabetes Study Risk Engine and the Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator. Analyses included χ(2), κ scores, and logistic regressions. RESULTS: The Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator identified 50.4% of patients as high risk versus 23.5% by the United Kingdom Prospective Diabetes Study Risk Engine. κ score for agreement identifying high-risk status was 0.3642. Among patients at high risk, African Americans (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.24-0.86) and those with uncontrolled diabetes (OR 0.30, 95% CI 0.16-0.56) had lower odds of disagreement, whereas nonsmokers had higher odds (OR 2.98, 95% CI 1.57-5.69). Among patients at low risk, women (OR 3.83, 95% CI 1.64-8.91), African Americans (OR 5.96, 95% CI 3.07-11.59), and those with high high-density lipoprotein (OR 2.82, 95% CI 1.48-5.37) showed greater odds of disagreement. CONCLUSIONS: Improved risk assessment methods are needed to identify patients with diabetes mellitus who benefit from aspirin for the primary prevention of CVD. Prospective trials are needed to provide additional evidence for aspirin use in this population.

Teaching quality improvement in a primary care residency.

BACKGROUND: Several organizations emphasize that medical education should include how to improve patient outcomes effectively using quality improvement (QI) methods. In spite of the importance of teaching QI principles, limited literature exists on the implementation and evaluation of these in residency programs. METHODS: The Clinical Scholars Program was established in 1996 to provide residents an opportunity to participate in a scholarly activity. The program, fully integrated into a community-based, university-affiliated family medicine residency program, is currently structured as a longitudinal educational experience, with specific time lines in which all second- and third-year residents are required to participate in and successfully complete a project before graduation. Factors influencing project success are also presented. RESULTS: During the five-year period evaluated, 61 residents completed 53 Scholars projects, 39.6% of which were QI projects. Residents have delivered 86 local presentations, 50 state presentations, 11 national presentations, and 8 international presentations. Nine resident projects have been published in peer-reviewed journals. Factors associated with successful interventions include focus on a topic relevant and common in primary care practice, change in the system of patient care (for example, use of group visits, providing patient education directly to the patient prior to his or her visit), use of the electronic medical record to provide relevant clinical information during office visits, and interdisciplinary team participation in the project. CONCLUSION: This program is an example of the successful integration of scholarly activity and QI education into a residency program. It serves as a potential model for other residency programs to meet the needs of residency training and to promote QI and research in primary care practices.

Dizziness: a diagnostic approach.

Dizziness accounts for an estimated 5 percent of primary care clinic visits. The patient history can generally classify dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness. The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis. Many medications can cause presyncope, and regimens should be assessed in patients with this type of dizziness. Parkinson disease and diabetic neuropathy should be considered with the diagnosis of disequilibrium. Psychiatric disorders, such as depression, anxiety, and hyperventilation syndrome, can cause vague lightheadedness. The differential diagnosis of dizziness can be narrowed with easy-to-perform physical examination tests, including evaluation for nystagmus, the Dix-Hallpike maneuver, and orthostatic blood pressure testing. Laboratory testing and radiography play little role in diagnosis. A final diagnosis is not obtained in about 20 percent of cases. Treatment of vertigo includes the Epley maneuver (canalith repositioning) and vestibular rehabilitation for benign paroxysmal positional vertigo, intratympanic dexamethasone or gentamicin for Meniere disease, and steroids for vestibular neuritis. Orthostatic hypotension that causes presyncope can be treated with alpha agonists, mineralocorticoids, or lifestyle changes. Disequilibrium and lightheadedness can be alleviated by treating the underlying cause.

A limited effect on performance indicators from resident-initiated chart audits and clinical guideline education.

BACKGROUND AND OBJECTIVES: Clinical practice guidelines are useful as tools to reduce variation and improve clinical outcomes in performance-improvement initiatives. The aim of this study is to examine, in a family medicine residency practice, the effect of incorporating education about clinical practice guidelines for specific medical conditions and services on specific quality of care indicators. METHODS: An educational intervention regarding the implementation of clinical practice guidelines and the use of quality indicators for selected disease states or medical services was developed and implemented into a family medicine residency program. Residents completed a review of the records of selected patients who either were affected by the selected medical condition or were eligible for the medical service being provided, before and after participating in a specific seminar addressing guidelines addressing that condition. RESULTS: Based upon the comparison between the chart reviews, some quality indicators significantly improved following the presentations (ie, documentation of oral examination in children and in patients with chronic illnesses, attempts to decrease medications in patients with anxiety disorders, compliance with measuring HgbA1C in patients with diabetes mellitus), while others did not. CONCLUSIONS: The effect of an organized approach through presentation and chart review of specific quality indicators regarding medical problems frequently encountered in family medicine had a modest and inconsistent effect on the practice behaviors of family medicine residents.

Extended- and continuous-cycle oral contraceptives.

Five new oral contraceptives, classified as extended- or continuous-cycle oral contraceptives, have been approved by the United States Food and Drug Administration. These agents have various combinations of estrogen and progestin, and different effects on the length of women's menstrual cycles. Usually they shorten the duration of menses, decrease the frequency of menses to 4 times/year, or completely eliminate menses. These new oral contraceptives are given in the following regimens: 24 days followed by placebo for 4 days (24/4), 84 days followed by placebo for 7 days (84/7), or continuously (without placebo). These agents contain ethinyl estradiol 20 microg-drospirenone 3 mg (24/4); ethinyl estradiol 20 microg-norethindrone 1 mg (24/4); ethinyl estradiol 30 microg-levonorgestrel 150 microg (84/7); ethinyl estradiol 30 microg-levonorgestrel 150 microg (84/7) with very low-dose ethinyl estradiol (10 microg/day) for 7 days; and ethinyl estradiol 20 microg-levonorgestrel 90 microg continuously. Clinical trials have demonstrated that extended- and continuous-cycle oral contraceptives are as effective in preventing pregnancy as traditional oral contraceptives. These new agents also have similar adverse effects; however, the only significantly different adverse effect compared with traditional oral contraceptives in clinical trials was change in bleeding pattern. These oral contraceptives are associated with more breakthrough bleeding and spotting than the traditional pills. Long-term effects on efficacy and safety are not known, as these new products generally have been used for only 1-2 years. Extended- and continuous-cycle oral contraceptives are a new option for women desiring decreased menses or for whom decreased menses may alleviate symptoms of coexisting medical conditions.

Improving anticoagulation therapy using point-of-care testing and a standardized protocol.

PURPOSE: Many patients in primary care require anticoagulation with warfarin for the prevention of venous and systemic embolism. Achieving the goal international normalized ratio (INR) with warfarin is challenging. The purpose of this quality improvement initiative was to increase the proportion of patients taking warfarin with an INR value within the goal range. METHODS: We included all patients identified on an anticoagulation log in the family medicine residency practice during 3 time periods: baseline, after point-of-care (POC) testing was initiated (intervention period 1), and after a standardized warfarin-dosing protocol was implemented (intervention period 2). Educational sessions were conducted during each intervention period. Measures included the frequency of INR monitoring and the percentage of office visits in which patients' values were within the goal INR range. Data were analyzed using descriptive statistics, the Student t test, and the chi2 test. RESULTS: At baseline, patients had an average of 2.6 INR tests performed, and 30.8% were within the INR goal range. Using POC testing, the frequency of monitoring increased to 4.3 INR tests per patient (P = .04), but the percentage of patients within the INR goal remained low at 32.1% (P=.88). When physicians implemented the standardized protocol to guide warfarin dosing, the frequency of testing was similar (3.8 tests per patient), but the percentage of patients within the INR goal increased to 45.9% (P<.04). CONCLUSIONS: POC testing increased the frequency of INR testing, and additional use of a standardized protocol for warfarin dosing increased the percentage of patients within the INR goal range. This model of anticoagulation management could be easily implemented in any family medicine office.

Inpatient care in a community hospital: comparing length of stay and costs among teaching, hospitalist, and community services.

INTRODUCTION: Specific patient care measures and cost of hospitalization are being studied as health care providers and payers are seeking methods to improve the hospital care of patients. This study's purpose was to examine the length of stay and cost of inpatient care by a family medicine teaching service in comparison with the hospitalists' and community physicians' services in the same community hospital. METHODS: We analyzed inpatient admissions to either a family medicine teaching service (FMTS), hospitalist physician group, or the patient's own primary care community physician in a 290-bed, for-profit, community hospital over a 12-month period. Outcome variables investigated included length of stay, fixed costs, variable costs, and readmission rate. RESULTS: A total of 5,453 hospital admissions were analyzed. Patients admitted to the FMTS experienced a significantly shorter length of stay and had significantly lower fixed, variable, and total costs per admission. No significant differences in readmission rates were noted. CONCLUSIONS: The care provided by a teaching service as indicated by length of stay, costs, and readmission rates compared favorably with the care provided by other physicians.

Does a research requirement affect match rates for family medicine residency programs?

BACKGROUND AND OBJECTIVES: The effect of a research requirement on initial Match rates in family medicine has not been previously studied. This study's purpose was to examine the relationship between family medicine residency programs with a research requirement and initial Match rates for those programs in the National Resident Matching Program (NRMP). METHODS: Using information from the American Academy of Family Physicians (AAFP) and the NRMP, program characteristics were obtained, and the 2005 initial and 5-year aggregate Match rates were calculated. The relationship between the presence of a research requirement and fill rates (initial and 5-year aggregate) was analyzed using analysis of variance. To control for variables known to affect Match rates, multivariate analysis was conducted. RESULTS: About one third of residency programs (31.4%) indicated that they have a resident research requirement. No significant difference in the initial Match rates nor the 5-year aggregate was noted between programs with or without a research requirement. The association did not change after controlling for program location, structure, and size of program. CONCLUSIONS: A research requirement in a family medicine residency program does not significantly affect Match rates in the NRMP.

Integration of Clinical Pharmacists in Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: Clinical pharmacists are valued educators and practitioners within family medicine residency programs (FMRPs). Since the last survey of clinical pharmacists within FMRPs, there have been significant advancements to pharmacy education and training as well as growth of interprofessional education and collaborative practice within family medicine. The objective of this study is to describe the integration of clinical pharmacists within FMRPs. METHODS: All 480 Accreditation Council for Graduate Medical Education (ACGME)-approved FMRPs were contacted to identify clinical pharmacists involved with their programs. An electronic survey was distributed to these 253 pharmacists. Questions addressed educational, clinical, scholarly, and administrative activities. RESULTS: Of 396 FMRPs reached, 208 (52.5%) reported 253 clinical pharmacists within their programs. Survey responses were received from 142 (56.1%) pharmacists. Academic appointments in colleges/schools of pharmacy and medicine were held by 105 (75.5%) and 69 (50.0%) respondents, respectively. Eighty-nine (64.0%) pharmacists reported a single source of salary, 19.1% of which received full support from the FMRP. Clinical pharmacists dedicated an average of 50.4% of their overall time to the FMRP, and 14.5% of pharmacists dedicated all of their time to the FMRP. Time within the FMRP was spent on patient care (52.9%), teaching (31.6%), research/scholarship (7.5%), administrative activities (5.9%), and drug dispensing (0.7%). DISCUSSION: Prevalence of clinical pharmacists within FMRPs has increased since 2000, from 27.9% to 52.5%. However, the amount of time dedicated to the FMRPs has decreased. This shift from teaching to a more clinical role may reflect both a growth of patient-centered, interprofessional care and a needed mechanism to assist funding these positions.

Clinical Pharmacists as Educators in Family Medicine Residency Programs: A CERA Study of Program Directors.

BACKGROUND AND OBJECTIVES: The clinical pharmacist's role within family medicine residency programs (FMRPs) is well established. However, there is limited information regarding perceptions of program directors (PDs) about clinical pharmacy educators. The study objectives were (1) to estimate the prevalence of clinical pharmacists within FMRPs and (2) to determine barriers and motivations for incorporation of clinical pharmacists as educators. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) distributed an electronic survey to PDs. Questions addressed formalized pharmacotherapy education, clinical pharmacists in educator roles, and barriers and benefits of clinical pharmacists in FMRPs. RESULTS: The overall response rate was 50% (224/451). Seventy-six percent (170/224) of the responding PDs reported that clinical pharmacists provide pharmacotherapy education in their FMRPs, and 57% (97/170) consider clinical pharmacists as faculty members. In programs with clinical pharmacists, 72% (83/116) of PDs reported having a systematic approach for teaching pharmacotherapy versus 22% (21/95) in programs without. In programs without clinical pharmacists, the top barrier to incorporation was limited ability to bill for clinical services 48% (43/89) versus 29% (32/112) in programs with clinical pharmacists. In both programs with and without clinical pharmacists, the top benefit of having clinical pharmacists was providing a collaborative approach to pharmacotherapy education for residents (35% and 36%, respectively). CONCLUSIONS: Less than half of FMRPs incorporate clinical pharmacists as faculty members. Despite providing collaborative approaches to pharmacotherapy education, their limited ability to bill for services is a major barrier.

Comparison of Alcohol Use Disorder Screens During College Athlete Pre-Participation Evaluations.

BACKGROUND AND OBJECTIVES: The US Preventive Services Task Force (USPSTF) recommends screening adults for alcohol misuse, a challenge among young adults who may not have regular primary care. The pre-participation evaluation (PPE) provides an opportunity for screening, but traditional screening tools require extra time in an already busy visit. The objective of this study was to compare the 10-item Alcohol Use Disorders Identification Test (AUDIT) with a single-question alcohol misuse screen in a population of college-aged athletes. METHODS: This cross-sectional study was performed during an athletic PPE clinic at a college in the Southeastern United States among athletes ages 18 years and older. Written AUDIT and single-question screen "How many times in the past year have you had X or more drinks in a day?" (five for men, four for women) asked orally were administered to each participant. Sensitivity, specificity, and positive and negative predictive values for the single-question screen were compared to AUDIT. RESULTS: A total of 225 athletes were screened; 60% were female; 29% screened positive by AUDIT; 59% positive by single-question instrument. Males were more likely to screen positive by both methods. Compared to the AUDIT, the brief single-question screen had 92% sensitivity for alcohol misuse and 55% specificity. The negative predictive value of the single-question screen was 95% compared to AUDIT. CONCLUSIONS: A single-question screen for alcohol misuse in college-aged athletes had a high sensitivity and negative predictive value compared to the more extensive AUDIT screen. Ease of administration of this screening tool is ideal for use within the pre-participation physical among college-aged athletes who may not seek regular medical care.

Antibiotics for the secondary prevention of ischemic heart disease: a meta-analysis of randomized controlled trials.

BACKGROUND: Infections have been suspected in the pathogenesis of ischemic heart disease (IHD) for more than 100 years. Chlamydia pneumoniae has been identified in atherosclerotic specimens, and in some studies antibody titers to C pneumoniae have been related to the risk of myocardial infarction. The numerous clinical trials that have studied the use of antibiotics in the secondary prevention of IHD have had conflicting results. METHODS: This study is a meta-analysis of the published randomized controlled trials on the secondary prevention of IHD with antibiotics. Studies included in the analysis were limited to those studies that used antibiotics effective against C pneumoniae, enrolled patients with known IHD, and examined clinical outcomes related to IHD. Inclusion in the analysis was limited to well-designed randomized controlled trials that met inclusion criteria established by an expert panel. RESULTS: Nine published studies, with a total of 11 015 participants, were identified that met the criteria for this meta-analysis. Four of the studies reported a benefit from antibiotics, whereas 5 found no effect. A funnel plot of the published studies did not suggest the existence of other unpublished data. The combined effect found no benefit from antibiotics in the prevention of cardiovascular events in subjects with known IHD (relative risk, 0.94 [95% confidence interval, 0.86-1.03]) or mortality (relative risk, 0.94 [95% confidence interval, 0.79-1.12]). CONCLUSION: In patients with known IHD, macrolide antibiotics for C pneumoniae did not result in a statistically significant reduction in recurrent cardiac events or mortality over 3 months to 3 years.

A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial.

BACKGROUND: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care. OBJECTIVE: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke. DESIGN: 2-year randomized, controlled clinical trial with the practice as the unit of randomization. SETTING: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record. PARTICIPANTS: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients. INTERVENTIONS: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches. MEASUREMENTS: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator. RESULTS: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]). LIMITATIONS: The study involved a small number of practices and lacked a pure control group. CONCLUSIONS: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.

Association between Balint training and physician empathy and work satisfaction.

BACKGROUND AND OBJECTIVES: Balint training is used in many family medicine residency programs to encourage self-reflection and exploration of the physician-patient encounter. There is limited objective research, however, on outcomes of Balint training. This study's purpose was to determine whether Balint training is associated with differences in physician empathy and work satisfaction. METHODS: The Jefferson Scale of Physician Empathy and a validated survey on physician work satisfaction were mailed to 182 graduates of the Medical University of South Carolina (MUSC) Family Medicine Residency Program (113 Balint attendees and 69 nonattendees). The Dillman method of survey design was followed. RESULTS: The two groups were not statistically different in demographic measures. Balint attendees had a similar mean empathy score (119.4) as nonattendees (116.7). There was also no statistically significant difference in overall work satisfaction or satisfaction with financial compensation. Balint attendees were, however, more likely to say they would choose the same specialty if they could choose again than did nonattendees (86.1% versus 55%). CONCLUSIONS: There was no association found between Balint training and physician empathy, financial satisfaction, or overall work satisfaction. However, physicians who completed Balint training at the MUSC Family Medicine Residency Program seemed more satisfied with their choice of family medicine as a specialty.

Suggested guidelines for pharmacotherapy curricula in family medicine residency training: recommendations from the Society of Teachers of Family Medicine Group on Pharmacotherapy.

Rational drug use has increasingly received public policy attention in efforts to maintain quality health care at lower costs. Prescribing habits are developed during residency training, and education regarding rational drug use should be an integral part of the residency curricula. Considering that many medical errors in family medicine are related to incorrect medication management, there is need for a focused education in pharmacotherapy. This paper outlines suggested guidelines for pharmacotherapy curricula in family medicine residency training, as recommended by the Society of Teachers of Family Medicine Group on Pharmacotherapy. A pharmacotherapy curriculum should include common conditions managed in family medicine, as well as general principles of pharmacotherapy. This should allow for repeated exposure to core topics over a 3-year cycle and be delivered in various settings (didactic teaching, longitudinal active learning, point-of-care education, and rotations). The curriculum should apply and evaluate pharmacotherapy education according to the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME). Although physician faculty can be responsible for pharmacotherapy education, a clinical pharmacist is uniquely qualified to provide this service. Overall, family medicine residents need comprehensive instruction in pharmacotherapy to develop rational prescribing habits. A structured pharmacotherapy curriculum may assist in achieving this goal and in meeting the ACGME core competencies for residency training.

Hypertension management and control in primary care: a study of 20 practices in 14 states.

STUDY OBJECTIVE: To describe the management and control of hypertension in primary care practice. DESIGN: Retrospective medical record review. SETTING: Twenty primary care practices in 14 states. PATIENTS: Thirteen thousand forty-seven patients with hypertension. MEASUREMENTS AND MAIN RESULTS: Diagnoses, drugs prescribed, and blood pressure readings were extracted from the electronic medical record at each practice in the study. For patients with hypertension and comorbid diagnoses, the most recent blood pressure and antihypertensive drugs prescribed were determined. Analyses assessed the blood pressure control rates and the association between control and demographic variables, frequency of visits to the practice site, and pharmacologic treatment patterns. Among the 20 practices in the study, 13,047 patients had received a diagnosis of hypertension and their blood pressures had been measured within the previous 12 months. One third of the patients had comorbid coronary heart disease, diabetes mellitus, heart failure, and/or renal insufficiency. The most recent blood pressure reading was below 140/90 in half the patients. Control was associated with age 60 years or younger, female sex, more than one visit to the practice, more than one comorbidity, and type of practice (p<0.01, logistic regression). Wide variability was noted among practices in the use of multiagent antihypertensive therapy, and in antihypertensive therapy by drug class. Among patients without comorbidity treated with one drug, systolic blood pressure did not differ significantly by drug class. Diastolic blood pressure was slightly lower in patients prescribed thiazide diuretics than in those prescribed angiotensin receptor blockers (p=0.03, analysis of covariance). CONCLUSION: Blood pressure control in primary care practice can be much better than reports usually indicate. Good control in this study was not due to specific drug choice, but instead may have been due to regular monitoring of blood pressure and motivation of the practice to improve patient care.

Comparison of changes in blood pressure measurements and antihypertensive therapy in older, hypertensive, ambulatory care patients prescribed celecoxib or rofecoxib.

STUDY OBJECTIVE: To determine if changes in blood pressure and changes in class or dosing of antihypertensive drugs were significantly different in patients treated with celecoxib versus rofecoxib, two cyclooxygenase (COX)-2 inhibitors. DESIGN: Retrospective cohort study. SETTING: Thirty-one ambulatory care practices that shared an electronic medical record. PATIENTS: Nine hundred sixty men and women over age 55 years with stable hypertension. INTERVENTION: Patients had to have at least a 30-day supply of celecoxib or rofecoxib (any dose) prescribed between July 1, 1999, and June 30, 2000. MEASUREMENTS AND MAIN RESULTS: Patients were followed for 6 months, and logistic regression and survival models were used to compare outcomes between groups while adjusting for confounders. Baseline characteristics of 517 patients receiving celecoxib and 443 receiving rofecoxib were similar. No significant differences were observed, regardless of the COX-2 inhibitor prescribed, in the proportion of patients whose systolic blood pressure increased by 20 mm Hg, whose diastolic blood pressure increased by 15 mm Hg, or who were prescribed a new class of antihypertensive drug. Compared with patients taking celecoxib, those taking rofecoxib were significantly more likely (odds ratio 1.68, 95% confidence interval 1.09-2.60) to have had the dosage of their antihypertensive drug increased and also the dosage increased sooner (p<0.05). New-onset cardiac and renal comorbidity, number of physician visits, and changes in body weight and laboratory values were not significantly different between the groups. CONCLUSION: No significant differences in blood pressure changes or in the proportion of patients who were prescribed a new class of antihypertensive drug were found between rofecoxib- and celecoxib-treated patients. However, significantly more rofecoxib-treated patients had the dosage of their existing antihypertensive drug increased compared with those receiving celecoxib.

The effect of ethnicity on outcomes in a practice-based trial to improve cardiovascular disease prevention.

BACKGROUND: Health disparities are a growing concern. Recently, we conducted a practice-based trial to help primary care physicians improve adherence with 21 quality indicators relevant to the primary and secondary prevention of cardiovascular disease and stroke. Although the primary concern in that study was whether patients in intervention practices outperformed those in control practices, we were also interested in determining whether minority patients were more, less, or just as likely to benefit from the intervention as non-minorities. METHODS: Baseline (fourth quarter 2000) and follow-up (fourth quarter 2002) data were obtained from 3 intervention practices believed to have at least 10% minority representation. Two practices had a black (non-Hispanic) population sufficient for analysis, while the other had a sufficient Hispanic population. Within each practice, changes in the 21 indicators were compared between the minority patient population and the entire patient population. The proportion of measures in which minority patients exhibited greater improvement was calculated for each practice and for all 3 practices combined, and comparisons were made using non-parametric methods. RESULTS: For all black patients, the observed improvement in 50% of 22 eligible study indicators was better than that observed among all white patients in the same practices. The average changes in the study indicators observed among the black and white patients were not significantly different (p = 0.300) from one another. Likewise for all minority patients in all 3 practices combined, the observed improvement in 14 of 29 (43.3%) eligible study indicators was better than that observed among all white patients. The average changes in the study indicators among all minority patients were not significantly different from the changes observed among the white patients (p = 0.272). CONCLUSIONS: Among 3 intervention practices involved in a quality improvement project, there did not appear to be any significant disparity between minority and non-minority patients in the improvement in study indicators.

Using the electronic medical record to enhance the use of combination drugs.

The objective of this study was to increase combination drug prescriptions through the use of electronic point-of-care reminders, thereby maintaining quality while decreasing medication costs. The electronic medical record (EMR) was used to identify all patients who were potential candidates for one of the following 3 currently available combination drugs: fluticasone-salmeterol, amlodipine-benazepril, or glyburide-metformin. Point-of-care electronic reminders were attached to the medication record of the EMR for each patient, and providers were asked to consider using the available combination medication. Of the patients who had electronic reminders attached to their charts and were seen at the clinic during the study period, 47 of 175 were switched to a combination medication. A cost-savings analysis showed a total annual savings of dollars 6,159.30. Point-of-care reminders are a simple and effective tool for quality-improvement interventions. Combination drugs may play an important role in controlling medication costs.