Quality-of-care assessment. II. Outpatient medical care following hospital dismissal after myocardial infarction.

This study was undertaken to compare process and outcome methods of quality assessment of medical care in outpatient office practice. Follow-up care after hospitalization for first acute myocardial infarction was used as the model. One hundred fifty-two patients followed up for a minimum of 2 years comprised the study group. An expert committee of cardiologists and internists in community practice established the process criteria for satisfactory care and predicted outcomes of continuing disability and mortality. Using weighted process criteria and a weighted performance index permitted demonstration of a significant association between process items performed at the first posthospitalization visit and 2-year mortality. A significant association could not be demonstrated between later process of care and outcome at 2 years. The outcome assessment study disclosed that predicted disability and mortality rates compared closely with observed outcomes. However, this method for evaluating the quality of outpatient medical care is weakened because little information is available to provide the basis of prediction of satisfactory outcome rates in complicated cases. Although both the process and outcome methods of quality assessment have short comings, the latter method is recommended because satisfactory outcomes is the essential criterion of quality medical care. Moreover, when process items are not specified outcome assessment maintains the flexibility of individual physician practice. Refinement of satisfactory outcome prediction for common illnesses managed in office practice should be the goal for future studies.

Preemployment and periodic physical examination of airline pilots at the Mayo clinic, 1939-1974.

A descriptive study of medical disqualifications and deaths in an airline pilot population revealed that, of 2,751 pilot applicants, 145 (5.3%) were rejected by the preemployment company medical examination. Of the 145, 117 were rejected because of a primary disqualifying "laboratory" abnormality. During the lifetime of the airline, 103 pilots have retired because of medical reasons, primarily cardiovascular, and 120 have died, the majority in aircraft accidents. The rate of medical disqualification is minimal before the age of 45 years, but it increases rapidly thereafter. By use of the actuarial survivorship method, it was determined that the chance of a pilot reaching retirement age in this airline company was less than 50%, although his chance of not reaching retirement age because of medical reasons was only 20%. Based on the results of this study, a departure from the "traditional" periodic company medical examination program is suggested.

Airline pilot disability: the continued experience of a major US airline.

This study details our continued experience with preemployment screening and medical disability in a large group of pilots from one airline from 1975 through 1982. During this period, 368 pilot applicants underwent preemployment screening and 73 of these were rejected for employment because of medical reasons. The majority (45) of these were unsuitable for psychological reasons. Medical disability accounted for approximately 20% of the pilots separated from the company during the period of study. Age-specific disability rates increased rapidly after age 45 years, with cardiovascular disease responsible for more than 50% of these medical losses. Disability rates of older pilots have decreased considerably compared with previous rates: the age-adjusted rate for pilots age 45 years or older has decreased from 27.50/1,000 person-years to 8.97/1,000 person-years (p less than 0.0001). The reasons for this reduction remain unclear, but changes in the interpretation of the Federal Aviation Administration regulations and changes in company policies may have contributed. The role of preventive medicine in the form of regular medical surveillance is uncertain, with no direct evidence of a beneficial effect.

Airline pilot medical disability: a comparison between three airlines with different approaches to medical monitoring.

To study the impact of airline medical departments on pilot disability, three major U.S. airlines, nominally airlines A, B, and C, were chosen because they had distinctly different medical programs. Airline A provided essentially no medical review. Airline B performed preemployment screening and assessment of individual disability claims, along with an irregular pilot review. Airline C provided basically the same services as airline B but also screened pilots annually. The total cohort comprised 12,866 pilots providing 79,797 person-years of experience. Between 1 January 1975 and 31 December 1982, medical losses in all three airlines increased rapidly after pilots reached the age of 45 years, with cardiovascular disease responsible for approximately 50% of the losses. For pilots 45 years old or older, the age-specific disability rates in airline A were significantly higher than those in airlines B and C; rates for airlines B and C were not significantly different. The data suggest that airlines with active medical departments have lower pilot medical disability rates than do airlines without such departments. Data also suggest that preemployment screening and assessment of individual disability claims are more important determinants of long-term disability rates than are regular (annual) pilot health reviews.

Epidemiology of Ankylosing spondylitis in Rochester, Minnesota, 1935-1973.

The Mayo Clinic records linkage facility for residents of Rochester, Minnesota, Yielded 102 cases of ankylosing spondylitis (AS) diagnosed from 1935 through 1973. The incidence did not change significantly over the 39 years. Three times as many males as females were affected. In contrast to another recent report, survivorship of males with AS was not different from that of the general population, whereas survivorship of females with AS was reduced. The overall prevalence was 129/100,000.