Participation by internists in primary care; Results of a survey of Mayo clinical alumni.

In late 1972, a survey of Mayo Graduate School alumni was undertaken to determine if changes were needed to make the internal medicine residency program more relevant to such medical practice in the 1970s. Responses were obtained from 783 of the 1,109 former residents in internal medicine to whom questionnaries were sent. Althought nearly half of the responders indicated a subspecialty component to their practice,73% indicated they spend more than half of their time in the delivery of parimary car; and additional 15% reported that primary care occupied from 20% to 50% of their professional time. There was agreement that more general internists are needed and that better geographic distribution of physicians would improve health care delivery.

The Mayo three-community hypertension control program. IV. Five-year outcomes of intervention in entire communities.

Beginning in 1974, the Mayo three-community hypertension control program initiated intervention studies in three southeastern Minnesota communities. This paper reports on the blood pressure outcomes 5 years after the inception of graduated programs involving public and professional education, detection, referral, and, in one community, systematic stepped care. Despite differences in local physician-population ratios and organization of medical care, perseverant long-term reductions of blood pressure were noted in all communities. However, the mean diastolic pressures were lower and the number of individuals at goal (diastolic blood pressure 90 mm Hg or less) was higher in the community offering categorical care. These data suggest that while programmatic efforts to control hypertension resulted in favorable blood pressure declines, the outcomes were particularly impressive in the community with a categorical hypertension clinic model offering systematic management of hypertensive patients.

Economic outcome under Medicare prospective payment at a tertiary-care institution: the effects of demographic, clinical, and logistic factors on duration of hospital stay and part A charges for medical back problems (DRG 243).

We investigated the effects of prospectively identified factors on the duration of hospital stay and part A charges in 240 hospitalizations (of 230 patients) for the diagnosis-related group "medical back problems" (DRG 243) at a tertiary-care institution in 1985 to determine whether heterogeneity existed within this reimbursement category. We confirmed our initial postulates that nonosteoporotic fractures and neck problems, as well as hospitalizations primarily for myelography after outpatient neurologic evaluation, had considerably different economic outcomes and thus excluded these categories from further analysis. Statistical analysis (forward stepwise regression) of the remaining 132 patients who had "general medical back problems" showed that increasing age, associated osteoporosis, and therapeutic injections best explained variation in the natural logarithm of duration of stay (R2 = 0.16). Total number of diagnoses, spondylosis, associated osteoporosis, age, therapeutic injections, and performance of special procedures best explained the variation in the logarithm of part A charges (R2 = 0.29). The ability to identify factors within a specified category that affect the duration of hospitalization and part A charges jeopardizes the fairness of prospective payment, and we believe that DRG 243 should be adjusted for age, comorbidity, and readily identifiable clinical syndromes that have disparate economic consequences. Because of poorly substantiated efficacy and a significant association with longer hospital stays and higher part A charges, clinicians should review the use of therapeutic injections for medical back problems. Analysis of case-mix such as ours should be helpful in promoting efficient practice and ensuring the fairness of any reimbursement system.

Acute cystitis: a prospective study of laboratory tests and duration of therapy.

The efficacy of single-dose therapy with trimethoprim-sulfamethoxazole (TMP-SMZ) and the cost-effectiveness of routine urinalyses and cultures were studied in a prospective randomized trial of 200 women who presented with symptoms of acute lower urinary tract infection. Without the physician's knowledge of the results of urinalysis or culture, the patients were randomly assigned to receive either a single dose or a 10-day multiple-dose course of TMP-SMZ and were followed up for 6 months. Of the 136 patients with positive urine cultures, 68 received single-dose therapy with TMP-SMZ--10 of whom had relapses--and 68 received multiple-dose therapy with TMP-SMZ--only 2 of whom had relapses (P less than 0.02). Fifteen patients in each treatment group experienced reinfection. Side effects of rash and vaginitis were more common in patients who received multiple-dose therapy, but they were mild and well tolerated. Of the 51 patients with urethral syndrome, 48 became asymptomatic after therapy. None of the following tests predicted treatment outcome: pretreatment urinalysis, urine culture or susceptibility testing, antibody-coated bacteria testing, or routine follow-up urinalyses or urine cultures. Empiric therapy with TMP-SMZ in selected women with symptoms of acute uncomplicated urinary tract infection seems practical, safe, and cost-efficient. Considerable savings can be achieved by reserving urinalyses and urine cultures for patients with persistent or recurrent symptoms. Higher cure rates can be expected in patients who receive a standard 10-day course of therapy with TMP-SMZ compared with those who receive single-dose therapy with TMP-SMZ.

Utilization trends and risk factors for hospitalization in diabetes mellitus.

A population-based prevalence cohort of 1,111 residents of Rochester, Minnesota, who had diabetes mellitus on Jan. 1, 1975, was subjected to follow-up assessment for hospitalizations through Dec. 31, 1980. On the basis of these data, hospitalization rates were calculated for various clinical types of diabetes, and a risk factor analysis was done for non-insulin-dependent diabetes mellitus (NIDDM) to identify high-risk persons for subsequent intervention studies. The adjusted incidence density of hospitalization was 141.6 per 1,000 person-years for NIDDM and 331.3 per 1,000 person-years for insulin-dependent diabetes. Although the modeled clinical characteristics accounted for little variability in NIDDM-related hospitalization, age modified by the effect of gender was the strongest risk factor found (multivariate hazard ratios: 1.0 and 1.43, respectively, for male and female patients younger than 65 years old; 1.88 and 1.83, respectively, for male and female patients 65 years old or older); coronary heart disease, diabetic retinopathy, and persistent proteinuria were associated with a 50% increased risk. Although older patients with NIDDM (especially men) are at greatest risk for a first hospitalization, clinical factors alone seem inadequate to account for these hospitalizations. The effect of Medicare's prospective payment systems (PPS) was studied by using a data base for Olmsted County, Minnesota, to determine whether PPS decreased the rate of hospitalizations among patients with diabetes. Among Olmsted County residents 65 years of age or older, the adjusted rate of diabetes-associated hospitalizations decreased from 26.5 per 1,000 person-years in 1980 to 16.7 in 1985, whereas the adjusted rate of all other hospitalizations increased from 259.5 per 1,000 person-years to 261.9. Thus, PPS may have reduced hospitalization rates in elderly patients with diabetes.

Quality-of-care assessment. I. Outpatient management of acute bacterial cystitis as the model.

A study was undertaken to determine whether a process audit of outpatient medical care would correlate significantly with the outcomes of care and thus prove to be a valid method for assessing the quality of medical care in the outpatient setting. Acute bacterial cystitis in women was selected as the model for study. A series of 42 cases was reviewed by retrospective analysis of patient records supplemented by follow-up interviews and collection of a follow-up urine culture from each patient to document the outcome of treatment. No positive association was demonstrated between the processes for satisfactory care selected by the expert criteria committee and the observed outcomes. Reasons for this failure in the present study and for deficiencies of the process audit method in general are discussed.

A decline in carcinoma of the stomach. A diagnostic artifact?

During the past 50 years or more, a dramatic decline in the mortality from gastric carcinoma has been observed in virtually every country in the world, including the United States. Some investigators suspect that this decline is due to refinements in the diagnosis and classification of abdominal malignancies rather than being a true decline in the incidence of gastric cancer. Because the record system in Rochester, Minnesota, ensures the identification of virtually every patient in the local population with a serious illness, and the level of diagnosis is high, it seemed appropriate to study the incidence and long-term trends of gastric cancer in this community. Trend analysis for the period 1935 through 1979 revealed a consistent decline in the incidence of gastric carcinoma whether death certificates as the sole source of cases were included or not. Analysis of either all clinically confirmed or only tissue-confirmed cases revealed a statistically significant decrease in stomach carcinoma throughout the study period. These declines were observed even if only the more recent periods (1955 through 1979) were examined. The reasons for this finding remain obscure, but the study suggests that improvements in diagnostic accuracy alone cannot account for this remarkable downward trend in gastric malignancy.

The Mayo Three-Community Hypertension Control Program. I. Design and initial screening results.

The Mayo Three-Community Hypertension Control Program implemented graduated programs for the control of high blood pressure in three rural southeastern Minnesota communities, beginning in 1974. Prevalence of hypertension (when defined as diastolic blood pressure, at initial screening, of 95 mm Hg or more) was similar to that found for comparable groups by age and sex in the United States generally, but an atypically high frequency of known but untreated hypertension was found. Programs of public and professional information, systematic household screening, continuing professional education (two communities), and a new community hypertension clinic (one community) were initiated, and plans were made to evaluate the programs simultaneously by means of total rescreening of persons found to be hypertensive initially. The present report describes in detail the design of the program and the results of initial screening in relation to findings in other populations at the time. Subsequent reports assess the impact of each program on its target community and of a community hypertension clinic within the one setting where this component of a model program was established.

The Mayo Three-Community Hypertension Control Program. III. Outcome in a community-based hypertension clinic.

As part of a broader community program to evaluate approaches to hypertension control, a Community Hypertension Clinic, staffed by two nurse practitioners, was set up in a rural community. Hypertensive persons were identified either by an initial central blood pressure screening or by a subsequent home screening. Slightly more than half of the hypertensive patients at initial screening, or 256 persons, elected to go to the Community Hypertension Clinic for second-stage screening, whereas the remainder elected to see their physicians or to do neither. After secondary screening at the Clinic, 120 patients eventually came under care and were managed by the nurse practitioners. After 2 years of follow-up, 57% of the Clinic patients had office-recorded diastolic blood pressures of less than 90 mm Hg. The Community Hypertension Clinic dropout rate was only 5% after 30 months of operation, for participants whose duration of follow-up ranged from 12 to 27 months (median 16 months), when a repeat home blood pressure screening examination was performed. Comparison of outcomes was thus possible between persons who attended the Community Hypertension Clinic and those who were referred to their physicians' offices. Persons with more severe hypertension most often elected to go to the Clinic, whereas patients with milder degrees of hypertension tended to go to their private physicians for follow-up or failed to make the recommended second-stage screening contact altogether. Greater declines in blood pressure were observed in the Clinic group.

The Mayo Three-Community Hypertension Control Program. II. Outcome of intervention in entire communities.

A pronounced decline in blood pressure levels of hypertensive patients occurred in each of three rural Minnesota communities 1 to 2 years after the inception of community programs to control high blood pressure in these populations. An experimental hypertension clinic was established in one community to integrate a nurse practitioner into a physician-supervised program of long-term patient management. In the community with this innovative, partially subsidized practice arrangement, we observed declines in diastolic pressures of hypertensives. However, comparable degrees of blood pressure reduction occurred in the two other communities, with traditional solo or small group practice arrangements, where intervention was limited to detection and referral alone or was supplemented with continuing education of physicians in the management of hypertension. The evaluation of these three community programs suggests, among other conclusions, that this innovative community model for hypertension control, based on the recommendations of the Inter-Society Commission for Heart Disease Resources, contributed to favorable short-term blood pressure outcomes for the community. The observation of similar overall outcomes as measured by blood pressure reduction in all three communities was unexpected; the clinic's impact appears to have been matched by the effectiveness of screening and referral, alone or with continuing education, in the two other communities.

Coronary heart disease in residents of Rochester, Minnesota, 1950-1975. I. Background and study design.

The unique medical data resource for the population of Rochester, Minnesota, is centered on the records of the Mayo Clinic and the Olmsted Medical and Surgical Group, which for several decades have provided nearly all medical care in this community. This resource has been utilized in a study of the incidence rates and secular trend in coronary heart disease for the period 1950-1975 among residents of Rochester. A total of 3,080 patients fulfilled the clinical and other criteria for inclusion in this study. The patients, classified by initial manifestation of coronary heart disease, consisted of 1,321 with myocardial infarction, 1,215 with angina pectoris, and 544 with sudden unexpected death. In this paper the background, clinical definitions, and study design are presented.

The Mayo three-community hypertension control program. V. Cost-effectiveness of intervention.

This paper compares the costs of a categorical clinic model for community hypertension intervention with the costs of two less resource-intensive hypertension programs. Three categories of costs are measured for each program: program costs, patient costs, and time costs. Total costs are expressed in terms of costs per hypertensive patient controlled under each program. When adjusted for differences in hypertension prevalence and screening costs in the three community programs, the cost-effectiveness of the categorical clinic model is questionable. These results suggest that careful analyses of the categorical clinic model in other communities should be conducted before public resources are committed to the establishment of such models on a widespread basis.

Altering residency curriculum in response to a changing practice environment: use of the Mayo internal medicine residency alumni survey.

To elicit the opinions of practicing internists who had graduated from a single internal medicine residency program about the adequacy of their training and its relevance to their medical practice, we mailed a survey to 1,342 physicians who had spent at least 1 year in the Mayo internal medicine residency training program. Of this group, 703 alumni (52%) responded to the survey, 532 of whom were currently practicing internal medicine. Our detailed analysis was based on responses from these 532 and, for some aspects of evaluation, on the 121 general internists who had completed residency training after 1970. Of the respondents, 42% spent more than 80% of their time in general medicine, and 53% had at least some subspecialty practice; 55% were involved in teaching, 20% in some research, and 37% in various administrative duties. In 27%, all patient-care activities involved primary care, an increase from 18% in a 1979 survey and 9% in 1972. Of those who were subspecialists, 67% spent more than half their time in subspecialty practice. Of those who were trained after 1970, 90% were board certified. Most respondents thought that their training in the internal medicine subspecialties was adequate, that additional procedure training was needed in joint aspiration, line placement, and flexible sigmoidoscopy, and that many allied medical areas were important to their practice and necessitated additional training. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient training. Alumni surveys can be useful in restructuring a residency program to meet the needs of the trainees.

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.

Assessment of prediction of mortality by using the APACHE II scoring system in intensive-care units;.

Some investigators have suggested that information on quality of care in intensive-care units (ICUs) may be inferred from mortality rates. Specifically, the ratio of actual to predicted hospital mortality (A/P) has been proposed as a valid measure for comparing ICU outcomes when predicted mortality has been derived from data collected during the first 24 hours of ICU therapy with use of a severity scoring tool, APACHE II (acute physiology and chronic health evaluation). We present a comparison of mortality ratios (A/P) in four ICUs under common management, in two hospitals within a single institution. Significant differences in A/P were detected for nonoperative patients (0.99 versus 0.67;P = 0.014) between the two hospitals. This variation was traced to uneven representation of a subset of patients who had chronic health problems related to diseases that necessitated admission to the hematology-oncology or hepatology service. No differences in A/P were seen between the two hospitals for operative patients or for nonoperative patients on services other than hematology-oncology or hepatology. Thus, differences in A/P detected by using the APACHE II system not only may reside in operational factors within the ICU organization but also may be related to weaknesses in the APACHE II model to measure factors intrinsic to the disease process in some patients. We suggest that case-mix must be examined in detail before concluding that differences in A/P are caused by differences in quality of care.

Family history of alcoholism in patients with chronic fatigue.

Persistent fatigue is a common functional physical complaint. This study reports a possible relationship between parental alcoholism or advanced parental age at the patient's birth and the functional fatigue syndrome.

Trends in cardiac surgery. Five-year study of a defined population.

The total number and types of cardiac operations performed on residents of Olmsted County, Minnesota, from 1973 through 1977 were studied through the use of the medical-records linkage system at the Mayo Clinic. During this time, 213 patients underwent 216 operations. The rates of cardiac operations per 10,000 population increased from 4.1 in 1973 to 5.9 in 1977. Operations other than for coronary artery bypass showed no significant trends over time, and the average rate was 2.5 per year. The incidence of coronary artery bypass operations increased from 1.5 in 1973 to 4.0 in 1977. On the basis of the rates for open-heart operations and under conditions similar to those in this community, a population of approximately 380,000 persons less than 15 years of age would be required to ensure 75 cases requiring open-heart operations per year, and a population of approximately 230,000 persons more than 14 years of age would provide 200 adult open-heart cases per year. Thus total populations of approximately 1,380,000 and 310,000 of all ages would be required to meet these minimum standards for pediatric and adult open-heart operations.

Use of medical services and satisfaction with ambulatory care among a rural Minnesota population.

Patient satisfaction with health care services and the use of ambulatory care in rural southeastern Minnesota were surveyed before and after physician manpower was increased. This report is confined to the findings in 1974, before the three local practicing physicians were joined by two additional physicians. The physician to population ratio at the time of the initial survey was 1 to 6,200 in 1974 and 1 to 2,500 with the additional physicians in 1975.In this area the population of 12,400 centered around the town of Zumbrota. A total of 1,332 persons completed questionnaires, and 796 filled out a second questionnaire concerning patient satisfaction with health care. The scores on 40 items formed 18 satisfaction indices.Use of health services was lower than in the National Health Survey of 1969; the mean number of visits per year in Zumbrota was 3.3 compared with 4.3 for the national sample. The volume of use in the Zumbrota region was low, particularly among adults. Use of services was not significantly related to the education, occupation and income of the residents. About 10 percent of the population accounted for half of the total number of visits.Only a few of the 18 patient satisfaction indices were related to the respondent's income and occupation, but 5 were related to educational level. Satisfaction with health care services was generally higher in this rural population than among the people in four urban areas that were surveyed using the same satisfaction indices.The question raised by the findings in this survey-are rural areas in general as deprived and unsatisfied with health care as the literature suggests-remains unsettled. Changes over time in use and patient satisfaction are being assessed in the resurvey to seek possible explanations of the low utilization and high degree of patient satisfaction in this area.

Impact of increased physician supply on use of health services: a longitudinal analysis in rural Minnesota.

Prevalence studies of the use of ambulatory health care services have consistently reported relatively lower demand for services in rural areas. Such studies have implied that low use rates may be fixed characteristics of rural populations and may be resistant to the influence of manipulable variables such as supply of physicians. This longitudinal study suggests that use rates are in fact significantly changed after improvement of manpower resources, but that the effects are limited to the vicinity of new practice locations.