On the pharmacological actions of a diuretic, fenquizone, with particular reference to its site of action.

The pharmacological actions of a diuretic drug, fenquizone have been investigated and its effects compared with well characterized diuretics in rats, mice and rabbits. Changes in sodium and potassium excretion and urine volume were similar in magnitude and duration to those of the thiazide diuretics over dose range 0.05-100 mg kg-1. Free water clearance in rabbits was decreased indicating an action at the cortical diluting site in the nephron and since free water reabsorption was relatively unaffected it appears unlikely to have actions at other sites. Calcium and phosphate excretion studies also suggested that the predominant effects are those occurring at the cortical diluting segment of the nephron. Additional parameters not affected by the drug were blood flow to the cortex and medulla of the kidney (and other major organs), plasma glucose concentration and plasma urate concentration.

Physical therapy education in family practice residency programs.

BACKGROUND: This study investigated the role and extent of physical therapy education in family practice residency programs. Physical therapy is not specifically included in graduate curricula guidelines, and the literature contains little information on its involvement in programs. METHODS: A questionnaire was developed to determine how physical therapy education is taught in family practice residencies. The questionnaire was mailed to all (391) directors of US-accredited family practice residency programs. RESULTS: A total of 256 directors (65.5%) responded. The majority of directors (67%) stated that there was a significant need for the physical therapy component. Only 52% (133/256), however, included physical therapy in their curricula. Physical therapy education was most frequently (67.6%, 92/136) included in required rotations (eg, orthopedics) and taught mostly by hospital-based physical therapists (77.0%, 104/135) or subspecialists (55.6%, 75/135). CONCLUSION: This study shows that physical therapy education offers a potentially relevant and important element of family practice residency training, but it has been underemphasized.

The effect of faculty private practice experience on appropriate charging for professional services.

Private practice experience is widely considered invaluable for academic family physicians, especially for clinical efficiency and for charging appropriately for professional services. This study tested the hypothesis that faculty members with private practice experience charged more appropriately for professional services. Patient-physician encounters were rated in terms of propriety of charges by consensus of two faculty physicians and compared to the actual level of service marked on the encounter form. Private practice experience for faculty resulted in less undercharging (21% of encounters undercharged versus 31% for faculty without that experience, P = .03). Physicians with private practice experience undercharged on average $.36 per encounter, versus $1.94 for providers without that experience (Kruskal-Wallis test, P = .27). Physicians with private practice experience also tended to perform more procedures but not to bill for more. Academic family physicians with private practice experience demonstrated more appropriate billing practices for professional services, but ideally preference for this type of academic physician should be based on other attributes, such as breadth of experience and efficiency in patient care.

Helminths of wintering geese in Texas.

Ten Canada geese (Branta canadensis), 24 snow geese (Chen caerulescens) and 22 white-fronted geese (Anser albifrons) from coastal Texas (USA) were examined for helminths. Three cestode, seven nematode, and three trematode species were collected. Gizzard nematodes (Amidostomum anseris, A. spatulatum and Epomidiostomum crami) infected 53 of 54 birds. Gross lesions were not attributed to helminth infections and the host population does not appear to be impaired by them.

Northern bobwhites as disease indicators for the endangered Attwater's prairie chicken.

Because of limited access to the endangered Attwater's prairie chicken (Tympanuchus cupido attwateri), we used a related species, the northern bobwhite (Colinus virginianus), as a surrogate for disease evaluation. Free-living northern bobwhites (n = 62) on the Attwater Prairie Chicken National Wildlife Refuge (near Eagle Lake, Texas, USA) were examined during spring and fall 1993 for helminthic endoparasites and specific antibodies against the infectious agents responsible for nine infectious diseases. Trichostrongylus cramae, Raillietina sp., and Strongyloides avium were collected from 97, 44, and 32% of northern bobwhites examined, respectively. Dispharynx nasuta and Syngamus trachea also were found. No gross lesions due to parasites were observed. Specific antibody to Pasteurella multocida was found in 3 of 53 plasma samples. It is possible that potentially pathogenic species such as P. multocida, T. cramae, and D. nasuta could threaten sympatric Attwater's prairie chickens.

Serologic and parasitologic survey of the endangered Attwater's prairie chicken.

Because conservation biologists have postulated that infectious diseases may have potentiated the endangerment of the Attwater's prairie chicken (Tympanuchus cupido attwateri), free-living prairie chickens were surveyed from all remaining populations for helminthic endoparasites and antibody against the etiological agents of nine infectious diseases. Samples from 4 of 27 adult males were positive for anti-Pasteurella multocida antibody. All other serologic tests were negative (n = 19). We identified Dispharynx nasuta, a parasite previously associated with disease in other grouse from North America, in one of three adult Attwater's prairie chickens examined. Evidence of Trichostrongylus cramae was found for eight of nine suitable samples, which represents the first report of this parasite in prairie grouse. The mean intensity of T. cramae in Attwater's prairie chicken was 1,019.3 (Range = 3-1,906; n = 3). Further work is needed to determine whether P. multocida, T. cramae, or D. nasuta are detrimental to Attwater's prairie chicken populations. If so, conservation biologists could reduce the prevalence and incidence of these parasites and potentially gain more time to address the habitat conditions thought to be the ultimate cause of population declines.

Coding and reimbursement of primary care biopsy and destruction procedures.

Current medical practice requires physicians to accurately report services provided to patients. Billing for destruction of benign and malignant lesions and for surgical, needle, and endoscopic biopsy procedures involves the selection of specific 1992 Current Procedural Terminology (CPT) codes. Payment for these procedures by third-party payers often requires the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding for neoplastic lesions. This review explains the proper codes to use in identifying common biopsy and destruction procedures performed by primary care physicians. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions for selecting site-specific biopsy and destruction codes are provided.

Coding and reimbursement of primary care debridement and excision procedures.

Current medical practice requires physicians to accurately report services provided to patients. Patient billing for debridement and excision procedures involves the selection of specific 1992 Physicians' Current Procedural Terminology codes. Although a site-specific surgical procedure code often yields higher reimbursement than a general procedure code, physicians should select the code that most accurately reflects the procedure performed. This review identifies the codes used to report destruction and excision procedures performed by primary care physicians. Included in this review are skin debridement, burn debridement, excision of benign and malignant lesions of the skin and subcutaneous tissue, cyst and ganglion excision, nail excision, anorectal lesion excision, shave, paring, and skin tag excision procedures, and foreign body removal. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions are provided for selecting between multiple coding options when more than one code describes the service provided.

Billing practices of North Carolina family physicians.

BACKGROUND: This study describes billing practices of family physicians. Significant increases in the reimbursement for family physicians are expected from implementation of the resource-based relative value scale (RBRVS). However, the real impact of the RBRVS is unknown since little is known about how family physicians use the present reimbursement system to charge their patients. METHODS: A random sample of 270 North Carolina family physicians was surveyed, using standardized progress notes of five hypothetical patients. RESULTS: One hundred thirty-eight (51%) physicians responded; 107 (77.5%) were in private practice. Family physicians in private and nonprivate practices were similar in their Current Procedural Terminology (CPT) coding and level of service for each hypothetical case. Family physicians in smaller communities showed greater variation in CPT coding of visits than did family physicians in larger communities, and they were more likely to use CPT codes that indicated a lower level of visit. Rural family physicians demonstrated a significant inverse relationship between the CPT level of visit coded (ranging from "brief," with a CPT code of 90040, to "comprehensive," coded CPT 90080) and the amount they charged established patients for a "limited" visit (CPT 90050). CONCLUSIONS: These findings suggest that the lower income of rural physicians is due, in part, to billing at a lower CPT code, and thus charging less for comparable services, than urban physicians. The findings also lend further support to contentions that federal reimbursement reforms will have less impact on the incomes of rural physicians than originally expected.

Treatment of a patient with an infected hepatic cyst.

Symptomatic hepatic cysts are infrequently seen by family physicians. We review the literature and describe the diagnosis and management of a patient with cystic liver disease and a dominant infected hepatic cyst. The treatment included percutaneous drainage, intravenous antibiotic therapy, and sclerotherapy infusion using sterile alcohol (95% ethanol).

Accuracy of patient encounter and billing information in ambulatory care.

BACKGROUND: This study examined the degree of accuracy of billing data in an academically affiliated family practice. METHODS: The progress notes from 1253 consecutive visits were independently reviewed by two family physicians, and the diagnoses, use of procedures, and level of service were determined for each visit. Discrepancies between the reviewers were resolved by consensus. These data were compared with the data on the corresponding billing form that had been completed by the care providers (ie, physicians on the faculty, physicians in training, family nurse practitioners, and nurses). RESULTS: There was poor agreement between the billing form and progress note on level of service and number of diagnoses (kappa = 0.37 and kappa = 0.28, respectively). The progress note usually indicated that a higher level of service should have been billed for a visit than actually was billed. Underreporting of the number of diagnoses was substantial; the billing forms listed only 69% of the diagnoses identified in the progress notes. In 60% of visits, each diagnosis on the billing form had a matching diagnosis in the progress note. This could be improved to 78% of visits if broad categories of disease were used. Residents were similar to faculty in the accuracy of reported level of service and types of diagnoses, but were more likely to underreport the number of diagnoses. CONCLUSIONS: Ambulatory care data from computerized billing files may not be sufficiently accurate for proper reimbursement of physician services or for use in research.

Physician referrals from a rural family practice residency clinic: a pilot study.

Primary care physicians see large volumes of unscreened patients in the office setting, and referral to more specialized colleagues is always an option. Discretionary factors may play an important role in the referral decision. In this study, three family physicians retrospectively rated 410 referrals from a rural academic practice for the need for referral based on lack of specialized skills or knowledge by family physicians and the probability of adverse patient outcome. Referrals relating to cancer and pregnancy were rated as less discretionary than other referrals. Specialties receiving the highest proportion of mandatory or probably mandatory referrals were ophthalmology and cardiology. Half of all referrals studied were considered to be elective or possibly elective, although 97 percent of referrals to dermatology were considered elective or probably elective. These findings support the hypothesis that there is considerable clinical discretion in a large proportion of referrals. Hence, imposition of specific criteria for referral in primary care practice (thereby limiting discretion in initiating a referral) could significantly decrease the number of referrals, and consequently decrease the income of subspecialists and tertiary care centers.

Effect of oral magnesium supplementation on selected cardiovascular risk factors in non-insulin-dependent diabetics.

OBJECTIVE: To evaluate the impact of oral magnesium supplementation on risk factors for end-organ disease in patients with non-insulin-dependent diabetes mellitus (NIDDM). DESIGN: A 16-week randomized, double-blind, placebo-controlled crossover trial. SETTING: Outpatient center of an academic family medicine residency program. PATIENTS: Twenty-eight patients (age range, 28 to 84 years; 57.1% black; 85.7% women) with NIDDM controlled by diet and/or an oral hypoglycemic, with a serum cholesterol levels over 5.20 mmol/L (200 mg/dL). INTERVENTION: Following a 2-week placebo run-in period, each patient was randomized to receive either sustained-release magnesium chloride (Slo-Mag), 384 mg/d, or an identical-appearing placebo for 6 weeks. After a 2-week interim washout period, each patient was then treated with the alternative regimen for an additional 6-week period. MAIN OUTCOME MEASURES: The systolic and diastolic blood pressure and levels of serum glucose, low-density and high-density lipoprotein and total cholesterol, triglycerides, and serum and total erythrocyte magnesium were measured at the beginning, midpoint, and end of each 6-week treatment phase. RESULTS: Systolic blood pressure fell an average of 7.4 mm Hg (P < .05) with treatment. There was no significant change in diastolic blood pressure or levels of serum glucose, low-density and high-density lipoprotein and total cholesterol, triglycerides, or serum and erythrocyte magnesium. CONCLUSIONS: Oral magnesium supplementation in the doses and duration studied is modestly effective in reducing systolic blood pressure in patients with NIDDM but has little impact on other important biochemical parameters related to diabetes-associated end-organ disease.