Effect of erythromycin on feeding intolerance in very low birth weight infants: a preliminary observation

The objective of the study was to measure the change in physicians' attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p < .005) and less for quality improvement (first survey 85% vs second survey 67%, p < .008) over time. These findings may create a barrier to physicians' adoption of practice guidelines.     

Postoperative nausea and vomiting. A retrospective analysis in patients undergoing elective craniotomy

CONTEXT: Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. OBJECTIVE: To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. DESIGN: Cross-sectional questionnaire. SETTING: A total of 89 California physician groups with capitated contracts. PARTICIPANTS: A total of 910 primary care physicians (80% response rate). MAIN OUTCOME MEASURE: Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. RESULTS: Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). CONCLUSION: These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.     

Skills that Iowa family physicians desire in a new physician partner

BACKGROUND AND OBJECTIVES: The importance of specific skills in primary care continues to be debated. As a result, there is not consensus on which skills need to be stressed during residency training. Our project asked community-based family physicians to rate the importance of specific skills in a new family physician partner. METHODS: Data were collected through a cross-sectional survey of all active members of the Iowa Academy of Family Physicians. Participants were surveyed by mail, using a list of 83 skills pertinent to primary care. Physicians were asked to rate the importance of a new member of their practice having the individual skills on this list. RESULTS: A total of 546 family physicians (67%) completed questionnaires. Fourteen skills (seven cognitive and seven psychomotor) were reported to be "essential" or "very important" by at least 80% of the physicians. A total of 43 skills were rated as "essential" or "very important" by at least 50% of responding family physicians. Many of the hospital-based procedural skills, particularly those used in an intensive care setting, were rated as less important. The importance ratings of many skills were associated with the physicians' ages, size of their primary hospitals, and availability of other medical specialties. CONCLUSIONS: Family physicians tended to rate office-based procedural skills, counseling skills, and management skills as "essential or very important" to their practices. These rating might be used to guide residency training in family practice.     

When medical group and HMO part company: disenrollment decisions in Medicare HMOs

Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.     

Preferences of physicians and their patients for end-of-life care

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.     

Medicare managed care. How physicians can make it better

The federal government is attempting to control anticipated, increased Medicare health care costs by providing the senior population with incentives to encourage their movement into managed care programs. For-profit corporate HMOs that currently dominate the managed care arena are coming under increased competitive pressure at a time when their perception of profiteering is undergoing increased public scrutiny. If physicians are to take advantage of this window of opportunity and successfully enter the Medicare managed care marketplace, they must identify the major deficiencies existing in the current model, and fashion a new product that divests itself of the profit orientation of current corporate HMOs. A nonprofit version of a highly integrated, multispecialty provider service organization (PSO) provides an appropriate model to effectively compete with the corporate HMO. The ideal physician-controlled managed care model must: develop a responsive policy board structure; create practice guidelines that decrease variation in physician practice; achieve an appropriate balance between primary and specialty medical care; and adopt a quality-assurance program that effectively addresses both process and outcome data.     

Medical management of obesity

CONTEXT: Since the initiation of managed health care, little information has been available on whether family planning agencies are seeking ways to serve (and obtain reimbursement for serving) the growing number of clients who are managed care enrollees. METHODS: A 1995 mail survey sought information from a nationally representative sample of publicly funded family planning agencies about the agencies' involvement with managed health care plans and related clinic services, policies and practices. Completed surveys were received from 603 agencies, for an overall response rate of 68%. RESULTS: One-half of all publicly funded family planning agencies had served known enrollees or managed care plans. One-quarter (24%) had served managed care enrollees under contract, while others sought out-of-plan reimbursement for services provided to enrollees (13%) or used other sources to cover the cost of these services (12%). Family planning clinics administered by hospitals and community health centers were more likely than other types of clinics to have contracts to provide full primary-care services to managed care enrollees, whereas Planned Parenthood affiliates were more likely to have contracts that covered the provision of contraceptive care only. Clinics administered by health departments rarely had secured managed care contracts (10%), and only 36% reported even serving managed care enrollees. CONCLUSIONS: The challenges presented by managed care, and agencies' responses to these challenges, vary according to the type of organization providing contraceptive care. Family planning agencies need to seek relationships with managed care organizations based on those services that their clinics can best supply.     

Effects of toothbrush design and brushing proficiency on plaque removal

BACKGROUND: Primary care physicians frequently use antibiotics for nonindicated conditions and conditions for which antibiotics have not been shown to be effective. The intention of this study was to determine whether shifting the costs from the insurer to physicians in a staff model health maintenance organization (HMO) influenced antibiotic prescribing. METHODS: A random sample of patients in whom upper respiratory infections (URIs) (n = 334) or acute bronchitis (n = 218) were diagnosed within a 12-month period was selected from a large multispecialty group practice whose population was predominantly fee-for-service (FFS) and from a staff model HMO. Detailed chart reviews were performed to verify the diagnosis and note secondary diagnoses, identify whether an antibiotic or other medication was prescribed, assess whether diagnostic testing was performed, and determine the specialty of the clinician. RESULTS: After excluding patients seen with sinusitis, otitis media, or streptococcal pharyngitis, 334 patients with URIs and 218 patients with acute bronchitis remained for analysis. For URIs, antibiotic prescribing was higher in the HMO population than in the FFS group (31% vs 20%, P = .02). In patients with acute bronchitis, HMO patients were also more likely to have an antibiotic prescribed, but the difference was not statistically significant (82% vs 73%, P = .11). Further analyses showed that while HMO physicians were more likely to prescribe antibiotics, they were less likely to prescribe other medications for acute bronchitis or use diagnostic tests for evaluation of patients with URIs or bronchitis. CONCLUSIONS: Shifting costs from insurer to physicians through managed care appears to reduce diagnostic testing for URIs and acute bronchitis, but does not decrease excessive use of antibiotics and may actually increase antibiotic use for URIs.     

Gag rules and trade secrets in managed care contracts. Ethical and legal concerns

Gag rules-clauses in managed care contracts that prevent physicians from disclosing information that the plan may find disparaging, but that could relate directly to the patient's health-have recently been the subject of ethical condemnation and legislative prohibition. Another serious problem in managed care contracts, trade secrets, or guidelines and quality assurance mechanisms that are imposed on physicians while their origins are shrouded in proprietary secrecy, have by contrast received little attention. Responses to these ethical challenges to the physician's integrity must involve individual physicians, managed care organizations, professional organizations, and public policymakers.     

Asian blepharoplasty with a short-pulsed contact Nd-Yag laser: limited-incision resectable laser double fold with internal medial and lateral functional epicanthoplasty

PURPOSE: To determine how often primary care physicians screen adolescents for important risk factors and to determine how rates of screening vary by physicians' specialty and practice setting, patients' age, and type of risk factor. METHODS: A stratified random sample of 343 California physicians who are Board certified in pediatrics, family practice, or internal medicine, and physicians in these specialties who specialized in adolescent medicine were surveyed about their screening practices using a mailed questionnaire. Subjects were asked the percentage of routine comprehensive physical examination during which they personally queried or screened each age group of adolescents (11-14 years old and 15-18 years old) for each of the following risk factors: high blood pressure, alcohol use, cigarette use, sexual activity, and drug use. RESULTS: The frequency with which primary care physicians reported actually screening younger and older adolescents for the various risks were approximately: 93% and 96% for high blood pressure, 70% and 84% for alcohol use, 74% and 82% for drug use, 67% and 83% for sexual activity, and 76% and 86% for smoking, respectively. For all risk factors, providers screened older adolescents more frequently than younger adolescents (p < 0.01). Finally, screening rates varied by specialty (p < 0.01) but not by practice setting. CONCLUSIONS: This study found that California physicians frequently screen adolescents for a variety of risk factors. However, the reported rates may not be consistent with published guidelines. Interventions may need to be developed which focus on improving primary care physicians' adolescent-specific screening practices.     

Primary care physicians' medical decision making for late-life depression

OBJECTIVE: To describe primary care physicians' clinical decision making regarding late-life depression. DESIGN: Longitudinal collection of data regarding physicians' clinical assessments and the volume and content of patients' ambulatory visits as part of a randomized clinical trial of a physician-targeted intervention to improve the treatment of late-life depression. SETTING: Academic primary care group practice. PATIENTS/PARTICIPANTS: One-hundred and eleven primary care physicians who completed a structured questionnaire to describe their clinical assessments immediately following their evaluations of 222 elderly patients who had reported symptoms of depression on screening questionnaires. INTERVENTIONS: Intervention physicians were provided with their patient's score on the Hamilton Depression rating scale (HAM-D) and patient-specific treatment recommendations prior to completing the questionnaire regarding their clinical assessment. MAIN RESULTS: Those physicians not provided HAM-D scores were just as likely to rate their patients as depressed, as determined by specific query of these physicians regarding their clinical assessments. A physician's clinical rating of likely depression did not consistently result in the formulation of treatment intentions or actions. Treatment intentions and actions were facilitated by provision of treatment algorithms, but treatment was received by fewer than half of the patients whom physicians intended to treat. Barriers to treatment appear to include both physician and patient doubts about treatment benefits. CONCLUSIONS: Lack of recognition of depressive symptoms did not appear to be the primary barrier to treatment. Recognition of symptoms and access to treatment algorithms did not consistently result in progression to subsequent stages in treatment decision making. More research is needed to determine how patients and physicians weigh the potential risks and benefits of treatment and how accurately they make these judgments.     

Is gatekeeping better than traditional care? A survey of physicians' attitudes

CONTEXT: Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven. OBJECTIVE: To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost. DESIGN: Cross-sectional survey of primary care physicians SETTING: Outpatient facilities in metropolitan Boston, Mass. PARTICIPANTS: All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded. OUTCOMES MEASURES: Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care. RESULTS: Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans. CONCLUSIONS: Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.     

Differential diagnosis of posterior cranial fossa: potentialities and unsolved problems

This study describes nurse practitioners' (NPs) practice and employment trends, primary care/direct patient care involvement, scope of practice issues, productivity, and demographic characteristics. Data were collected by mailed survey from 2,499 NPs in New York State. NPs were predominantly certified as Adult, Pediatric or Family NPs. The vast majority of NPs were working (64.1% full-time; 22.7% part-time). Fifty percent said they spend over 80% of their time providing primary care. Over 50% of the NPs employed in non-hospital settings said that their organizations had contracts with four or more managed care organizations.     

The effect of physician practice organization on efficient utilization of hospital resources

OBJECTIVE: This study examines variations in the efficient use of hospital resources across individual physicians. DATA SOURCES AND SETTING: The study is conducted over a two-year period (1989-1990) in all short-term general hospitals with 50 or more beds in Arizona. We examine hospital discharge data for 43,625 women undergoing cesarean sections and vaginal deliveries without complications. These data include physician identifiers that permit us to link patient information with information on physicians provided by the state medical association. STUDY DESIGN: The study first measures the contribution of physician characteristics to the explanatory power of regression models that predict resource use. It then tests hypothesized effects on resource utilization exerted by two sets of physician level factors: physician background and physician practice organization. The latter includes effects of hospital practice volume, concentration of hospital practice, percent managed care patients in one's hospital practice, and diversity of patients treated. Efficiency (inefficiency) is measured as the degree of variation in patient charges and length of stay below (above) the average of treating all patients with the same condition in the same hospital in the same year with the same severity of illness, controlling for discharge status and the presence of complications. PRINCIPAL FINDINGS: After controlling for patient factors, physician characteristics explain a significant amount of the variability in hospital charges and length of stay in the two maternity conditions. Results also support hypotheses that efficiency is influenced by practice organization factors such as patient volume and managed care load. Physicians with larger practices and a higher share of managed care patients appear to be more efficient. CONCLUSIONS: The results suggest that health care reform efforts to develop physician-hospital networks and managed competition may promote greater parsimony in physicians' practice behavior.     

Managed care liability update

As the volume of litigation involving managed care grows, the liability issues become clearer. For example, recent decisions demonstrate that failure to provide access to qualified physicians, failure to process claims appropriately, denial of claims and undue delay of treatment can and do lead to liability. Moreover, the federal Employment Retirement Income Security Act of 1974 (ERISA) won't protect the managed care providers, and physicians may sue the managed care organization if its policies or agents open them to liability.     

Termination conceivable and inconceivable.

Suggests that psychoanalysts seem to have deep-seated resistances to thinking about termination in a way that promotes clinical and scientific growth and focuses on the factors in the analyst that make termination inconceivable. Factors influencing obstacles to conceiving of termination are examined including aspects in the history of psychoanalysis, the theoretical models held by analysts, and the kind of termination experience analysts themselves have had. It is argued that major sources of analytic resistance to termination issues lie in several areas including: analysts' failure to acknowledge mismanagement of termination by the psychoanalytic pioneers, the unexamined repetition of past technical errors (e.g., forced terminations), the denial that analysts also have reactions to the loss of a patient, and the denial that strongly held psychoanalytic models will influence what emerges and what is attended to during termination. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Physicians'' experiences and beliefs regarding informal consultation

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.     

Variations in the management of primary care: effect on cost in an HMO network

OBJECTIVE: To determine the relation to cost of different aspects of the management of primary care among group practices within a health maintenance organization network. MEASURES: A cross-sectional survey study of medical practices conducted with Blue Cross Blue Shield of Minnesota, St Paul. The subjects were group practices accepting financial and administrative responsibility for primary care services in the managed care plans of Blue Cross Blue Shield of Minnesota. One hundred twelve primary care practices and 153397 enrollees were included in this analysis. The principal resource use measure in this study was nonhospital cost per member per year estimated from payments to providers plus subscriber-eligible liability. RESULTS: The medical directors' responses revealed considerable variability in the management of primary care in these 112 practices. Group practice characteristics consistently associated with lower nonhospital cost were patient identification of a primary care physician, cost of care profiling, more frequent physician profiling, more patients per hour in the clinic, a higher proportion of primary care physicians in the specialty of family or general practice, and a greater number of physicians in the group practice. CONCLUSIONS: Results of this study demonstrate substantial variation in the management of primary care among group practices participating in a health maintenance organization network. These differences are associated with significant variation in the nonhospital cost of care for enrollees.     

Attitudes and expectations of 1995 gastroenterology graduates about gastroenterology

OBJECTIVE: To learn more about current attitudes and expectations of recent (June 1995) graduates of gastroenterology fellowship programs, why they chose either a private practice or academic career, and what impact managed care or health care reform had in their decision. METHODS: Between April and June 1995, and 8-page, 35-question survey questionnaire was mailed to graduating fellows and returned for evaluation. RESULTS: Graduates believed managed care had an impact on job availability, but it was not a factor in their job choice. Forty percent of the respondents reported that finding a job was either difficult or very difficult. The majority of respondents (67%) are pursuing a career in private practice. Most private practice physicians (PP) trained in 2-yr programs whereas academic physicians (AC) trained for the most part in 3-yr programs. The principal criteria on which decisions regarding job selection were based were similar between the two groups: co-workers, geographic location, access to patient care, and ability to perform endoscopy. Respondents in PP and AC expected to work 50-70 h/wk, care for patients with similar diseases, and have ample time for family. They would choose GI again as a career and believed that there is a future in GI. Salary expectations varied markedly between the two groups, and AC physicians were more concerned about their future financial needs. Twenty percent of PP physicians and 71% of AC physicians plan to participate in clinical research. CONCLUSIONS: Recent graduates of gastroenterology fellowship programs continue to have high expectations of their future careers. Although some had difficulty finding a job and stated that, although managed care had an impact on the job market, it had not yet become a major factor in their job selection.     

Physician's attitudes toward the ill aged and nursing homes

A survey of physicians in private practice (exclusive of pediatricians) was conducted in a medium sized suburban city in the New York metropolitan area, to determine whether physicians' attitudes toward the ill aged and nursing homes were predictors of the quality of medical care available to area nursing home patients. Questionnaires were circulated to 302 practitioners. Of the 28 percent who responded, 32 percent were psychiatrists, 15 percent primary care physicians and 8 percent orthopedists. Physicians felt competent to manage the ill aged, although 50 percent had had no significant degree of exposure to geriatric medicine in their medical education, and 70 percent of the primary care group had had none. Primary care and older physicians were more likely to treat patients in nursing homes. Almost 40 percent viewed the nursing home as a place to die. Although 85 percent studied that physicians should be involved in the nursing home displacement process, only 21 percent believed that they continued to be in charge of their patients after placement. The findings demonstrate generalized medical disinterest in the care of ill aged patients in institutions. The persons responsible for awarding government grants and those involved in planning medical school curricula should pay more attention to the needs of the chronically ill aged.