Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study. SETTING: A public hospital in Atlanta, Georgia. PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse. CONCLUSIONS: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.     

Transition to a computer-based record using scannable, structured encounter forms

OBJECTIVE: To evaluate the quality of documentation and user satisfaction with a structured documentation system for pediatric health maintenance encounters, using scanned paper-based forms to generate an electronic medical record. DESIGN: (1) A retrospective medical record review comparing 16 structured (ST) records with 16 contemporaneously created unstructured records, (2) a questionnaire evaluation of user satisfaction, and (3) an electronic records review of patients seen 1 year following the full implementation of the system to evaluate persistence of the effect. SETTING: The Yale-New Haven Hospital Pediatric Primary Care Center, New Haven, Conn, an inner-city clinic in an academic center. PARTICIPANTS: (1) A random sample of 16 health maintenance records completed by first- and second-year residents in February 1996 matched for patient's age and provider training level with 16 contemporaneously documented visits, (2) 16 of 18 pediatric level 1 residents and 14 of 16 pediatric level 2 residents who completed questionnaires, and (3) all electronic records of health maintenance visits during February 1997. MAIN OUTCOME MEASURES: The number of data elements documented and the percentage of records that record specific components of the health maintenance encounter. User satisfaction was specified on a Likert scale. RESULTS: Overall, residents in the ST records group documented more data elements per visit than did those in the unstructured records group. The number of developmental items documented was 11.5 per visit in the ST records group and 4.8 per visit in the unstructured records group (P = .004). Likewise, anticipatory guidance was more thoroughly documented in the ST records group--8.3 items per visit vs 2.5 items per visit (P < .001). Ninety percent of the users preferred the ST records. One year after the adoption of the ST recording system, high levels of thoroughness persisted. CONCLUSIONS: Structured, scannable encounter forms can facilitate documentation of patient care and are well accepted by users. They can provide an effective mechanism to ease the transition to a computer-based patient record.     

Direct observation of community-based ambulatory encounters involving medical students

CONTEXT: The current shift of predoctoral medical education from inpatient tertiary settings to community-based, ambulatory practice has raised questions about the effect of the medical student on the process of patient care. OBJECTIVE: To determine how the presence of a medical student during the ambulatory medical encounter affects the use of clinical time and patient satisfaction. DESIGN: Cross-sectional, multimethod study using direct observation of ambulatory care by research-trained nurses. SETTING: A total of 16 community-based family practice offices accepting family practice clerkship students. PATIENTS: A total of 452 outpatient visits with and without student involvement. MAIN OUTCOME MEASURES: Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Study 9-item visit rating scale. RESULTS: When students were involved, physicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01), and answering questions (P=.04). Despite these differences, patients were equally satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. There was no difference in time spent in treatment planning, physical examination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minutes, P=.6) student involvement. There was no decrease in patient satisfaction when students were involved. Physicians were more likely to discuss another family member's problems when a student was present (P=.001). Students were directed to care for minority patients at a disproportionate rate (P=.001), controlling for confounding variables. CONCLUSIONS: Medical student involvement alters the content but not the duration of the ambulatory medical encounter. Application of validated measures indicate that students did not impair patient satisfaction or hinder the physicians' ability to ensure that patient expectations for the visit were met.     

How do physicians talk with their patients about risks?

To describe the communication about risk between community-based physicians and their patients, the authors audiotaped 160 physician-patient encounters in the private practices of 19 physicians. Coding was done using a structured scheme to identify the presence of talk about risk of future illness, and to describe its characteristics. Patient understanding and satisfaction were assessed through an interview. Risk discussion occurred in 26% (95% CI 19%-33%) of the visits, quantitatively in two cases and specifically with respect to outcome in 48% (95% CI 40%-56%) of the visits. The patients initiated only 16% of this discussion but were, in general, satisfied with their care and the information they had received, but they had poor recall of the specifics of the discussion.     

Incidence of endocrine complications and clinical disease severity related to genotype analysis and iron overload in patients with beta-thalassaemia

OBJECTIVES: This study determined demographic characteristics, satisfaction with care, and likelihood of follow-up dentist visits for patients seen in office-based, independent, dental hygienist practices. METHODS: New patients were surveyed after their initial visits to independent hygienist practices to assess their demographic characteristics and satisfaction with care at both the beginning of practice operations and 18 months after the start of these practices. Follow-up surveys were sent to patients 12 and 24 months after their initial visits to the independently practicing dental hygienists to determine if patients had visited a dentist. RESULTS: Most respondents were white, female, had attended some college, and reported high family incomes. Ninety-eight percent of respondents were satisfied with their dental hygiene care. Follow-up questionnaires revealed that over 80 percent of respondents visited the dentist within 12 months of receiving dental hygiene care in independent settings. This level of follow-up care with dentists was found both for respondents who reported having a regular dentist at their initial visits with the hygienists and for those who reported not having a regular dentist. CONCLUSIONS: Independent practice by dental hygienists provided access to dental hygiene care and encouraged visits to the dentist.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis

OBJECTIVE: To evaluate the utility of "clinic room" case presentation in the ambulatory care setting. BACKGROUND: Neurology is increasingly an outpatient specialty. The transition from ward to clinic presents challenges for student and resident education. Interaction between attending physician and trainee is limited by busy patient schedules. New educational strategies must be developed to address the particular challenges of the outpatient clinic. One strategy to increase the quality and length of attending-trainee interaction is case presentation in the patient's presence. METHODS: The authors randomized 100 patients seen in an academic neuromuscular clinic to presentation in a conference room or clinic room. In the latter, all interaction between the trainee and attending occurred in the patient's presence. The attending recorded the time spent with the trainee and patient. The patient was asked to complete a survey and provide certain demographic information. RESULTS: The two groups were similar demographically. Time spent by the attending physician was similar between the two settings. Although there was no difference in patient satisfaction, those randomized to clinic room presentation were significantly more likely (p < 0.002) to feel their questions were answered adequately. There were trends toward these patients feeling less embarrassed, feeling that they were treated respectfully, and feeling that adequate time was spent with them. CONCLUSIONS: Although clinic room presentation does not save attending time, it allows for a more dynamic and intensive interaction among teacher, student, and patient.     

Risk factors for noncompliance with glaucoma follow-up visits in a residents' eye clinic

OBJECTIVE: This study aimed to identify factors associated with compliance with glaucoma follow-up visits. DESIGN: Computer records of a university residents' eye clinic were reviewed to identify a random sample of all persons who had an examination with International Classification of Disease (ICD) 9 coding (ICD9) for glaucoma suspect or glaucoma during a 2-year period (1991-1993) to undergo telephone interview. PARTICIPANTS: Those who were seen at least every 6 months regardless of earlier return instructions were defined as compliant with follow-up (controls, n = 362). Those who had any lapse between visits of longer than 6 months were defined as noncompliant (cases, n = 362). RESULTS: Interviews were completed for 196 cases and 242 controls. Noncompliant persons were significantly more likely to be suspects for glaucoma rather than to have definite glaucoma and to be dissatisfied with waiting time in the clinic (29.1% vs. 17.8%, P < 0.005) and to state that they did not take their glaucoma medications as prescribed (25.4% vs. 13.4%, P < 0.004). They also were less likely to have been prescribed eyedrop medication. A high percentage of both patients and controls knew that glaucoma can lead to blindness (85.2% and 88.4%, respectively). The most common reasons patients gave for not keeping follow-up visits were the perception that their eye problem was "not serious enough," the cost of examinations, and that the doctor did not tell them to come back. CONCLUSION: Compliance with follow-up visits for glaucoma is associated with markers for early disease. Attempts to improve compliance might focus on improved communication of the seriousness of the disease and improvements in clinic waiting time.     

Eating habits of employees in the metal industry: determinants and patterns]

OBJECTIVE: To describe the proportion of frequent attenders among primary health care patients and their sociodemographic characteristics, morbidity and reasons for encounter. DESIGN: A cross-sectional case-control study. SETTING: A municipal health centre in Oulainen, a small rural town in northern Finland. PARTICIPANTS: Three hundred and four frequent attenders (eight or more visits to health centre physicians (GPs) during the year 1994) and 304 age- and sex-matched controls. MAIN OUTCOME MEASURES: Sociodemographic characteristics, numbers of encounters, chronic diseases classified by ICD-9 and reasons for encounter coded by the International Classification of Primary Care chapter codes (ICPC). RESULTS: 4.7% of the population aged 15 years or older and 6.8% of the annual patients were frequent attenders and they made 23.5% of all encounters with GPs. The frequent attenders had lower basic education and there were more people on disability pension among them. They had significantly more mental disorders and diseases of the musculoskeletal and digestive systems than the controls. The frequent attenders' most common reasons for encounter were musculoskeletal problems, and they had significantly more musculoskeletal, digestive system and psychiatric reasons for encounters than the controls. CONCLUSIONS: Frequent attenders express more somatic and less psychiatric reasons for encounter than can be assumed according to their morbidity. The role of somatization is discussed.     

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.     

Nuclear DNA damage during NAD(P)H oxidation by membrane redox chains

The objective of this study was to develop a valid and reliable discriminative index that measures parent satisfaction with the medical care of their infant in the NICU. We developed an initial questionnaire (Item Reduction Questionnaire) by reviewing the literature, surveying 63 NICU clinicians, and interviewing 125 parents of infants in 2 tertiary level NICUs regarding what they liked and disliked about the medical care of their infants. We administered the Item Reduction Questionnaire, which included 154 items, to 60 parents, who rated the frequency and importance of these items. We included the items identified most frequently as sources of dissatisfaction and rated most important in a second, briefer instrument, the Neonatal Index of Parent Satisfaction (NIPS). To measure reliability we administered the NIPS to 47 parents twice, separated by a 1-week interval. We assessed validity by comparing actual to predicted correlations between NIPS scores and other measures: parent's global rating of satisfaction, medical caregiver ratings of mother's satisfaction, medical caregiver ratings of father's satisfaction, and parents' perception of their infant's health status. We also compared mean NIPS scores for parents who did and who did not report incidents when errors occurred in the medical care of the infant. Of 154 items generated, we included 27 in the NIPS. The intraclass correlation between two administrations of the NIPS to the same 47 parents was 0.71. As predicted, there was a high correlation (0.61) between the NIPS score and parent global rating of satisfaction, and much lower correlations with other variables. Mean NIPS scores for parents who did and who did not report errors differed significantly (difference, 14.6; 95% CI around difference, 5.8-23.5; p < 0.001). The NIPS is likely to be a useful measure for discriminating between parents who differ in terms of their satisfaction with the medical care of their infant in the NICU.     

Association of symptoms of depression with diagnostic test charges among older adults

BACKGROUND: Previous studies have documented greater use of health services by depressed persons and have postulated that health care costs could be reduced overall through better recognition and treatment of depression. OBJECTIVE: To determine whether a greater burden of medical illness contributes to excess charges for diagnostic tests among older adults with symptoms of depression. DESIGN: Prospective cohort study. SETTING: A primary care group practice at an academic institution. PATIENTS: 3767 patients 60 years of age and older who completed testing on the Centers for Epidemiologic Studies Depression Scale (CES-D) during routine office visits. MEASUREMENTS: Charges for all inpatient and ambulatory diagnostic testing for 2 years, including clinical pathology, diagnostic imaging, and special procedures; number of visits to the ambulatory care center or emergency department; and number of hospitalizations. The Ambulatory Care Group case-mix approach, which is based on ambulatory diagnoses, was used as a measure of health status and expected resource consumption. RESULTS: Patients with symptoms of depression (CES-D scores > or = 16) were significantly younger (66.6 compared with 68.1 years; P < 0.001), more likely to be white (50.5% compared with 33.9%; P = 0.001), and more likely to be female (75.8% compared with 67.6%; P = 0.001) than were those without these symptoms (CES-D scores < 16). They also had more nonpsychiatric comorbid conditions, had more visits to the ambulatory care center (9.2 compared with 7.8; P < 0.001), were more likely to use the emergency department (52.3% compared with 40%; P = 0.001), were more likely to be hospitalized (22.4% compared with 17%; P = 0.002), and had greater median total diagnostic test charges for a period of 1 year ($583 compared with $387; P < 0.001). The difference in charges, most of which were clinical pathology charges (54.2%), persisted into the second year. Ambulatory Care Group assignment was independently associated with diagnostic test charges. The CES-D summary score was not independently associated with diagnostic test charges when controlling for Ambulatory Care Group assignment. CONCLUSIONS: Patients with symptoms of depression accrue greater average diagnostic test charges. However, these data suggest that such patients also have a greater burden of comorbid nonpsychiatric illness. Efforts to improve outcome and decrease cost for patients who have late-life depression must target interventions to improve the care of psychiatric and medical illness concurrently.     

Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996

OBJECTIVE: This report describes ambulatory care visits in the United States across three ambulatory care settings--physician offices, hospital outpatient departments, and hospital emergency departments. Statistics are presented on selected patient and visit characteristics for all ambulatory care visits and separately for each setting. METHODS: The data presented in this report were collected by means of the 1996 National Ambulatory Medical Care Survey (NAMCS) and the 1996 National Hospital Ambulatory Medical Care Survey (NHAMCS). These surveys are part of the ambulatory care component of the National Health Care Survey that measures health care utilization across a variety of providers. The NAMCS and NHAMCS are national probability sample surveys of visits to office-based physicians (NAMCS) and visits to the outpatient departments and emergency departments of non-Federal, short-stay and general hospitals (NHAMCS) in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1996 an estimated 892 million visits were made to physician offices, hospital outpatient departments, and hospital emergency departments in the United States, an overall rate of 3.4 visits per person. Visits to office-based physicians accounted for 82.3 percent of ambulatory care utilization, followed by visits to emergency departments (10.1 percent) and outpatient departments (7.5 percent). Persons 75 years and over had the highest rate of ambulatory care visits. Females had significantly higher rates of visits to physician offices and hospital outpatient departments than males did. About two-thirds of ambulatory care visits by black persons were to physician offices. There were an estimated 129.3 million injury-related ambulatory care visits during 1996 or 48.9 visits per 100 persons.     

Managed care and the treatment of skin disease, 1995. Continued growth and emerging dominance

OBJECTIVE: To document changes in type of financing for office-based visits for the treatment of common skin conditions and to dermatologists. DESIGN: Data from a national survey of visits to office-based practitioners conducted by the National Center for Health Statistics were used. The stratified sampling technique permits estimation of the total number of office visits with specific characteristics in the United States. SETTING: A national probability sample of visits to office-based practitioners occurring in 1995. SUBJECTS: In 1995, 36,875 visits were sampled. Of these, 2121 were for common skin problems to any physician and 1886 were visits for any reason to dermatologists. MAIN OUTCOME MEASURES: The distribution source of payment and presence of managed care arrangements for office visits for common skin problems and to dermatologists. INTERVENTION: None. RESULTS: In 1995, preferred provider and health maintenance organizations provided payment for 34% of all ambulatory care and 38% of office visits for common skin complaints. CONCLUSION: Managed care is already the dominant mechanism of payment for the treatment of skin disease for many patient groups and in many areas of the country. Preferred provider organizations are much more likely to employ dermatologists to provide care of common skin problems than are health maintenance organizations. If the recent trends continue, by year 2000 most patients seen by dermatologists will be seen under the auspices of managed care systems.     

Changes in NMDAR2 subunit mRNA levels during pentobarbital tolerance/withdrawal in the rat brain: an in situ hybridization study

BACKGROUND: Urban academic medical centers provide care for large populations of vulnerable older adults. These patients often suffer a disproportionate share of chronic illnesses, disabilities, and social stressors that may increase health care costs. OBJECTIVE: To describe the distribution and content of total healthcare costs accrued over a 4-year period by a community of older adults cared for in an urban academic healthcare system and to describe high-cost patients and utilization patterns. DESIGN: A cohort study. SETTING: A tax-supported public healthcare system consisting of a 450-bed hospital and seven community-based ambulatory care centers. PATIENTS: 12,581 patients aged 60 years and older who had at least two ambulatory visits and/or one hospitalization within the healthcare system from 1993 through 1995. MEASUREMENTS: Patient demographic and clinical characteristics, hospital and ambulatory utilization rates, and all healthcare costs accrued from 1993 through 1996 were determined. Costs were estimated from the perspective of the healthcare system using cost to charge ratios. MAIN RESULTS: The mean patient age was 70 years, 60% were women, 44% were Black, and 83% were covered by Medicare and/or Medicaid. Nearly 25% of patients were obese, 15.8% had a history of smoking, and 15.5% had evidence of malnutrition. The mean number of ambulatory visits per year was 4.3 (+/-7.2), and 38.1% of patients had been hospitalized one or more times. Within the 4-year window, 24.1% of patients had missed five or more appointments with their primary care physicians, 32.7% of patients had five or more unscheduled clinic visits, and 12.5% had five or more emergency room visits. Total health care costs for 4 years for this cohort of older adults was $125.2 million dollars, with per capita annual mean costs of $3893. Expenditures associated with hospitalizations accounted for 63.6% of healthcare costs. Total inpatient and outpatient costs for the 38% of patients hospitalized at least once accounted for 85.3% of all health care expenditures. Patients who died in the hospital did not accrue significantly greater costs than patients who died out of the hospital. Simulations of a random 5% adverse selection of high-cost patients among two capitated systems resulted in cost shifts of $11.1 million. Recorded smoking history, obesity, and low serum albumin were significantly associated with excess costs. CONCLUSIONS: Healthcare costs are concentrated in a significant minority of older adults. Costs accrued in conjunction with hospital stays dominate healthcare expenditures for this cohort of older adults. However, most older adults (83%) have one or fewer hospital episodes in a 4-year period. Although patients who died accrued greater healthcare costs, these costs were not higher when the death occurred in the hospital. Self-care behaviors are an important target for interventions to reduce costs.     

Assessment of medical care by elderly people: general satisfaction and physician quality

OBJECTIVE: To identify personal characteristics and factors related to health and patterns of healthcare utilization associated with the elderly people's satisfaction with medical care. DATA SOURCES/STUDY SETTING: Data from the 1991 Medicare Current Beneficiary Survey (MCBS) on 8,859 persons age 65 and over living in the community. STUDY DESIGN: Items reflecting general satisfaction with care and views of physician quality are examined and, based on factor analysis, grouped in dimensions of two (global quality, access) and three (technical skills, interpersonal manner, information-giving), respectively. The relationship of high levels of satisfaction in each dimension to personal characteristics of elderly people, and to measures of access and utilization, is assessed using logistic regression. PRINCIPAL FINDINGS: While satisfaction is high, with over 90 percent surveyed expressing some satisfaction, there is substantial variation with less likelihood of high satisfaction among those 80 or older, with less education and income and in poorer health. Longer waiting time at visits and less frequent visits are factors in lower satisfaction as well. A favorable perception of physician quality, especially regarding technical skills, appears to play a significant role in satisfaction with global quality of care. CONCLUSIONS: Studies of patient satisfaction in elderly people are rare. Some factors expected to be related to positive assessment based on earlier studies, were, e.g., better health and shorter waiting time, while others were not, e.g., increasing age. Elderly people appear to place greater importance on physician technical skills, as opposed to interpersonal dimensions, in assessing global quality. These findings suggest the need for a better understanding of how elderly people evaluate care and what they value in interactions with the healthcare system.     

A symptom-based measure of the severity of chronic lung disease: results from the Veterans Health Study

STUDY OBJECTIVES: We developed a symptom-based measure of severity for chronic lung disease (CLD) that can be readily administered in ambulatory care settings and be used to supplement general health-related quality of life (HRQoL) assessments and pathophysiologic indicators in research and clinical care. DESIGN: Cross-sectional data from the Veterans Health Study, an observational study of health outcomes in patients receiving Veterans Affairs (VA) ambulatory care. SETTING: Four VA outpatient clinics. STUDY SUBJECTS: Two hundred ninety-two participants with CLD were identified on the basis of patient report of having a physician's diagnosis of chronic bronchitis, emphysema, or asthma and either using inhaled medications or having a productive cough on most days for 3 months. MEASUREMENTS AND RESULTS: Participants were scheduled for an in-person interview in which they completed a CLD questionnaire and measurements of peak expiratory flow rate (PEFR). They were also mailed an HRQoL questionnaire, the Short Form Health Survey (SF-36). The CLD questionnaire included six symptom items chosen by an expert panel (two items each for dyspnea, wheezing, and productive cough). The combination of these items yielded a CLD severity index that correlated significantly with all eight scales of the SF-36 (range of r, -0.19 to -0.37; p<0.01). In contrast, PEFR had statistically significant correlations only with two SF-36 scales: physical functioning and bodily pain. CONCLUSIONS: The CLD severity index is a reliable and valid patient-administered instrument that may be used to evaluate the effects of CLD on general HRQoL and predict future health services utilization.