Provider choice and continuity for the treatment of depression

The role of specialist versus generalist providers regularly surfaces in health-care reform debates about costs and quality of care. By changing incentives to seek and deliver care, different payments systems can affect both the probability of initial specialty care and the duration of this patient-provider relationship. The authors compare provider selection (psychiatrist, nonphysician mental-health specialist, general medical provider) and duration of this relationship among depressed patients in prepaid and fee-for-service plans. Regarding initial care, depressed patients in prepaid plans are significantly less likely to see a psychiatrist and more likely to see a nonphysician mental-health specialist than patients in fee-for-service plans. Although the mix of providers differs, patient demographic and clinical characteristics have similar effects on specialty in both payment systems, ie, there are no differences in who gets specialty care by type of payment, but in how many get specialty care. The average duration of a patient-provider relationship is significantly shorter in prepaid plans. Durations are significantly shorter for patients of both psychiatrists and general medical providers in prepaid plans, but do not differ by payments type for nonphysician therapists. In both payments systems, patients of nonphysician providers end the relationship sooner than patients of psychiatrists or general medical providers. Although the authors find provider switching to be associated significantly with discontinuing antidepressant medication, there is no significant direct effect on patient health outcomes.     

Computerized health maintenance tracking systems: a clinician's guide to necessary and optional features. A report from the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems

BACKGROUND: To promote preventive health care by primary care physicians and the development of computerized health maintenance tracking systems, the American Cancer Society sponsored an expert advisory group to define necessary and desirable, but optional features of computer-based health maintenance tracking software for use in primary care practice. METHODS: Systematic literature review and structured consensus development were followed by independent expert critique. RESULTS: Necessary input features include a comprehensive, practice-specific health maintenance protocol, multiple entry codes to indicate the current status of each procedure, and a mechanism for patient-specific exclusion or alteration of procedure frequency. Necessary features of the information management system include a linkage to a demographic data system, optional tracking of all or selected patients, identification of each patient's primary provider, and the ability to provide either a paper or electronic interface for the provider. Necessary outputs include provider reminders, patient reminders sent regularly regardless of visit status, and summary reports of provider and patient compliance. CONCLUSIONS: Although the ideal computer-based health maintenance tracking system is still evolving, knowledge of these necessary and optional features can aid clinicians interested in buying or developing a system for their own practice.     

Classifying rehabilitation inpatients by expected functional gain

OBJECTIVES: To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented here groups patients according to their gains in functional status during the rehabilitation stay. METHODS: Data from 84,492 patients discharged from 252 rehabilitation facilities in 1992 were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The gain-FRGs system used four predictor variables: (1) diagnosis leading to disability, admission scores on the (2) motor and (3) cognitive subscales of the FIM, and (4) patient age. RESULTS: The gain-FRGs system contained 74 patient groups and explained 21% of the variation in functional gain for patients in a different set of records withheld for validation. CONCLUSIONS: The gain-FRGs system should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone.     

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.     

Tracking medical students' clinical experiences with a computerized medical records system

A fully computerized system for recording and reporting of medical students' patient contacts has been developed and successfully used in a high-volume outpatient practice. In contrast to previously described systems, the need for manual recording and/or entry of patient data has been eliminated by the use of an existing, integrated computerized medical records system. This makes possible the generation of frequent reports and timely review and adjustment of student experiences. The system has broad applicability and may also be useful for research in medical education.     

Reorganizing departments of psychiatry, hospitals, and medical centers for the 21st century

Market forces are reshaping health care, transforming it from a public service into a product that is sold in a highly competitive marketplace. This transformation has been particularly disruptive for hospital departments of psychiatry and medical centers that were the early targets for managed care efforts at cost containment. To survive, health care institutions have embarked on a clinical and administrative re-engineering process. The author describes a series of steps for reconfiguring departments, hospitals, and medical centers as they enter the 21st century. The steps include identifying the leadership team, formulating a mission statement and strategic plan, creating a legal entity capable of achieving the organization's goals, drawing up an organizational chart, and developing the provider network. Other steps in the process include enhancing the continuum of services offered, developing administrative capability, dealing with managed care, paying attention to fundamental business practices, integrating psychiatric services into the health care system, and marketing psychiatric services.     

Contributions to patient adherence: Is it time to share the blame?

Poor adherence to treatment is well recognized and contributes significantly to treatment failures in medical care. Studies examining contributing factors have focused predominantly on the patient. Studies examining provider influences have primarily examined communication styles or educational practices. M. R. DiMatteo et al (see record 1993-26883-001) show that other characteristics of the provider may influence patient behavior. Particularly interesting is the finding that baseline adherence predicts adherence 2 yrs later. Although this study opens the door to an examination of provider characteristics and their influence on patient behavior, care needs to be taken to avoid too rapid an acceptance of the discrete findings. The study used self-report by interview, a measure that can be significantly biased. However, this study provides future avenues to explore using more objective measures of patient adherence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abciximab therapy in percutaneous intervention: economic issues in the United States

Whether abciximab therapy should be the standard of care during percutaneous intervention in the United States depends on its efficacy, safety, and economics. In view of the EPIC, CAPTURE, and EPILOG data, few question the superior efficacy and relative safety of abciximab compared with conventional high-dose heparin therapy during percutaneous intervention. Economic considerations have been the major issue limiting its use. Review of the economic data demonstrates that the incremental direct medical care cost of abciximab therapy is $290 to $600 per patient treated in the EPIC and EPILOG populations. In the patients with acute myocardial infarction and unstable angina, abciximab appears to reduce direct medical costs (produce cost savings) at 6 months. Given abciximab's significant incremental effectiveness, its relatively small incremental cost yielded a highly cost-effective therapy in the EPIC and EPILOG patient populations. Additional economic issues relate to minimizing bleeding complications, indirect costs, reduced frequency of emergency procedures, and rationalizing provider/payor policies and incentives to produce the optimal individual patient and societal outcomes. The currently available data concerning the efficacy, safety, and cost provide a compelling argument for embracing abciximab therapy in the treatment of patient subsets where it will be a cost-saving or cost-neutral adjunct to percutaneous coronary intervention. In other subsets, the direct medical cost will likely not be fully recouped, but the incremental cost-effectiveness will compare favorably to other widely accepted therapies.     

Telemetry in health care

This article reviews the use of telemetry in health care. Monitoring of biological signals of medical importance such as the EKG, EEG, and EOG are described. Employment of telemetry in critical medical and surgical environs such as the delivery and operating suites is covered. The enormous importance of telemetry compatible with public communication systems such as voice grade telephone lines for remote medical care is discussed. The article does not enter into strictly engineering systems aspects in any detail; this was not the intent of the author. Nor is there any pretence to a completeness obviously not possible within its confines. It does concentrate on radio (wireless) telemetry transmissions over relatively great distances with freedom of patient movement.     

Do depressed patients in different treatment settings have different levels of well-being and functioning?

Differences in the functioning and well-being of adult patients with current or past depressive disorder who visited clinicians of different specialties in HMOs, solo practices, or large multispecialty group practices were examined. For patients in different systems, there were no significant differences in functioning and well-being across 12 domains tested. Patients of mental health specialists had worse mental health and more limitations in social activities, whereas patients of medical clinicians had worse physical functioning, more pain, more physical/psychophysiologic symptoms, and worse health perceptions. Thus, each system of care had depressed patients with a similar functioning and well-being "burden," but specialty sectors had patients with slightly different functioning and well-being profiles, probably reflecting patient selection of type of provider. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reperfusion injury delays healing of intestinal anastomosis in a rat

This SAEM position paper clarifies the role of emergency medicine in health care delivery. It builds upon the working definition of emergency medicine developed by the American College of Emergency Physicians in 1994 by describing the health care role of emergency physicians (EPs). EPs are first-contact providers who care for all patients regardless of age, gender, time of presentation, or ability to pay. They remain the only continuously accessible specialty for patients seeking help and solace in the health care system. They are an essential link in the health care continuum between primary care physicians, specialists, the out-of-hospital system, the patient, inpatient services, and communication services. The EP's role is in organizing and monitoring the emergency care delivery system. Part of this role is to better align the health care provider training and ability with the specific medical needs of a patient. The emergency health care system remains the essential medical safety net for all individuals needing care in this country.     

Patient-reported medical outcomes according to physician type and region

The purpose of the present study was to determine whether patients with common foot disorders have different medical outcomes depending on whether podiatrists, orthopedic surgeons, or other physicians provided their medical care in rural or urban areas. A validated medical effectiveness score was formulated using indirect standardization of risk-adjusted morbidity, based on patient reports from a national random household interview survey of 3,270 subjects. Patients in rural and urban areas did not differ significantly in medical outcomes across provider types, but there was a trend for patients in rural areas to have poorer outcomes. The medical effectiveness score of podiatrists was 3.9 times higher (indicating more beneficial outcomes) than that of orthopedic surgeons or other physicians (p < 0.01). Patients that visited podiatrists for common foot problems reported significantly more beneficial outcomes than those who visited other types of health care providers.     

Structure of two fragments of the third cytoplasmic loop of the rat angiotensin II AT1A receptor. Implications with respect to receptor activation and G-protein selection and coupling

Managed care is an increasingly widespread way of delivering health care that combines medical care provider systems (doctors, nurses, clinics, hospitals) with the payor system (health insurance). This article gives a historical overview of managed health care, discusses managed HIV care, and managed care reform.     

Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination's guidelines, all four recommendations can be classified as 'level C' with a quality of evidence of II.     

Informatics support to medical diagnosis. General information obtained from a first structured contact with the patient

BACKGROUND: The methods and characteristics of clinical data gathered at the initial steps of development of a computerized system to aid medical diagnosis are reported. The objectives of the study were as follows: to describe the overall method and to set a framework for developing an intellectual model of the medical diagnosis procedure. MATERIAL AND METHODS: A structured medical interview and physical examination using an informatic program on PC compatible portable computers were completed in a sample 1,238 patients attending the outpatient clinics of our institution. Data obtained were compared with information in the patient's medical record taking as reference pattern the record of physicians in charge of the patients. Diagnosis were codified according to WHO International Classification of Diseases (ICD-9-CM). RESULTS: The distribution of symptoms and signs corresponding to the different organs and systems was analyzed. Each subdivision afforded a range of 1.3 to 3.9 abnormal findings per patient. A total of 3,571 diagnoses were codified for the whole group 1,238 patients with a mean (standard deviation) of 3 (2) diagnoses per patient (range 0-12). The distribution of diagnostic groups varied depending on the consideration of the main diagnosis or the concomitant diagnoses that defined the patient's clinical context. The most frequent main diagnoses included tumors, cardiovascular diseases, gastrointestinal disorders, and genitourinary tract diseases. CONCLUSIONS: As shown by results obtained in a sample of 1,238 patients, there is a very complex situation in clinical practice due to the simultaneous occurrence of several clinical patterns. This finding should be taken into account when developing clinical decision making support systems. The use of a structured medical interview or a structured and standard medical visit may be an adequate tool to clarify this matter and to contribute to standardization of clinical concepts and situations.     

Billing third party payers for pharmaceutical care services

OBJECTIVE: To describe the steps pharmacists must complete when seeking compensation from third party payers for pharmaceutical care services. DATA SOURCES: Government publications; professional publications, including manuals and newsletters; authors' personal experience. DATA SYNTHESIS: Pharmacists in increasing numbers are meeting with success in getting reimbursed by third party payers for patient care activities. However, many pharmacists remain reluctant to seek compensation because they do not understand the steps involved. Preparatory steps include obtaining a provider/supplier number, procuring appropriate claim forms, developing data collection and documentation systems, establishing professional fees, creating a marketing plan, and developing an accounting system. To bill for specific patient care services, pharmacists need to collect the patient's insurance information, obtain a statement of medical necessity from the patient's physician, complete the appropriate claim form accurately, and submit the claim with supporting documentation to the insurer. Although many claims from pharmacists are rejected initially, pharmacists who work with third party payers to understand the reasons for denial of payment often receive compensation when claims are resubmitted. CONCLUSION: Pharmacists who follow these guidelines for billing third party payers for pharmaceutical care services should notice an increase in the number of paid claims.     

A voice-enabled, structured medical reporting system

Kurzweil Applied Intelligence received a research grant from the National Institute of Standards and Technology (NIST) Advanced Technology Program to develop a prototype voice-enabled, structured medical reporting system. In typical usage, the physician dictates to the system, which then uses automatic speech recognition and medical knowledge bases to produce a structured report. This report can then be formatted and viewed on a computer screen, stored in databases of patient information, transmitted to other systems, used to support outcome studies, or viewed on a Web browser. The output reports are structured according to two standard, platform-independent formats: SGML and CORBA. These formats represent the data in a way that can be read by both computers and humans, and efficiently communicated to a wide range of databases and communications protocols.     

Controlling the hemodynamic response to laryngoscopy and endotracheal intubation

The hemodynamic response to the stress of laryngoscopy and endotracheal intubation does not present a problem for most patients. However, patients with cardiovascular or cerebral disease may be at increased risk of morbidity and mortality from the tachycardia and hypertension resulting from this stress. These hemodynamic effects gained notice after the introduction and use of muscle relaxants, such as curare and succinylcholine, for endotracheal intubation at the time of anesthesia induction. A variety of anesthetic techniques and drugs are available to control the hemodynamic response to laryngoscopy and intubation. The method or drug of choice depends on many factors, including the urgency and length of surgery, choice of anesthetic technique, route of administration, medical condition of the patient, and individual preference. The possible solutions number as many as the medications and techniques available and depend on the individual patient and anesthesia care provider. This paper reviews these medications and techniques to guide the clinician in choosing the best methods.     

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.     

A computerized obstetric medical record

Duke University has utilized computerized obstetric medical records since 1971. System evolution is described. Deficiencies in the current system appear to evolve from the computer/human interface rather than from basic system design. Critical elements in system success are physician acceptance of the appearance of data collection sheets and printed notes and continual rapid response in programing modification to allow for physician individuality and changes in medical practice. The limiting factor in the potential usefulness of such a system is the rate of incomplete data collection. It is suggested that if the physician were to enter data directly into the computer through a terminal, data collection would be more accurate and complete.