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BACKGROUND: During the past decade, a confluence of forces has changed the practice of medicine in unprecedented ways. Anecdotal reports suggest that, in response, some physicians are leaving the practice of medicine or retiring earlier than they otherwise would have. OBJECTIVE: We sought to examine how physician demographic characteristics, practice characteristics, and career satisfaction are related to physician decisions to leave the practice of medicine or substantially cut back their practice hours. DESIGN: Data for this study are from the first 2 rounds of the Community Tracking Study (CTS) Physician Survey, a series of nationally representative telephone surveys of physicians first conducted in 1996. Subsequent rounds of the survey included physicians sampled in the previous round, which allowed us to ascertain their career status 2 years after their initial interviews. SUBJECTS: Primary care and specialist physicians initially spending at least 20 hours per week in direct patient care activities were studied. MAIN OUTCOMES MEASURES: Physicians cutting back their practice hours to less than 20 hours per week or leaving the practice of medicine altogether. RESULTS: Of the 16,681 physicians interviewed for whom we also had information about their career status 2 years later, 462 (2.8%) had retired and 499 (3.0%) had reduced time spent in patient care to less than 20 hours per week. In multinomial logistic analyses that examined both outcomes, full- or part-owners of practices were both less likely to retire and to cut back hours. Internal medicine specialists and psychiatrists were less likely to retire (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.48-0.99 and OR 0.33, 95% CI 0.18-0.60 respectively) whereas surgical specialists were more likely to retire (OR 1.6, 95% CI 1.1-2.2). Physician satisfaction was strongly related to both outcomes. For instance, very dissatisfied physicians were both more likely to retire (OR 2.34, 95% CI 1.6-3.5) and cut back on their hours (OR 3.6, 95% CI 2.32-5.6). CONCLUSIONS: Our findings demonstrate that dissatisfied physicians were 2 to 3 times more likely to leave medicine than satisfied physicians. These findings have implications for physician manpower projections and quality of care. [ABSTRACT FROM AUTHOR]

Purpose: To examine the effect of symptom duration on visual and anatomical outcomes following pars plana vitrectomy repair of primary macula-off rhegmatogenous retinal detachments., Methods: This is a retrospective, consecutive, interventional case series. All eyes underwent repair of macula-off rhegmatogenous retinal detachment with a 20-gauge, 23-gauge, or 25-gauge standard 3-port pars plana vitrectomy. Eyes with previous retinal surgery, giant retinal tear, Grade C or higher proliferative vitreoretinopathy, or less than 6 months of follow-up were excluded from the study. The main outcome measure studied was final best-corrected visual acuity (BCVA) as dependent on the duration of macular detachment symptoms. The secondary outcomes studied were single surgery anatomical success and complication rates. Visual acuity analysis was performed on all eyes that were pseudophakic by the final follow-up visit., Results: Overall, 81 eyes of 81 patients met inclusion criteria, with a mean follow-up length of 55 months (range, 6-171 months) and mean duration of macular detachment symptom of 12 days (range, 1-64 days). The mean final BCVA was 20/40 (range, 20/20 to hand motion), with 70% (n = 57) of all patients obtaining 20/40 or better final BCVA. Patients with symptom duration of 6 days or less achieved better final BCVA (mean 20/25, n = 34) than patients with longer symptom duration (mean 20/50, n = 47) (t-test, P = 0.0030; α = 0.005). After 7 days of macular detachment, no significant difference was seen in final BCVA (t-test, P > 0.05). The overall single surgery anatomical success rate was 88% (71 of 81 eyes). There was no correlation between the single surgery anatomical success rate and duration of macular detachment symptom (Fisher's exact test, P > 0.10)., Conclusion: Primary pars plana vitrectomy repair results in good final visual outcome for patients with primary macula-off rhegmatogenous retinal detachments. Surgical repair within 6 days of the symptom onset yielded better visual outcomes. After 7 days, visual outcome was not affected by the timing of the surgical repair. Anatomical outcome following pars plana vitrectomy repair is not affected by symptom duration.

Background: Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels., Objective: To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal., Design: Retrospective cohort study., Subjects: Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years., Measures: Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for., Results: Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk., Conclusions: Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.