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Context: The National Practitioner Data Bank (NPDB) is believed to be an important source of information for peer review activities by the majority of those who use it. However, concern has been raised that hospitals may be underreporting physicians with performance problems to the NPDB.Objective: To examine variation in clinical privileges action reporting by hospitals to the NPDB, changes in reporting over time, and the association of hospital characteristics with reporting.Design: Retrospective cohort study of privileges action reports to the NPDB between 1991 and 1995, linked with the 1992 and 1995 databases from the Annual Survey of Hospitals conducted by the American Hospital Association.Setting and Participants: A total of 4743 short-term, nonfederal, general medical/surgical hospitals throughout the United States that were continuously open between 1991-1995 and registered with the NPDB.Main Outcome Measures: (1) Reporting of 1 or more privileges actions during the 5-year study period and (2) privileges action reporting rates (numbers of actions reported per 100000 admissions).Results: Study hospitals reported 3328 privileges actions between 1991 and 1995; 34.2% reported 1 or more actions during the period. The range of privileges action reporting rates for these hospitals was 0.40 to 52.27 per 100000 admissions, with an overall rate of 2.36 per 100000 admissions. The proportion of hospitals reporting an action decreased from 11.6% in 1991 to 10.0% in 1995 (P=.008). After adjustment for other factors, urban hospitals had significantly higher reporting than rural hospitals (adjusted odds ratio [OR], 1.21 [95% confidence interval [CI], 1.02-1.43]), while members of the Council of Teaching Hospitals of the Association of American Medical Colleges had significantly lower reporting than nonmembers (adjusted OR, 0.54 [95% CI, 0.40-0.73]). There were notable regional differences in reporting, with the east south Central region having the lowest rate per 100000 admissions (1.49 [95% CI, 1.33-1.65]).Conclusions: The results of this study indicate a low and declining level of hospital privileges action reporting to the NPDB. Several potential explanations exist, 1 of which is that the information reported to the NPDB is incomplete. [ABSTRACT FROM AUTHOR]

Context: Despite increased emphasis on primary care in the United States, most care continues to be provided by specialists. The extent to which specialists incorporate elements of primary care in their approach to ambulatory patients is unknown.Objectives: To examine the extent to which selected medical and surgical subspecialties provide generalist care to Medicare patients, and to compare patterns of care between specialists and generalists.Design: A cross-sectional study of all ambulatory care recorded in Part B of the Washington State Medicare Claims Database in 1994 and 1995.Setting: Ambulatory practices in Washington State.Patients: Medicare beneficiaries 65 years or older who made office visits to the study physicians.Main Outcome Measures: The extent to which individual specialties accounted for the majority of visits made by patients to physicians (a measure of continuity), provided care outside the traditional domain of their specialty (a measure of comprehensiveness), and provided influenza immunization.Results: A total of 373 505 patients constituted the sample. Patients had an average of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and family physicians differ systematically from the practices of most specialists. Approximately half (49.8%) of all ambulatory visits to general internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medical specialist and 11.7% of surgical specialist visits. The rate of influenza immunization was 55.4% for patients who received the majority of their care from generalists, 47.7% from medical specialists, and 39.6% from surgical specialists. Pulmonologists, general surgeons, and gynecologists were more likely than other specialists to provide services outside their specialty.Conclusions: Most specialists do not assume the principal care responsibility for elderly patients, although a substantial proportion of patients see only specialists for their care. Selected specialties assume the generalist role more often, particularly when they provide the majority of outpatient care for an individual patient. [ABSTRACT FROM AUTHOR]

Background: Federal legislation has recently been proposed to designate obstetrician-gynecologists (OBGs) as primary care physicians. The Institute of Medicine identifies care unrestricted by problem or organ system as an essential characteristic of primary care. We examined the degree to which OBGs in the state of Washington offer this aspect of primary care to their elderly patients by investigating the type and amount of nongynecologic care they provide. Methods: Using 1994 Part B Medicare claims data for Washington residents, we identified visits made by women aged 65 years and older to OBGs (N=10,522) and 9 other types of specialists. Diagnoses were classified as in or out of the domain of care traditionally provided by each specialty. Visit volumes, proportion of out of domain visits, and the frequency of diagnoses were reported. Results: Of the patient visits to obstetrician-gynecologists, 12.2% had nongynecologic diagnoses. The median percentage of nongynecologic visits for individual OBGs was 6.7%. Patients who saw OBGs received 15.4% of their overall health care from an OBG; patients who saw family physicians received 42.9% of their total health care from a family physician. Conclusions: In 1994, a small amount of the care that Washington OBGs provided to their elderly patients was for nongynecologic conditions. Studies are needed to evaluate how the practices of OBGs have changed since the 1996 implementation of a primary care requirement in obstetrics-gynecology residencies, and if adopted, how legislation designating OBGs as primary care physicians affects the health care received by elderly women. [ABSTRACT FROM AUTHOR]

Objective: Our goal was to compare the quality of diabetic care received by patients in rural and urban communities., Study Design: We performed a retrospective analysis of claims data captured by the Medicare program., Population: We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994., Outcome Measures: The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination., Results: A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests., Conclusions: Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. Health Care Financing Administration's National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.

Objectives: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician., Methods: The Health Care Financing Administration's National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994., Results: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician., Conclusions: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician--regardless of specialty--may reduce emergency department use.

Context: Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology., Data Source: 1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State., Results: For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists.", Conclusion: Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists."

Objective: To compare health maintenance procedure rates of Medicare patients with different levels of disability., Study Design: Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL)., Results: Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community., Conclusions: Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care., Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation., Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different., Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Objective: To compare influenza vaccination billing rates for patients seen by physiatrists with those of four other specialties: neurology, rheumatology, family practice, and internal medicine., Design: Retrospective cohort analysis using Medicare billing data., Patients: 234,164 Medicare outpatients seen in Washington state between September 1 and December 31, 1994., Results: Based on Medicare's billing data, only 6 of 99 physiatrists ordered vaccinations, and they immunized only 159 (6%) of the patients seen. An additional 1,109 (42%) patients seen by physiatrists were vaccinated by other physicians. Physiatric patients were less likely to have been vaccinated than those seen by internists, family practitioners, or rheumatologists (p < .002), but equally likely as those seen by neurologists (p = .07). A significantly smaller percentage of physiatrists ordered vaccinations than all other specialties (p < .04). Utilizing pre-existing survey data, the misclassification rate (those immunized but not billed) was estimated at 22% of our original cohort. Thus, approximately 800 patients, one third of those seeing physiatrists, may not have been immunized. We estimated the increase in hospitalization costs to be $117 per nonvaccinated patient (total >$90,000)., Conclusions: Missed opportunities for vaccination by physiatrists appear to be more frequent than in other specialties and have potentially large health and economic costs.

Background: In 1989 Washington State implemented a comprehensive expansion of its Medicaid perinatal program, augmenting services, increasing provider reimbursement, and broadening eligibility. This study examines the influence of this legislation on physicians' obstetric practices and attitudes toward caring for pregnant Medicaid patients., Methods: Family physicians and obstetrician-gynecologists were surveyed at the start and 18 months after the Medicaid expansion. The study sample comprised physicians responding to the survey in both years., Results: A greater proportion of family physicians provided unlimited obstetric care to Medicaid patients after the expansion. Sixty percent of family physicians and 56 percent of obstetrician-gynecologists were more willing to provide prenatal care to Medicaid patients as a result of the expansion. Physicians and their office staff were more comfortable with Medicaid patients in the later time period. Many physicians felt that they were better able to link their patients to a variety of social services after the expansion., Conclusions: A Medicaid expansion program can increase provider participation in Medicaid and increase provider comfort in caring for Medicaid patients.

Objective: To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties., Data Sources/study Design: A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed., Findings/conclusions: Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia).

Background: There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort., Methods: Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations., Results: Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier., Conclusions: The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future.