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The authors randomly selected 400 physicians from a population of 1,545 practicing physicians providing follow-up care to patients who received bone marrow or blood stem cell transplants at the Fred Hutchinson Cancer Research Center to determine interest in receiving Internet-based transplant information. In a two-factor completely randomized factorial design, the 400 physicians were assigned to receive mailed surveys with either no compensation or a $5 check and either no follow-up call or a follow-up call 3 weeks after mailing. Overall, 51.5% of the physicians returned the mailed surveys. Comparison of logit models showed that inclusion of a $5 check in the mailer significantly (p = .016) increased the probability of returning the surveys (57.5% vs. 45.5%). In contrast, the telephone follow-up had no overall effect. The authors concluded a modest financial reward can significantly improve physician response rates to research surveys but a telephone follow-up may be inefficient and even ineffective. [ABSTRACT FROM AUTHOR]

Objective: Although the decision about how frequently to see outpatients has a direct impact on a provider's workload and may impact health care costs, revisit intervals have rarely been a topic of investigation. To begin to understand what factors are correlated with this decision, we examined baseline data from a Department of Veterans Affairs (VA) Cooperative Study designed to evaluate telephone care.Design: Observational study based on extensive patient data collected during enrollment into the randomized trial. Providers were required to recommend a revisit interval (e.g., "return visit in 3 months") for each patient before randomization, under the assumption that the patient would be receiving clinic visits as usual. POPULATION/SETTING: Five hundred seventy-one patients over age 55 cared for by one of the 30 providers working in three VA general medical clinics. Patients for whom immediate follow-up (Measurements: Mean revisit interval was adjusted for patient factors using a regression model that accounted for patients being nested within providers and providers being nested within sites. Four patient-level variable blocks (illness burden-patient, travel time, illness burden-physician, and prior utilization) were sequentially entered into a linear model to determine their role in explaining the variance in revisit intervals. Physician identity was also entered after four blocks.Main Results: Recommended revisit intervals ranged from 1 month to over 1 year with the most common recommended intervals being 2, 3, or 6 months. About 10% of the variance in revisit interval was explained by illness measures independent of provider (e.g., general health perception) and travel time. Adding other illness measures (e.g., diagnoses, medications) and prior utilization (e.g., clinic visits) doubled the variance explained (R2 =.21). Finally, the identification of individual provider doubled the explained variance again (R2 =.45). After adjusting for patient factors, the average revisit interval for individual providers ranged from 8 to 26 weeks (8 to 19 weeks when restricted to the 16 staff physicians). There were also substantial differences across the three sites (adjusted means: 14, 17, and 11 weeks).Conclusions: Even after adjusting for a detailed array of patient-level data, primary care providers have different practice styles regarding the timing of return visits. These may, in turn, reflect the local "culture" in which they practice. How many patients providers are able to care for may be determined by the providers' inclinations toward the timing of follow-up visits. [ABSTRACT FROM AUTHOR]

Cost is increasingly important in the evaluation of health care. Though charges are often used as a proxy for cost, some health care systems such as the Veterans Administration do little or no billing. This article describes, presents examples of, and evaluates four options for determining the cost of care within the Department of Veterans Affairs: measuring input costs, the Department's cost accounting system, the reimbursement system, and use of charges from a surrogate health care facility. Each approach is evaluated for accuracy, ability to compare the costs of different treatments, and effort required to estimate cost. [ABSTRACT FROM AUTHOR]

Abstract Background To compare VA inpatient and outpatient utilization and expenditures of veterans seeking primary care in community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs) in fiscal years 2000 (FY00) and 2001. Methods The sample included 25,092 patients who obtained primary care exclusively from 108 CBOCs in FY00, 26,936 patients who obtained primary care exclusively from 72 affiliated VAMCs in FY00, and 11,450 "crossover" patients who obtained primary care in CBOCs and VAMCs in FY00. VA utilization and expenditure data were drawn from the VA's system-wide cost accounting system. Veteran demographic characteristics and a 1999 Diagnostic Cost Group risk score were obtained from VA administrative files. Outpatient utilization (primary care, specialty care, mental health, pharmacy, radiology and laboratory) and inpatient utilization were estimated using count data models and expenditures were estimated using one-part or two-part models. The second part of two-part models was estimated using generalized linear regressions. Results CBOC patients had a slightly more primary care visits per year than VAMC patients (p < 0.0001), but lower primary care costs (-$71, p < 0.0001). CBOC patients had lower odds of one or more specialty, mental health, ancillary visits and hospital stays per year, and fewer numbers of visits and stays if they had any and lower specialty, mental health, ancillary and inpatient expenditures (all, p < 0.0001). As a result, CBOC patients had lower total outpatient and overall expenditures than VAMC patients (p < 0.0001). Conclusion CBOCs provided veterans improved access to primary care and other services, but expenditures were contained because CBOC patients who sought health care had fewer visits and hospital stays than comparable VAMC patients. These results suggest a more complex pattern of health care utilization and expenditures by CBOC patients than has been found in prior studies. This study also illustrates that CBOCs continue to be a critical primary care and mental health access point for veterans.

Purpose: To determine how many rural hospitals in the United States performed coronary angioplasty; to compare patient outcomes in rural and urban hospitals; and to assess whether outcomes were better in rural hospitals in which more procedures were performed.Subjects and Methods: In 1996, among patients 65 years of age and older, 201,869 coronary angioplasties were performed in 996 hospitals that were included in the Medicare Provider Analysis and Review files. Geographic location was defined as rural or urban, according to U.S. Census Bureau criteria. Outcome variables were in-hospital death and coronary artery bypass surgery performed during the same admission. Hospital volumes were categorized as low (< or = 100 cases or fewer per year), medium (101 to 200 cases per year), or high (> 200 cases per year).Results: Fifty-one rural hospitals accounted for 4% of all angioplasties performed. After angioplasty, in-hospital mortality was greater in rural hospitals (8.1% versus 6.4%, P = 0.001) among patients with acute myocardial infarction, but was not different for patients without infarction (1.4% versus 1.3%, P = 0.41). Coronary artery bypass surgery rates during the same admission were similar in rural and urban hospitals. In general, in-hospital mortality and same-admission surgery rates were lower in high-volume centers in both rural and urban areas.Conclusion: Although in-hospital mortality after angioplasty for acute myocardial infarction was worse in low- and medium-volume rural centers, overall outcomes in rural and urban hospitals were similar. [ABSTRACT FROM AUTHOR]

Studies from a variety of settings have indicated that outcomes for coronary angioplasty are improved when performed in institutions with high caseloads (> 400/year). The purpose of this investigation was to examine the volume outcome hypothesis for coronary angioplasty in a 20% stratified sample of acute care, non-federal hospitals in 17 states. Data were derived from the Nationwide Inpatient Sample from the Health Care Cost and Utilization Project releases 2 and 3. From these records, 163,527 angioplasties from 214 hospitals were selected. Outcomes included hospital mortality, same-admission coronary artery bypass surgery, and a combined end point of either death or same-admission surgery, or both. Hospital volumes were defined as low (< or = 200 cases/year), medium (201 to 400), and high (> 400). Analyses were conducted separately for patients with and without a principal discharge diagnosis of acute myocardial infarction (AMI). For both AMI and no-AMI groups, the rates of adverse outcomes were generally lower in high-volume institutions, and this finding was true in both univariate and multivariate analyses. Although 27% of hospitals were in the low-volume category, only 5% of all procedures were performed in these institutions. Projecting to all United States hospitals for the 2 years, if all procedures performed in low-volume centers had been done in high-volume institutions, 137 deaths could have been averted (90 AMIs, 47 no-AMIs) as well as 404 (46 AMIs, 358 no-AMIs) same-admission surgeries. The results of this study support the hypothesis that better results are obtained in higher volume institutions, but also show that in 1993 and 1994, relatively few patients had their procedures performed in low-volume institutions. [ABSTRACT FROM AUTHOR]

Coronary angioplasty is performed > 1,000 times daily in a variety of health care settings in the public and private sectors in the USA. How outcomes for this procedure differ in the Department of Veterans Affairs and the private sector is unknown. The purpose of this study was to compare outcomes of coronary angioplasty performed in hospitals in the Department of Veterans Affairs and the State of Washington. This study used administrative data from the Department of Veterans Affairs patient treatment file (n = 8,326) and the State of Washington episode of illness file (n = 6,666) and included men who underwent coronary angioplasty in 1993 and 1994. Outcomes included (1) in-hospital mortality and mortality at 10 and 30 days after hospital admission, and (2) the use of coronary artery bypass surgery at similar intervals. Patients with a principal diagnosis of acute myocardial infarction were analyzed separately. Men in the Department of Veterans Affairs had more comorbid conditions than their counterparts in Washington State, and the length of hospital stay was longer in the former group. After using logistic regression to adjust for patient differences, mortality rates for the 2 groups of patients with acute myocardial infarction were similar, although bypass surgery was used more frequently in patients in Washington State. For patients without myocardial infarction, hospital and 10-day mortality did not differ with respect to health care system, and the use of bypass surgery subsequent to angioplasty was similar. In the Department of Veterans Affairs, most hospitals had low institutional caseloads (< 150 procedures per year), whereas > 40% of Washington State hospitals performed > or = 300 procedures per year. Although there were greatly differing institutional caseloads, mortality and the need for early bypass surgery were similar in the 2 systems. [ABSTRACT FROM AUTHOR]

It is estimated that >400,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in the Unites States annually. This study reports patient characteristics and outcomes for 163,527 PTCAs performed in 214 hospitals in 17 states from 1993 to 1994. These hospitals were a 20% random sample of hospitals in the Healthcare Cost and Utilization Project, which was designed to reflect hospitalization in the United States, generally. Cases with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes 36.01, 36.02, and 36.05 were defined as PTCA and were categorized as to whether acute myocardial infarction (AMI) was the principal discharge diagnosis. The average age of 44,270 AMI discharges (27%) was 62 +/- 12 years and that of 119,257 no-AMI cases (73%) was 64 +/- 11 years; 1/3 of both groups were women, 88% were white, and almost 90% had Medicare or private insurance as the primary payer. The states contributing the most cases were Florida (26%), California (12%), and Wisconsin (10%). Hospital mortality was 1.7% overall and was 3.8% for AMI and 0.8% for no-AMI cases. Bypass surgery performed during the same admission was 3.4% overall and was 4.5% and 3.0% for AMI and no-AMI cases, respectively. Multivariate analysis showed that advanced age, diabetes, female gender, and Medicaid payer status were associated with increased risk of mortality. National estimates from this 20% sample indicate that >850,000 PTCAs were performed in the 2 years, with 452,319 cases estimated for 1994. In 1994 there were an estimated 2,789 deaths and 9,903 bypass surgeries in the no-AMI subset of 327,856 procedures. For the AMI group of 124,463 procedures, there were 4,486 deaths and 5,799 bypass surgeries in 1994. This study of PTCA outcomes contains the largest number of cases as well as the most representative sample reported to date. [ABSTRACT FROM AUTHOR]

Focuses on the decline in the number of low-volume hospitals performing percutaneous transluminal coronary angioplasty (PTCA) in California from 1989 to 1996. Distribution of patients and hospitals by institutional volume; Potential explanations for the significant decline in low-volume centers performing PTCA.

Background: Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis., Methods: We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario., Results: In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence., Conclusions: HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available., Competing Interests: The authors have declared that no competing interests exist.

Background: Approximately 233,898 individuals in the Veterans Affairs healthcare network are hepatitis C virus (HCV)-infected, making the Veterans Affairs the single largest provider of HCV care in the USA. Direct-acting antiviral treatment regimens for HCV offer high cure rates. However, these medications pose an enormous financial burden, and whether HCV cure is associated with decreased healthcare costs is poorly defined., Aims: To measure downstream healthcare costs in a national population of HCV-infected patients up to 9 years post-HCV antiviral treatment, to compare downstream healthcare costs between cured and uncured patients, and to assess impact of cirrhosis status on cost differences., Methods: This is a retrospective cohort study (2004-2014) of hepatitis C-infected patients who initiated antiviral treatment within the United States Veterans Affairs healthcare system October 2004-September 2013. We measured inpatient, outpatient, and pharmacy costs after HCV treatment., Results: For the entire cohort, cure was associated with mean cumulative cost savings in post-treatment years three-six, but no cost savings by post-treatment year nine. By post-treatment year nine, cure in cirrhosis patients was associated with a mean cumulative cost savings of $9474 (- 32,666 to 51,614) per patient, while cure in non-cirrhotic patients was associated with a mean cumulative cost excess of $2526 (- 12,211 to 7159) per patient., Conclusions: Among patients with cirrhosis at baseline, cure is associated with absolute cost savings up to 9 years post-treatment compared to those without cure. Among patients without cirrhosis, early post-treatment cost savings are counterbalanced by higher costs in later years.

Hepatitis C virus (HCV) treatment has the potential to cure the leading cause of cirrhosis and hepatocellular carcinoma. However, only those deemed eligible for treatment have the possibility of this cure. Therefore, understanding the determinants of HCV treatment eligibility is critical. Given that effective communication with and trust in healthcare providers significantly influences treatment eligibility decisions in other diseases, we aimed to understand patient-provider interactions in the HCV treatment eligibility process. This prospective cohort study was conducted in the VA Pittsburgh Healthcare System. Patients were recruited after referral for gastroenterology consultation for HCV treatment with interferon and ribavirin. Consented patients completed semi-structured interviews and validated measures of depression, substance and alcohol use, and HCV knowledge. Two coders analyzed the semi-structured interviews. Factors associated with patient eligibility for interferon-based therapy were assessed using multivariate logistic regression. Of 339 subjects included in this analysis, only 56 (16.5%) were deemed eligible for HCV therapy by gastroenterology (GI) providers. In the multivariate logistic regression, patients who were older (OR = 0.96, 95%CI = 0.92-0.99, p = .049), reported concerns about the GI provider (OR = 0.40, 95%CI = 0.10-0.87, p = 0.02) and had depression symptoms (OR = 0.32, 95%CI = 0.17-0.63, p = 0.001) were less likely to be eligible. Patients described barriers that included feeling stigmatized and poor provider interpersonal or communication skills. In conclusion, we found that patients' perceptions of the relationship with their GI providers were associated with treatment eligibility. Establishing trust and effective communication channels between patients and providers may lower barriers to potential HCV cure.

Background: There is significant interest in measuring health care value, but this concept has not been operationalized in specific patient cohorts. The longitudinal outcomes and costs for patients after percutaneous coronary intervention (PCI) provide an opportunity to measure an aspect of health care value., Objectives: This study evaluated variations in 1-year outcomes (risk-adjusted mortality) and risk-standardized costs of care for all patients undergoing PCI in the Veterans Affairs (VA) system from 2007 to 2010., Methods: This retrospective cohort study evaluated all veterans undergoing PCI at any of 60 hospitals in the VA health care system, using data from the national VA Clinical Assessment, Reporting, and Tracking (CART) program. Primary outcomes were 1-year mortality and costs following PCI. Risk-standardized mortality and cost ratios were calculated, adjusting for cardiac and noncardiac comorbidities., Results: A median of 261 PCIs were performed in the 60 hospitals during the study period. Median 1-year unadjusted hospital mortality rate was 6.13%. Four hospitals were significantly above the 1-year risk-standardized median mortality rate, with median mortality ratios ranging from 1.23 to 1.28. No hospitals were significantly below median mortality. Median 1-year total unadjusted hospital costs were $46,302 per patient. There were 16 hospitals above and 19 hospitals below the risk-standardized median cost, with risk-standardized ratios ranging from 0.45 to 2.09, reflecting a much larger magnitude of variability in costs than in mortality., Conclusions: There is much smaller variation in 1-year risk adjusted mortality than in risk-standardized costs after PCI in the VA. These findings suggest that there are opportunities to improve PCI value by reducing costs without compromising outcomes. This approach to evaluating outcomes and costs together may be a model for other health systems and accountable care organizations interested in operationalizing value measurement., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the feasibility of using a multimedia program to teach caregivers of Veterans with cancer how to offer basic massage for supportive care at home., Methods: Feasibility was assessed according to partner availability, compliance with watching training materials and practicing massage regularly, compliance with data collection; perceived study materials burden; clarity of instructional and other study materials. Pre- and post-massage changes in patients' symptom scores were measured using a numerical rate scale. A semistructured exit interview was answered by patient and caregiver at the end of the study., Results: A total of 27 dyads were recruited. Veterans were 78% male. Forty-eight percent were diagnosed with hematologic malignancies (85%, advanced stage); 52% were diagnosed with solid tumors (64% advanced stage). Caregivers were 78% female; 81% were spouses. Out of the 27 pairs, 11 completed 8 weeks of data and practiced massage weekly. The majority of attrition (69%) was due to caregivers' burden. Caregivers reported instructional materials were clear, high quality, and easy to use. Patients were highly satisfied with receiving touch from their partners regularly. Post-massage symptom scores showed statistically significant decreases in pain, stress/anxiety, and fatigue. Perceived burden of data collection instruments was high, particularly for patients., Conclusion: It is feasible to use the TCC program to train caregivers of Veterans with cancer to offer massage for supportive care at home. Future studies should evaluate ways of providing support to caregivers, including offering massage to them, and easing the burden of data collection for patients.

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations.

Background & Aims: A significant proportion of patients with hepatitis C virus (HCV) infection discontinue antiviral treatment prematurely. Risk factors for discontinuation before 48 weeks among patients with genotype 1 HCV vary over the course of therapy. We investigated the rates and risk factors for treatment discontinuation within 12 weeks, 12-24 weeks, and 24-48 weeks., Methods: We retrospectively evaluated data from all Veterans Affairs (VA) patients with genotype 1 HCV who initiated pegylated interferon and ribavirin therapy from 2002-2007 (n = 11,019). We accounted for appropriate discontinuation because of viral nonresponse., Results: Overall, 53% of patients completed at least 38.4 weeks of therapy (80% of the projected 48 weeks), 16.5% discontinued early in the setting of viral nonresponse, and 30.9% discontinued despite viral response or in the absence of virologic data. Cirrhosis, diabetes, pretreatment substance use disorder, hemoglobin, and lack of hematopoietic growth factor use independently predicted discontinuation before 12 weeks (P < .05 for all). Among patients with documented early virologic responses, higher baseline levels of creatinine, depression, and lack of growth factor use predicted discontinuation from 12-24 weeks. No factors independently predicted discontinuation from 24-48 weeks among patients responding to treatment at 24 weeks., Conclusions: Early discontinuation of antiviral therapy is common. Use of growth factors was the strongest independent predictor of treatment retention before 24 weeks and should be evaluated prospectively. Early interventions may also be warranted for other risk factors for early discontinuation, such as pre-existing substance use, depression, cirrhosis, or diabetes., (Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients., Data Sources/study Setting: VA administrative and Medicare claims data from 2001 to 2004., Study Design: Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients., Principal Findings: A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3-4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80)., Conclusions: Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care., (Copyright © Health Research and Educational Trust.)

Background: To compare VA inpatient and outpatient utilization and expenditures of veterans seeking primary care in community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs) in fiscal years 2000 (FY00) and 2001., Methods: The sample included 25,092 patients who obtained primary care exclusively from 108 CBOCs in FY00, 26,936 patients who obtained primary care exclusively from 72 affiliated VAMCs in FY00, and 11,450 "crossover" patients who obtained primary care in CBOCs and VAMCs in FY00. VA utilization and expenditure data were drawn from the VA's system-wide cost accounting system. Veteran demographic characteristics and a 1999 Diagnostic Cost Group risk score were obtained from VA administrative files. Outpatient utilization (primary care, specialty care, mental health, pharmacy, radiology and laboratory) and inpatient utilization were estimated using count data models and expenditures were estimated using one-part or two-part models. The second part of two-part models was estimated using generalized linear regressions., Results: CBOC patients had a slightly more primary care visits per year than VAMC patients (p < 0.0001), but lower primary care costs (-$71, p < 0.0001). CBOC patients had lower odds of one or more specialty, mental health, ancillary visits and hospital stays per year, and fewer numbers of visits and stays if they had any and lower specialty, mental health, ancillary and inpatient expenditures (all, p < 0.0001). As a result, CBOC patients had lower total outpatient and overall expenditures than VAMC patients (p < 0.0001)., Conclusion: CBOCs provided veterans improved access to primary care and other services, but expenditures were contained because CBOC patients who sought health care had fewer visits and hospital stays than comparable VAMC patients. These results suggest a more complex pattern of health care utilization and expenditures by CBOC patients than has been found in prior studies. This study also illustrates that CBOCs continue to be a critical primary care and mental health access point for veterans.

Background: Colorectal cancer is the second most common fatal malignancy in the United States. Early detection using fecal occult blood tests has been shown to reduce mortality, but these tests are underutilized among those eligible for this screening. Attempts to increase use of fecal occult blood tests in eligible populations have focused on the provider, patient, or system. But none have examined whether a support-staff intervention is effective in achieving this aim. We therefore conducted a randomized controlled trial to test the impact of authorizing support staff to order fecal occult blood tests in a general internal medicine clinic organized into four teams., Methods: A total of 1,109 patients were included in the study, 545 of whom were in the two teams randomized to treatment. Univariate and multivariate regression analyses were used to evaluate the impact of the intervention., Results: The intervention resulted in significantly more fecal occult blood test ordering in the treatment group than in the control group for all patients (52% vs 15%, P < 0.001). Treatment fecal occult blood test cards were returned as frequently as the control cards for all patients (44% vs 48%, P = 0.571)., Conclusion: Delegation of selected screening tasks to support staff can enhance patient access to preventive care.

Background: Randomized trials of coronary stents versus conventional balloon angioplasty have demonstrated improved short- and long-term outcomes for selected patients receiving stents. The purpose of this study was to compare outcomes in patients receiving stents with those undergoing conventional balloon angioplasty in everyday clinical practice., Methods and Results: This study uses information from the Medicare Provider Analysis and Review files for fiscal years 1994 and 1996, the first year the coronary stent code was used. For patients 65 years of age and older, 165,657 cases in 1994 and 201,869 in 1996, including 74,836 cases with stent placement, were identified. Outcomes included hospital deaths, use of same- admission coronary artery bypass surgery, and either or both. Analyses were performed separately for those with and those without a principal diagnosis of acute myocardial infarction. Hospital mortality rates were similar in both years, but the use of same-admission coronary artery bypass surgery was lower in 1996. In that year, for both patients with and those without acute myocardial infarction, hospital death and the use of same-admission coronary artery bypass surgery were lower in the stent group. Additionally, results in the stent group were generally better at high-volume (>200 cases per year) institutions, as was the case for the prestent, 1994 results., Conclusions: This study documents improved short-term outcomes in older patients who undergo coronary stent placement. Stenting did not eliminate the finding of improved outcomes at high-volume centers.

Context: An increasing number of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) are receiving coronary stents., Objectives: To assess whether the introduction of coronary stenting has changed hospital mortality or same-admission coronary artery bypass grafting (CABG) and whether the hospital's procedure volume affects these outcomes., Design: Observational study using hospital claims., Setting: Nonfederal hospitals that performed PTCA in California in 1993 and 1996., Patients: 35,350 patients who underwent PTCA in 1993 (before the introduction of stenting) and 43,040 patients who had PTCA in 1996 (43% of whom received stents)., Measurements: Hospital stenting volumes for 1996 were divided into terciles; total PTCA procedures per year were categorized as low (< or = 200), medium (201 to 400), or high (> 400). Outcome variables included hospital death and coronary artery bypass grafting (CABG) performed during the same admission. Patients with a principal diagnosis of acute myocardial infarction (AMI) were analyzed separately from those without such a diagnosis., Results: From 1993 to 1996, the characteristics of patients undergoing PTCA did not change substantially. The use of same-admission CABG decreased by 13% (from 6.0% to 5.2%; P = 0.008) in the AMI group and by 30% (from 3.7% to 2.6%; P < 0.001) in the no-AMI group. Hospital mortality did not change significantly in either group. Procedure volume was not related to hospital mortality. However, rates of same-admission CABG were significantly lower at hospitals with high annual stenting volumes than at low-volume centers (1.3% vs. 2.3% among patients in the no-AMI group; P < 0.001)., Conclusions: Hospital mortality rates after PTCA have not changed considerably since the introduction and diffusion of coronary stenting. However, rates of same-admission CABG have decreased in recent years and are lowest at hospitals with high procedure volumes.

Objective: Although the decision about how frequently to see outpatients has a direct impact on a provider's workload and may impact health care costs, revisit intervals have rarely been a topic of investigation. To begin to understand what factors are correlated with this decision, we examined baseline data from a Department of Veterans Affairs (VA) Cooperative Study designed to evaluate telephone care., Design: Observational study based on extensive patient data collected during enrollment into the randomized trial. Providers were required to recommend a revisit interval (e.g., "return visit in 3 months") for each patient before randomization, under the assumption that the patient would be receiving clinic visits as usual. POPULATION/SETTING: Five hundred seventy-one patients over age 55 cared for by one of the 30 providers working in three VA general medical clinics. Patients for whom immediate follow-up (

Context: The decision about when to ask a patient to return to the clinic for his or her next visit is common to all outpatient encounters in longitudinal care. It directly affects provider workloads and has a potentially great impact on health care costs and outcomes., General Question: What are the effects of lengthening or shortening revisit intervals (the recommended period between one visit and the next) on health status and health care costs?, Specific Research Challenge: How can we change the average revisit interval while preserving provider input for individual patients?, Proposed Approach: Patients could be randomly assigned to either short or long revisit intervals. So that provider input would be preserved, providers would select from among three discrete categories of revisit intervals: near-term (1 to 2 months); intermediate-term (2 to 4 months); and long-term (4 to 8 months). On the basis of randomization, patients would receive appointments at either the lower or the upper bound of the category selected., Potential Difficulties: Because blinding would be almost impossible, providers might "game" randomization at subsequent visits., Alternate Approaches: A comparison of shorter and longer revisit intervals might be achieved with less direct approaches. In one such approach, patients would be randomly assigned to 1) having an appointment made immediately after the initial visit or 2) calling back for an appointment according to the interval recommended by the provider. In another approach, patient panel size would be held constant and providers would be randomly assigned to either an increased or a reduced number of clinic sessions.

Training designed to improve AIDS knowledge, attitude, and practice was delivered to 96 traditional healers in the Central African Republic. The training (17 to 36 hours) was conducted by traditional healers with the assistance of staff from the Ministry of Health. Training included the following topics: prevention of HIV transmission during traditional practice; diagnosis, treatment, and prevention of sexually transmitted diseases; condom promotion; AIDS education at the community level; psychosocial support for people with AIDS; and promotion of a positive image for traditional healers. The evaluation of the training consisted of a prospective assessment of knowledge and attitude immediately prior to and after training. These assessments were conducted using structured interviews. Improvement in knowledge and/or attitudes was observed in all areas assessed except for prevention of HIV transmission during traditional practice. We concluded that AIDS training can be successfully delivered to traditional healers.

This paper presents data collected from 899 clinicians across three Department of Veterans Affairs (VA) medical centers where existing terminal-based architecture was being replaced with client-server architecture. Surveys were conducted with physicians (n = 184), nurses (n = 355) and other clinicians (n = 360) gathering user characteristics and their perceptions of five deployment issues (e.g. adequacy of technical and institutional support and perceptions of the soon-to-be-implemented clinical workstation). Mean scores for the five deployment issues for all clinicians indicates perceptions are somewhat neutral. However, when data is analyzed according to job classification, significant (p = 0.05) differences in perceptions were noted among groups of clinicians (e.g., physicians and registered nurses). Results of analyzing data grouped by VA site (n = 3) indicates significant (p = 0.05) differences exist among sites in clinicians' perceptions of the deployment issues. A thoughtful deployment strategy including an in-depth assessment of clinician users by job classification and by location may produce important information, critical to the successful deployment of new technologies, in very large health management institutions.

Evidence-based practice in medicine promotes the performance of medicine based upon proven and validated practice. The CARE-PARTNER system presented here is a computerized knowledge-support system for stem-cell post-transplant long-term follow-up (LTFU) care on the WWW, which means that it monitors the quality of the knowledge both of its own knowledge-base and of its users. Its aim is to support the evidence-based practice of the LTFU clinicians and of the home-town physicians who actually care for the transplanted patients. Currently, three fundamental characteristics of CARE-PARTNER are accountable for its knowledge-support function: the quality of its knowledge-base, its availability on the WWW, and its learning from experience capability. As a matter of fact, the integration of a case-based reasoner in the reasoning framework enables the system to introspectively study its results, and to learn from its successes and failures, thus confronting the quality of the guidelines and pathways it reuses to the reality and complexity of the clinical cases.

Objective: To determine whether vaginal douching is associated with HIV infection., Methods: A total of 397 female patients who attended the referral clinic for sexually transmitted diseases in Bangui, Central African Republic, from August 1994 to February 1995, were interviewed regarding sexual behavior, sexual history, and vaginal douching during the previous 3 years. Pelvic examinations were conducted and vaginal and cervical fluids evaluated for genital infections. Blood was drawn for HIV and syphilis serologic testing., Results: The seroprevalence of HIV infection in the study population was 34%. Twenty-one per cent of the 115 HIV-seropositive women had a consistent practice of douching with commercial antiseptics versus 35% of the 223 HIV-seronegative women [odds ratio (OR), 0.6; 95% confidence interval (CI), 0.4-0.9; after adjusting for lifetime number of sexual partners, marital status, and condom use]. In contrast, a higher percentage of HIV-seropositive than HIV-seronegative women had a consistent practice of douching with a non-commercial preparation (14.8 versus 6.7%; adjusted OR, 1.7; 95% CI, 1.0-3.0)., Conclusion: Our results suggest that vaginal douching with non-commercial preparations is associated with an increased prevalence of HIV, whereas douching with commercial antiseptic preparations was associated with a lower prevalence of HIV. The findings from this cross-sectional survey require confirmation in prospective studies.

Many policy-makers and health economists are interested in designing and implementing user fee/quality improvement programs in public facilities in Sub-Saharan Africa on a national scale. This research addresses two design issues for a national program: (1) to what extent would user fees finance the costs of quality improvements, and (2) whether a uniform program could be implemented throughout the country or the user fees should differ between urban and rural areas or across health regions. A national survey was conducted to determine the population's willingness and ability to pay for seven quality improvements: (1) facility maintenance, (2) supervision of personnel, and drugs to treat (3) diarrheal diseases, (4) acute respiratory infections (ARI), (5) malaria, (6) intestinal parasites, and (7) sexually transmitted diseases (STDs). Willingness to pay for quality improvements was measured by contingent valuation techniques in which subjects were asked about expenditures for care at government facilities under a hypothetical user fee/quality improvement program. Ability to pay was measured by monthly expenditures for health care as a percentage of monthly household consumption. The majority of the population was willing to pay the cost of the quality improvements, which ranged from U.S. $0.40 to U.S. $4.00. Estimates of the percentage of the population that was willing to pay the cost of the quality improvements ranged from 81% for facility maintenance (an improvement with the lowest cost) to 64% for drugs to treat ARI (the improvement with the highest cost). The median willingness to pay ranged from U.S. $7.98 for drugs to treat malaria to U.S. $16.61 for drugs to treat diarrheal diseases. Willingness to pay was greater in rural areas than in urban areas. It was also greater in Health Region I than in Health Regions IV and V. The population was able to pay the estimated cost of all seven quality improvements. Median monthly health care expenditures per episode of illness was 2.6% of median monthly household consumption. In comparison, the estimated cost of the quality improvements ranged from 0.2 to 2.4% median monthly household consumption. The national user fee/quality improvement program has good prospects for financing the quality improvements because the majority of the population is willing to pay the estimated costs of the quality improvements and more than half of the population is willing to pay substantially more than the costs. It also appears that the user fees should differ between urban and rural areas and across some health regions.

Objective: To determine if the differences in IVF-ET success rates among clinics are due to chance alone., Design: Retrospective analysis of data reported by individual clinics., Setting: One hundred seventy-five clinics in 1989, 192 clinics in 1990, and 208 clinics in 1991 that reported IVF-ET success rates to the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine (formerly The American Fertility Society)., Patients: Women < 40 years of age with no male factor., Intervention: In vitro fertilization-ET., Main Outcome Measure: Delivery rate per retrieval and delivery rate per transfer., Results: The hypothesis that the differences among IVF-ET success rates for clinics is due to chance alone can be rejected. Seven clinics were found to have pregnancy rates significantly higher than average and six clinics were found to have pregnancy rates significantly lower than average. Significant correlations were found between different years in the success rates for individual clinics but not for success as a function of the number of patients treated., Conclusions: Success rates for a few clinics are significantly different from the average success rate, but success rates must be used with caution in selecting a clinic.

An important goal of the Adult Day Health Care (ADHC) Evaluation Study was to identify subgroups of patients assigned to ADHC for whom the health care costs were less than, or not higher than, the costs of similar patients assigned to customary care. Patients eligible for VA services because of a severe disability that occurred during military service had significantly lower costs when assigned to ADHC compared with customary care. For several types of patients, total health care costs were not significantly higher for those assigned to ADHC compared with those assigned to customary care: patients who at study intake 1) were at highest risk of going to a nursing home, 2) had high levels of physical dysfunction as measured by the Sickness Impact Profile, 3) had multiple behavior problems, and 4) were eligible for VA services because of a less severe service-connected disability but admitted to the ADHC for treatment of that disability. Two types of patients were found to have particularly high costs when assigned to ADHC compared with customary care: patients with low levels of physical dysfunction and patients with few behavior problems. Significant differences in the relative costs of ADHC versus customary care also were found between the 4 study sites.