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Context: Inappropriate medication use is a major patient safety concern, especially for the elderly population. Using explicit criteria, prior studies have found that 23.5% and 17.5% of the US community-dwelling elderly population used at least 1 of 20 potentially inappropriate medications in 1987 and 1992, respectively.Objectives: To determine the prevalence of potentially inappropriate medication use in community-dwelling elderly persons in 1996, to assess trends over 10 years, categorize inappropriate medication use according to explicit criteria, and to examine risk factors for inappropriate medication use.Design, Setting, and Participants: Respondents aged 65 years or older (n = 2455) to the 1996 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population were included. A 7-member expert panel was convened to categorize inappropriate medications.Main Outcome Measure: Prevalence of use of 33 potentially inappropriate medications.Results: In 1996, 21.3% (95% confidence interval [CI], 19.5%-23.1%) of community-dwelling elderly patients in the United States received at least 1 of 33 potentially inappropriate medications. Using the expert panel's classifications, about 2.6% of elderly patients (95% CI, 2.0%-3.2%) used at least 1 of the 11 medications that should always be avoided by elderly patients; 9.1% (95% CI, 7.9%-10.3%) used at least 1 of the 8 that would rarely be appropriate; and 13.3% (95% CI, 11.7%-14.9%) used at least 1 of the 14 medications that have some indications but are often misused. Use of some inappropriate medications declined between 1987 and 1996. Persons with poor health and more prescriptions had a significantly higher risk of inappropriate medication use.Conclusions: Overall inappropriate medication use in elderly patients remains a serious problem. Despite challenges in using explicit criteria for assessing inappropriate medications for elderly patients, such criteria can be applied to population-based surveys to identify opportunities to improve quality of care and patient safety. Enhancements of existing data sources to include dosage, duration, and indication may augment national improvement and monitoring efforts. [ABSTRACT FROM AUTHOR]

Background: As a result of market forces and maturing technology, generalists are currently providing services, such as colonoscopy, that in the past were deemed the realm of specialists.Objective: To determine whether there were differences in patient characteristics, procedure complexity, and clinical indications when gastrointestinal endoscopic procedures were provided by generalists versus specialists.Design: Retrospective cohort study.Patients: A random 5% sample of aged Medicare beneficiaries who underwent rigid and flexible sigmoidoscopy, colonoscopy, and esophagogastroduodenoscopy (EGD) performed by specialists (gastroenterologists, general surgeons, and colorectal surgeons) or generalists (general practitioners, family practitioners, and general internists).Measurements: Characteristics of patients, indications for the procedure, procedural complexity, and place of service were compared between generalists and specialists using descriptive statistics and logistic regression.Main Results: Our sample population had 167,347 gastrointestinal endoscopies. Generalists performed 7.7% of the 57, 221 colonoscopies, 8.7% of the 62,469 EGDs, 42.7% of the 38,261 flexible sigmoidoscopies, and 35.2% of the 9,396 rigid sigmoidoscopies. Age and gender of patients were similar between generalists and specialists, but white patients were more likely to receive complex endoscopy from specialists. After adjusting for patient differences in age, race, and gender, generalists were more likely to have provided a simple diagnostic procedure (odds ratio [OR] 4.2; 95% confidence interval [95% CI] 4.0, 4.4), perform the procedure for examination and screening purposes (OR 4.9; 95% CI, 4. 3 to 5.6), and provide these procedures in rural areas (OR 1.5; 95% CI 1.4 to 1.6).Conclusions: Although generalists perform the full spectrum of gastrointestinal endoscopies, their procedures are often of lower complexity and less likely to have been performed for investigating severe morbidities. [ABSTRACT FROM AUTHOR]

Objective: To determine the number and kinds of programs that medical schools and managed care organizations offer or plan to offer to retrain physician specialists to practice primary care medicine and to discover physicians' attitudes toward such retraining.Design: A survey was mailed in 1994 to all 126 medical schools and the 19 largest US managed care organizations to collect detailed information about existing and potential retraining programs. Physicians' attitudes toward retraining were elicited from participants in 3 geographically diverse focus groups. Selected specialists were polled through the national survey of the American Medical Association's Socioeconomic Monitoring System to ascertain the demand for retraining.Results: The majority of institutions contacted perceived a need for retraining, but few programs had been established. Programs being "considered" varied widely in duration, class size, target audience, accreditation, and projected training settings. Although unenthusiastic about retraining, physicians preferred programs that would expand their patient base, maintain the practice population, be inexpensive and close to home, and provide hands-on training in the eventual practice environment. Physicians also preferred a goal-oriented, part-time retraining program in a large group practice or managed care setting that would allow them to practice their specialty while retraining. Few planned or existing programs incorporate many of these features. The most likely candidates for retraining are subspecialty physicians who currently provide some primary care and are employed by a medical plan.Conclusions: Despite efforts by those who perceive that a need for more generalist physicians is stimulating interest in retraining specialists and subspecialists to provide primary medical care, physician interest and program availability remain low, and programs under development are not being designed to attract those who may seek retraining. This situation is probably fortuitous, because changed perceptions about the adequacy of the generalist physician workforce since the beginning of this study have diminished the call for retraining. [ABSTRACT FROM AUTHOR]

Editorial. Reports on the effect of the rapid evolution of the health care system in the United States in terms of cost consciousness, curricular reform for practicing in the managed care setting, and an increased focus on the economics of care delivery. Impediments in providing health care; Number of physicians and specialists in the US; The need for national direction in terms of defining regular and specialist-focused physicians.

This cost-consequences analysis of the Air Force/Texas Coronary Atherosclerosis Prevention Study compares the costs of lovastatin treatment with the costs of cardiovascular hospitalizations and procedures. The cost of lovastatin treatment was defined as the average retail price and the cost of drug safety monitoring and adverse experiences. Costs were determined by actual rates of hospitalizations and procedures. Within a trial, lovastatin treatment cost approximately $4,654/patient. Lovastatin treatment significantly reduced the cumulative rate of cardiovascular hospitalizations and procedures (p = 0.002). Over the duration of the study, the cumulative number of cardiovascular hospitalizations and related therapeutic procedures was significantly reduced by 29%. The time to first cardiovascular-related hospitalization or procedure was significantly extended by lovastatin (p = 0.002). Lovastatin reduced the frequency of cardiovascular hospitalization (28%), and cardiovascular therapeutic (32%) and diagnostic procedures (23%). Among therapeutic procedures, treatment reduced coronary artery bypass graft surgery by 19% and percutaneous transluminal coronary angioplasty by 37%. Total cardiovascular-related hospital days were reduced by 26% (p = 0.025). The between-group offset in direct medical costs was $524, which resulted in a 11% cost offset of lovastatin therapy over the mean study duration of 5.2 years. Lovastatin provides meaningful reductions in cardiovascular-related resource utilization and reductions in direct cardiovascular-related costs associated with the onset of coronary disease. [ABSTRACT FROM AUTHOR]

Objective: To develop Patient Safety Indicators (PSI) to identify potential in-hospital patient safety problems for the purpose of quality improvement., Data Source/study Design: The data source was 2,400,000 discharge records in the 1997 New York State Inpatient Database. PSI algorithms were developed using systematic literature reviews of indicators and hand searches of the ICD-9-CM code book. The prevalence of PSI events and associations between PSI events and patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and hospital charges were examined., Principal Findings: PSIs were developed for 12 distinct clinical situations and an overall summary measure. The 1997 event rates per 10,000 discharges varied from 1.1 for foreign bodies left during procedure to 84.7 for birth traumas. Discharge records with PSI events had twofold to threefold longer hospital stays, twofold to 20-fold higher rates of in-hospital mortality, and twofold to eightfold higher total charges than records without PSI events. Multivariate logistic regression revealed that PSI events were primarily associated with increasing age (p < .001), hospitals performing more inpatient surgery (p < .001), and hospitals with higher percentage of beds in intensive care units (p < .001)., Conclusions: The PSIs provide an efficient and user-friendly tool to identify potential inhospital patient safety problems for targeted institution-level quality improvement efforts. Until better error-reporting systems are developed the PSIs can serve to shed light on the problem of medical errors not limited solely to mortality because of errors.

Background: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found., A Road Map for Measures Development: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings., Conclusion: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.

Background: Quality problems in medical care are not a new finding. Variations in medical practice as well as actual medical errors have been pointed out for many decades. The current movement to write practice guidelines to attempt to correct these deviations from recommended medical practice has not solved the problem., Objective: In order to gain greater acceptance of these guidelines and to change the behavior of health care providers, the science of guideline implementation must be understood better., Research Design: A group of experts who have studied the problem of implementation in Europe and the United States was convened. This meeting summary enumerates the implementation methods studied to date, reviews the theories of behavioral change, and makes recommendation for effecting better implementation guidelines., Results: A research agenda was proposed to further our knowledge of effective evidence-based implementation.

Context: Epidural placement for labor in the general population of laboring women is associated with increased incidence of operative deliveries, prolongation of labor, and may be associated with an increased cesarean section rate. The risks and benefits associated with epidural placement for labor in the subpopulation of mothers at high risk for cesarean section have not been studied., Objective: To determine if a population of mothers and babies at high risk for cesarean section will have improved outcomes with labor epidural placement., Design: A decision and cost analysis examining epidural placement for labor on a population of women who are at high risk for unscheduled cesarean section and may benefit from scheduled cesarean section as determined by threshold analysis was performed. Outcomes and probabilities were determined through analysis of the Department of Defense's 1996 National Quality Management Program (NQMP) Birth Product Line data set containing more than 7000 deliveries. Outcomes were defined using variables comprised of all documented conditions that occurred during the peripartum and neonatal hospitalizations. The 1997 NQMP data set was used to validate the results., Setting: Military Treatment Facilities throughout the United States and abroad and civilian facilities in the United States providing care to military dependents., Patient Population: Active duty and dependent pregnant women and babies., Results: About 8% of mothers in this patient population were found to be at high risk for cesarean section. The decision and cost analyses showed that babies of the high risk mothers who received epidurals for labor had better clinical outcomes (p<0.05) and the procedure was cost neutral (p=0.23). The procedure did not increase the frequency of cesarean section, and there was no effect on maternal outcomes scores. These results were confirmed by the validation study., Conclusions: There is a sizable subpopulation of women at high risk for cesarean section whose babies may have better outcomes with epidural placement with no sacrifice in maternal outcomes or costs.

Objective: The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck., Study Design: A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios., Results: The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted., Conclusions: This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Background: As a result of market forces and maturing technology, generalists are currently providing services, such as colonoscopy, that in the past were deemed the realm of specialists., Objective: To determine whether there were differences in patient characteristics, procedure complexity, and clinical indications when gastrointestinal endoscopic procedures were provided by generalists versus specialists., Design: Retrospective cohort study., Patients: A random 5% sample of aged Medicare beneficiaries who underwent rigid and flexible sigmoidoscopy, colonoscopy, and esophagogastroduodenoscopy (EGD) performed by specialists (gastroenterologists, general surgeons, and colorectal surgeons) or generalists (general practitioners, family practitioners, and general internists)., Measurements: Characteristics of patients, indications for the procedure, procedural complexity, and place of service were compared between generalists and specialists using descriptive statistics and logistic regression., Main Results: Our sample population had 167,347 gastrointestinal endoscopies. Generalists performed 7.7% of the 57, 221 colonoscopies, 8.7% of the 62,469 EGDs, 42.7% of the 38,261 flexible sigmoidoscopies, and 35.2% of the 9,396 rigid sigmoidoscopies. Age and gender of patients were similar between generalists and specialists, but white patients were more likely to receive complex endoscopy from specialists. After adjusting for patient differences in age, race, and gender, generalists were more likely to have provided a simple diagnostic procedure (odds ratio [OR] 4.2; 95% confidence interval [95% CI] 4.0, 4.4), perform the procedure for examination and screening purposes (OR 4.9; 95% CI, 4. 3 to 5.6), and provide these procedures in rural areas (OR 1.5; 95% CI 1.4 to 1.6)., Conclusions: Although generalists perform the full spectrum of gastrointestinal endoscopies, their procedures are often of lower complexity and less likely to have been performed for investigating severe morbidities.

Background: Despite the growth in other home health care services, the number of house calls by physicians has declined dramatically during this century. We determined the frequency of house calls made by physicians to elderly U.S. patients in 1993 and analyzed the characteristics of the physicians and patients involved., Methods: We analyzed a 5 percent random sample of the 1993 Medicare Part B claims data for beneficiaries over the age of 65 who were not enrolled in health maintenance organizations (HMOs). With supplemental information from the Area Resource File and the American Medical Association's Physician Masterfile, we determined how many house calls were made, their cost, and a number of specific characteristics of the physicians and the patients., Results: In our 1993 sample, 36,350 house calls were made to 11,917 of the 1,357,262 patients. When extrapolated to all Medicare beneficiaries over age 65 and not enrolled in HMOs, these figures correspond to 727,000 house calls to 238,340 patients nationwide. We estimated the cost of these house calls to be $63 million. The patients who received house calls from physicians were older than those who did not, were more likely to die within the calendar year, had higher rates of hospitalization, and were more likely to receive care from other home health providers, hospice programs, and skilled-nursing facilities. Patients residing in rural areas and those in areas with high physician-to-population ratios had an increased likelihood of receiving a house call. The physicians who made house calls were more likely than others to be generalists, osteopaths, older, male, board-certified, practicing in the Northeast, and in solo practice., Conclusions: A very small percentage (0.88 percent) of elderly Medicare patients, mainly those who are very sick and near the end of life, receive house calls from physicians.

Objectives: This study sought to investigate the independent effect of ethnicity on the utilization of invasive cardiac procedures after acute myocardial infarction (AMI)., Background: The precise role of ethnicity in access to cardiovascular procedures is unknown, particularly because of difficulty in isolating ethnicity from financial and other socioeconomic factors. We conducted a retrospective analysis of the use of cardiac catheterization and coronary revascularization procedures after AMI in military health care beneficiaries. The Military Health Services System (MHSS) ensures equal access to care in an environment without financial incentives for procedural utilization; furthermore, socioeconomic differences between patients beyond ethnicity are minimized., Methods: Data were analyzed from the Civilian External Peer Review Program representing abstracted chart reviews from 125 military health care facilities worldwide for all patients (1,208 white; 233 nonwhite [155 black]) with the principal or secondary diagnosis of AMI from March to September 1993., Results: Rates of cardiac catheterization were similar in white and nonwhite patients (34.8 vs. 39.1%, p = 0.21). After controlling for age, gender, cardiovascular risk factors and AMI variables, including infarct size and other risk markers, there were no differences in the use of this procedure during the AMI admission in comparisons of white versus nonwhite patients (estimated odds ratio [OR] 0.96, 95% confidence interval [CI] 0.69 to 1.34) and white versus black patients (OR 1.19, 95% CI 0.80 to 1.78). However, white patients were significantly more likely than nonwhite patients to be "considered" for future cardiac catheterization (OR 1.77, 95% CI 1.19 to 2.61). Coronary revascularization within 180 days was not significantly affected by race in white versus nonwhite (OR 0.90, 95% CI 0.59 to 1.39) and white versus black patients (OR 1.11, 95% CI 0.65 to 1.89). Outcomes (30- and 180-day mortality and readmission rates) were similar for all race groups., Conclusions: There is a limited relation between ethnicity and the use of invasive cardiac procedures in the MHSS. These data raise the promise that characteristics of a health care system can mitigate ethnic bias in medicine.

This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence-based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations.

To evaluate the potential problems facing academic health centers (AHCs) as a result of market-driven health care reforms, we conducted case studies of seven nationally prominent AHCs during 1994. Findings suggest that although AHCs were not yet feeling the predicted impact of competition on their financial health and ability to sustain their academic missions of teaching, research, and care of vulnerable populations, they were adopting a variety of strategies for responding to those perceived threats, especially networking and cost reduction. They were placing considerably less emphasis on restructuring their research and teaching missions to prepare for anticipated fiscal pressure. Our analysis suggests that even the most successful AHCs are likely to be fundamentally altered by the revolutionary changes occurring in health care markets.