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Congestive heart failure (CHF) hospitalization and mortality rates among older Americans have increased dramatically in recent years. This retrospective study examines CHF incidence and survival for two cohorts of older persons in the periods 1970-74 and 1990-94. The study is conducted on a well-defined population ?65 y/o with 171,000 person-years of observation and access to complete medical records. Using Framingham Heart Study (FHS) clinical criteria for confirming CHF, we identified 387 and 1555 new cases of CHF in the respective periods. Comparing the 1970-74 and 1990-94 cohorts, incidence rates per 100,000 person-years remained unchanged among persons 65-74 y/o at 7.6 (95% CI 6.6-8.7) and 7.9 (7.3-8.5) but increased from 15.1 (12.6-17.6) to 18.4 (17.3-20.2) among persons 75-84 y/o and from 27.9 (16.0-38.8) to 41.6 (36.0-47.2) among persons 85+ y/o. Median survival in days for incident cases in the respective study periods were 906 (95% CI 603-1235) and 1392 (1077-1826) for persons 65-74 y/o; 705 (513-1076) and 856 (598-1214) for those 75-84 y/o; 410 (234-949) and 760 (456-874) for those 85+ y/o. Profiles of FHS diagnostic criteria were very similar for confirmed cases in the two study periods. This study documents significant increased CHF incidence among persons 75-84 y/o and 85+ y/o and increased survival time among incident CHF cases 65-74 y/o between the early 1970s and the early 1990s. Explanations for these findings are under study.

Objectives: To assess how well selected ICD-9-CM diagnosis codes predict adverse events; to model bias and power loss when vaccine safety analyses rely on unverified codes.Methods: We extracted chart verification data for ICD-9-CM diagnosis codes from six Vaccine Safety Datalink (VSD) publications and modeled biases and power losses using positive predictive value (PPV) estimates and ranges of code sensitivity.Results: Positive predictive values were high for type 1 diabetes (80%) in children, relative to WHO criteria, and intussusception (81%) in young children, relative to a standard published case definition. PPVs were moderate (65%) for inpatient and emergency department childhood seizures and low (21%) for outpatient childhood seizures, both relative to physician investigator judgment. Codes for incident central nervous system demyelinating disease in adults had high PPV for inpatient codes (80%) and low PPV for outpatient codes (42%) relative to physicians' diagnoses. Modeled biases were modest, but large increases in frequencies of adverse events are required to achieve adequate power if unverified ICD-9-CM codes are used, especially when vaccine associations are weak.Conclusions: ICD-9-CM codes for type 1 diabetes in children, intussusception in young children, childhood seizures in inpatient and emergency care settings, and inpatient demyelinating disease in adults were sufficiently predictive for vaccine safety analyses to rely on unverified diagnosis codes. Adverse event misclassification should be accounted for in statistical power calculations. [ABSTRACT FROM AUTHOR]

A survey of 8,034 primary care patients in a health maintenance organization examined the relationship between alcohol consumption and health care costs and service use. Costs were estimated from service use data for 1 year before and 2 years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared with total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Further study of former drinkers is warranted to examine the role of alcohol-related illnesses in the decision to quit drinking. [ABSTRACT FROM AUTHOR]

Background: Although substantial resources have been invested in communication skills training for clinicians, little research has been done to test the actual effect of such training on patient satisfaction.Objective: To determine whether clinicians' exposure to a widely used communication skills training program increased patient satisfaction with ambulatory medical care visits.Design: Randomized, controlled trial.Setting: A not-for-profit group-model health maintenance organization in Portland, Oregon.Participants: 69 primary care physicians, surgeons, medical subspecialists, physician assistants, and nurse practitioners from the Permanente Medical Group of the Northwest.Intervention: "Thriving in a Busy Practice: Physician-Patient Communication," a communication skills training program consisting of two 4-hour interactive workshops. Between workshops, participants audiotaped office visits and studied the audiotapes.Measurements: Change in mean overall score on the Art of Medicine survey (HealthCare Research, Inc., Denver, Colorado), which measures patients' satisfaction with clinicians' communication behaviors, and global visit satisfaction.Results: Although participating clinicians' self-reported ratings of their communication skills moderately improved, communication skills training did not improve patient satisfaction scores. The mean score on the Art of Medicine survey improved more in the control group (0.072 [95% CI, -0.010 to 0.154]) than in the intervention group (0.030 [CI, -0.060 to 0.1201).Conclusions: "Thriving in a Busy Practice: Physician-Patient Communication," a typical continuing medical education program geared toward developing clinicians' communication skills, is not effective in improving general patient satisfaction. To improve global visit satisfaction, communication skills training programs may need to be longer and more intensive, teach a broader range of skills, and provide ongoing performance feedback. [ABSTRACT FROM AUTHOR]

Objective: To reduce variability in primary care physicians' use of procedures for imaging the lumbar spine.Design: Controlled intervention using clinical practice guideline and practice pattern feedback.Study Sample: Sixty-seven internists and 28 family practitioners in a large, group-model HMO.Measurements and Main Results: Intervention group physicians received the clinical practice guideline for low back pain, followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine. Control group physicians received neither the guideline nor the feedback reports. Automated radiology utilization data were used to compare intervention and control group physicians' changes in use rates and variability in use rates over the course of the study period. Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study.Conclusions: Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed. [ABSTRACT FROM AUTHOR]

Attempts to explain the high cost of care in teaching hospitals have yielded conflicting results. This study was conducted to compare hospital charges and lengths of stay for two groups of patients: one cared for by a resident team and the other cared for by attending physicians. The study was conducted at a university-affiliated hospital in Portland, Oregon. An initial group of 5,451 admissions was examined, considering type of doctor (resident or attending), severity of illness, and patient demographic characteristics. A regression analysis revealed that total charges were similar in the two groups, but only 14% of the variance in log total charges was explained. A subgroup of 1,058 admissions in the eight most common diagnosis-related groups (DRGs) was further evaluated. In this analysis total charges for the resident patient group were 52% higher than charges for the patient group cared for by attending physicians. Forty-one per cent of the variance was explained, with type of doctor and severity of illness accounting for 5% and 10%, respectively. Further examination of one DRG indicated that additional factors not included in previous studies, such as extent of preadmission evaluation, ethical factors influencing treatment options, and patient expectations for care, may be important determinants of hospital charges. This study demonstrates that the high cost of resident care is not fully explained by currently available measures. [ABSTRACT FROM AUTHOR]

Objective: To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons.Design: Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician.Settings: One hundred twenty-four physician offices in Oregon and Colorado.Participants: Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (> or =2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty.Main Outcome Measures: Audiotape analysis using the Roter Interaction Analysis System.Results: Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons.Conclusions: Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups. [ABSTRACT FROM AUTHOR]