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Objective: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use.Design: Cohort observational study.Setting: A public hospital in Atlanta, Georgia.Patients: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years.Measurements and Main Results: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse.Conclusions: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs. [ABSTRACT FROM AUTHOR]

Objective: To identify correlates of controlled hypertension in a largely minority population of treated hypertensive patients.Design: Case-control study.Setting: Urban, public hospital.Patients: A consecutive sample of patients who were aware of their diagnosis of hypertension for at least 1 month and had previously filled an antihypertensive prescription. Control patients had a systolic blood pressure (SBP) < or = 140 mm Hg and diastolic blood pressure (DBP) < or = 90 mm Hg, and case patients had a SBP > or = 180 mm Hg or DBP > or = 110 mm Hg.Measurements and Main Results: Control subjects had a mean blood pressure (BP) of 130/80 mm Hg and case subjects had a mean BP of 193/106 mm Hg. Baseline demographic characteristics between the 88 case and the 133 control subjects were not significantly different. In a logistic regression model, after adjusting for age, gender, race, education, owning a telephone, and family income, controlled hypertension was associated with having a regular source of care (odds ratio [OR] 7.93; 95% confidence interval [CI] 3.86, 16.29), having been to a doctor in the previous 6 months (OR 4.81; 1.14, 20.31), reporting that cost was not a deterrent to buying their antihypertensive medication (OR 3.63; 1.59, 8.28), and having insurance (OR 2.15; 1.02, 4.52). Being compliant with antihypertensive medication regimens was of borderline significance (OR 1.96; 0.99, 3.88). A secondary analysis found that patients with Medicaid coverage were significantly less likely than the uninsured to report cost as a barrier to purchasing antihypertensive medications and seeing a physician.Conclusions: The absence of out-of-pocket expenditures under Medicaid for medications and physician care may contribute significantly to BP control. Improved access to a regular source of care and increased sensitivity to medication costs for all patients may lead to improved BP control in an indigent, inner-city population. [ABSTRACT FROM AUTHOR]

This paper examines the impact of public health insurance programs, whether structured as subsidies to health care providers (public hospitals and uncompensated care reimbursement funds) or as direct insurance (Medicaid), on the purchase of private health insurance. The presence of a public hospital is associated with a lower likelihood of private insurance for those with incomes between 100-200% and 200-400% of the poverty level. Uncompensated care reimbursement funds were associated with less purchase of private health insurance and a higher likelihood of being uninsured across all income groups. More generous Medicaid programs showed both safety-net and crowd out effects. [ABSTRACT FROM AUTHOR]

Objectives: To examine individual clinic staff members' experiences with using an immunization registry and to compare staff members' perceptions of immunization registries across different provider sites., Design: Cross-sectional survey using in-depth interviews and direct observation., Settings: The pediatric department of an urban community health center and 2 urban hospital-based pediatric primary care clinics., Participants: Twenty-five subjects were recruited using maximum variation sampling at each site. The subjects included clerks, clinic assistants, licensed practical nurses, a nurse practitioner, and registered nurses., Main Outcome Measures: Clinic staff members' perceptions of an immunization registry and frequency of registry use., Results: Differences were observed in subjects' perceptions of an immunization registry across provider sites. Although most subjects had positive attitudes toward the registry, they did not necessarily believe that the registry decreased their workload. The ability to access immunization registry data and actual use of the registry seem to be related to training of clinic personnel, location of the registry terminal, and helpfulness and availability of registry staff., Conclusion: Obtaining the opinions of immunization registry users is an important strategy to evaluate the usefulness of a registry in a site and target possible areas for improvement.

Objective: To determine whether patients with chest pain referred to a cardiologist from a gatekeeper managed care organization differ from those referred from an open-access managed care organization., Study Design: Retrospective study using clinical and claims data from a cardiac network database., Patients and Methods: We reviewed data from 1414 patients with chest pain or angina who were referred to a cardiologist between January 1, 1995, and June 30, 1996. We examined baseline clinical characteristics and subsequent physician practice patterns for these patients, who were referred from either a primary care gatekeeper model (n = 490) or an open-access model (n = 924)., Results: Although twice as many open-access patients were referred to a cardiologist, there were no differences in patient demographics or clinical characteristics at the time of referral. Cardiologists ordered similar diagnostic tests for patients from both types of managed care plans, and gatekeeper patients did not have a higher rate of abnormal tests. Rates of cardiac catheterization, coronary angioplasty, myocardial infarction, and hospitalization were similar in both groups. A significantly higher percentage of gatekeeper patients received a cardiac catheterization on the day of referral (7% versus 1%; P = .05). Open-access patients were significantly more likely to continue to be seen by a cardiologist (44% versus 28%; P < .01). Cardiology professional charges per patient were lower among gatekeeper patients ($972 +/- 1398 versus $1187 +/- 1897; P = .06), and total cardiology professional charges were significantly lower for the gatekeeper group because of the smaller number of patients seen., Conclusions: The type of cardiology services provided to patients with chest pain was not affected by the primary care administrative structure of the managed care organization, but the higher volume of patient referrals from the open-access plan may be an important consideration for cardiology practices participating in capitated contracts. The lower volume of referrals and coordination of care suggest potential cost advantages for the gatekeeper model.

Objective: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use., Design: Cohort observational study., Setting: A public hospital in Atlanta, Georgia., Patients: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years., Measurements and Main Results: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse., Conclusions: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.

Objective: To identify correlates of controlled hypertension in a largely minority population of treated hypertensive patients., Design: Case-control study., Setting: Urban, public hospital., Patients: A consecutive sample of patients who were aware of their diagnosis of hypertension for at least 1 month and had previously filled an antihypertensive prescription. Control patients had a systolic blood pressure (SBP) < or = 140 mm Hg and diastolic blood pressure (DBP) < or = 90 mm Hg, and case patients had a SBP > or = 180 mm Hg or DBP > or = 110 mm Hg., Measurements and Main Results: Control subjects had a mean blood pressure (BP) of 130/80 mm Hg and case subjects had a mean BP of 193/106 mm Hg. Baseline demographic characteristics between the 88 case and the 133 control subjects were not significantly different. In a logistic regression model, after adjusting for age, gender, race, education, owning a telephone, and family income, controlled hypertension was associated with having a regular source of care (odds ratio [OR] 7.93; 95% confidence interval [CI] 3.86, 16.29), having been to a doctor in the previous 6 months (OR 4.81; 1.14, 20.31), reporting that cost was not a deterrent to buying their antihypertensive medication (OR 3.63; 1.59, 8.28), and having insurance (OR 2.15; 1.02, 4.52). Being compliant with antihypertensive medication regimens was of borderline significance (OR 1.96; 0.99, 3.88). A secondary analysis found that patients with Medicaid coverage were significantly less likely than the uninsured to report cost as a barrier to purchasing antihypertensive medications and seeing a physician., Conclusions: The absence of out-of-pocket expenditures under Medicaid for medications and physician care may contribute significantly to BP control. Improved access to a regular source of care and increased sensitivity to medication costs for all patients may lead to improved BP control in an indigent, inner-city population.

Changes in the health care marketplace have had a profound effect on academic health centers and their traditional missions: teaching, patient care, and research. Many academic health centers have recognized the need to develop a capability for evaluating clinical practices and organizational restructuring. The Center for Clinical Evaluation Sciences at Emory University represents a model for the integration of evaluative capabilities into academic clinical practices.