Special issues in assessing care of Medicaid recipients

OBJECTIVES

The authors describe the process used to develop and test survey items targeted to Medicaid consumers for the Consumer Assessment of Health Plans Study (CAHPS). In addition, the authors highlight the special challenges in locating and surveying Medicaid recipients and provide recommendations for increasing response rates.

METHODS

The RAND CAHPS team reviewed the literature and existing questionnaires to identify health care issues and concepts important to Medicaid consumers. Three focus groups and 66 one-on-one cognitive interviews were conducted to test the relevance of our concepts and items and to identify additional concepts important to Medicaid consumers. After the cognitive interviews, the CAHPS Medicaid consumer survey was field tested using a sample of 930 adults and children receiving both Medicaid and Aid to Families with Dependent Children in Los Angeles County and Oklahoma. To determine if one particular mode were preferable for surveying a Medicaid population, our field test sample was divided randomly into a telephone-mode sample, a mixed-mode sample, and a second telephone-mode sample with enhanced locating procedures. Before finalizing the CAHPS 1.0 surveys, the full CAHPS item set was subjected to a formal literacy review.

RESULTS

The results of the focus groups and cognitive testing informed iterative versions of the list of concepts addressed by the Medicaid-targeted items. Concepts that were not relevant to Medicaid consumers or that consumers were unable to accurately attribute to a health plan were discarded. New concepts addressing important aspects of health care and the health care experience of Medicaid consumers were identified and added. Item wording and format were revised and refined based on the findings from focus groups, cognitive testing, the field test, and the formal literacy review. In the field test, the mixed-mode method achieved the best results with a 56% completion rate.

CONCLUSIONS

The testing and formatting efforts described in this article, in combination with a formal literacy review, led to the development of a Medicaid questionnaire that measures the important health care experiences of Medicaid consumers in a format that is "respondent-friendly." Our recommendations for surveying Medicaid recipients can benefit any survey of a Medicaid population.

IFN-gamma and CD8+ T cells restore host defenses against Pneumocystis carinii in mice depleted of CD4+ T cells

Host defenses against infection are profoundly compromised in HIV-infected hosts due to progressive depletion of CD4+ T lymphocytes and defective cell-mediated immunity. Although recent advances in antiretroviral therapy can dramatically lower HIV viral load, blood CD4+ T lymphocytes are not restored to normal levels. Therefore, we investigated mechanisms of host defense other than those involving CD4+ T lymphocytes against a common HIV-related opportunistic infection, Pneumocystis carinii (PC) pneumonia. Using CD4-depleted mice, which are permissive for chronic PC infection, we show that up-regulation of murine IFN-gamma by gene transfer into the lung tissue results in clearance of PC from the lungs in the absence of CD4+ lymphocytes. This resolution of infection was associated with a >4-fold increase in recruited CD8+ T lymphocytes and NK cells into the lungs. The role of CD8+ T cells as effector cells in this model was further confirmed by a lack of an effect of IFN-gamma gene transfer in scid mice or mice depleted of both CD4+ and CD8+ T cells. Cytokine mRNA analysis revealed that recruited, lung-derived CD8+ T cells had greater expression of IFN-gamma message in animals treated with the IFN-gamma gene. These results indicate that CD8+ T cells are capable of clearing PC pneumonia in the absence of CD4+ T cells and that this host defense function of CD8+ T cells, as well as their cytokine repertoire, can be up-regulated through cytokine gene transfer.

The use of cognitive testing to develop and evaluate CAHPS 1.0 core survey items. Consumer Assessment of Health Plans Study

OBJECTIVES

The main goal of the Consumer Assessments of Health Plans Study (CAHPS) is to develop an integrated set of tested, standardized surveys to obtain meaningful information from health plan enrollees about their experiences. The CAHPS project benefits from the complementary strengths of psychometric and cognitive testing.

METHODS

The CAHPS team conducted 150 cognitive interviews across three organizations in different geographic locations using multiple interview methods with different consumer populations. This article explains how cognitive testing was used in the CAHPS survey development process and shares the main findings from the cognitive interviews.

RESULTS

A modified report format is more appropriate when asking about specific aspects of plan enrollees' experiences, whereas a rating format is useful for asking about overall assessments. Specifying a longer reference period is preferable to asking about the most recent visit when capturing experiences with care, because some respondents get frustrated when they cannot include experiences other than the most recent visit. Explicit screeners and tailored inapplicable response categories are beneficial in mail questionnaires, so people know that they should not answer questions about which they have no relevant experience.

CONCLUSION

Cognitive testing was integral in the development and refinement of the CAHPS instrument. The cognitive testing findings contributed to an improved instrument that should capture consumers' health care and plan experiences with less response error than one not subjected to such testing. The cognitive testing process and findings can be useful to other researchers with similar survey development goals.

Physician practice management companies: should physicians be scared?

Physician practice management companies (PPMCs) manage nonclinical aspects of physician care and control physician groups by buying practice assets. Until recently, PPMCs were a favorite of Wall Street. Suddenly, in early 1998, the collapse of the MedPartners-PhyCor merger led to the rapid fall of most PPMC stock, thereby increasing wariness of physicians to sell to or invest in PPMCs. This article explores not only the broken promises made by and false assumptions about PPMCs, but also suggests criteria that physicians should use and questions would-be PPMC members should ask before joining. Criteria include: demonstrated expertise, a company philosophy that promotes professional autonomy, financial stability, freedom from litigation, and satisfied physicians already in the PPMC. The authors recommend that physicians seek out relatively small, single-specialty PPMCs, which hold the best promise of generating profits and permitting professional control over clinical decisions.

Angiotensin II-induced calcium signalling in isolated glomeruli from fish kidney (Oncorhynchus mykiss) and effects of losartan

Glomeruli were isolated from the kidney of freshwater-adapted rainbow trout, Oncorhynchus mykiss, to qualitatively evaluate changes in cellular calcium associated with angiotensin II ([Asn1Val5]-Ang II) receptor stimulation and antagonism by the Ang II receptor antagonist losartan. Microspectrofluorometry using the fluorescent calcium indicator dye Calcium Green recorded fluorescence changes in isolated single glomeruli. Isolated glomeruli containing ester-loaded Calcium Green showed an Ang-II-induced transient rise in fluorescence. This transient rise showed an increased peak amplitude with increased Ang II concentration (10(-9) to 10(-6) M), but only a very small response was detectable in glomeruli exposed to 10(-9) M Ang II. The biphenylimidazole compound losartan (=DuP 753), an antagonist of the mammalian AT1 subtype Ang II receptor, initiated a transient agonistic rise in glomerular fluorescence at high concentration (10(-5), 10(-4), and 10(-3) M). However, the responses to 10(-6) 10(-7) M losartan were small or very low in each case. Losartan (10(-4) or 10(-7) M) antagonised the Ang-II-induced signalling in isolated glomeruli exposed to 10(-7) or 10(-6) M Ang II, respectively. This is the first evidence for functional AT1-like Ang II receptors coupled to cellular calcium signalling in the glomeruli of rainbow trout.

Determinants of job stress and job satisfaction among supervisory and non-supervisory employees in a large Canadian teaching hospital

This article explores the extent to which hospital workers at a large teaching hospital at different managerial/supervisory levels (designated and non-designated supervisors, and non-supervisory staff), experienced job stress and job satisfaction prior to the re-engineering of hospital services. For all groups, increased levels of job demands were associated with higher levels of stress. Lower levels of decision latitude were associated with increased job stress for designated supervisors. Increasing levels of decision latitude were associated with both job stress and satisfaction for the other two groups. Co-worker support and teamwork contributed to increased job satisfaction for all groups.

Ultrasonographically guided percutaneous biopsy of gastric, small bowel, and colonic abnormalities: efficacy and safety

The purposes of this study were to evaluate the efficacy of sonographically guided percutaneous biopsy of gastric and bowel lesions and to document any associated complications. A retrospective review of all patients undergoing ultrasonographically guided biopsy of gastric, small bowel, or colonic lesions was performed. Cases were evaluated for size of lesion, location, efficacy in obtaining a diagnostic specimen, and any procedure-related complications. A total of 46 biopsies were performed in 44 patients over a 6 year period. Fifteen gastric, four duodenal, seven small bowel, 16 right colonic, and two left colonic lesions were identified. Histologic diagnosis included 20 adenocarcinomas, seven lymphomas, 10 mesenchymal tumors, and two cases of candidal enteritis. In 18 (41%) patients the initial fine-needle aspirate was negative, although 10 of these patients subsequently underwent ultrasonographically guided core biopsy with a diagnosis of neoplasm established in all 10. Two patients with an initial negative result on fine-needle aspiration underwent repeat aspiration, demonstrating malignancy. Two additional false-negative aspirates were obtained; these patients did not undergo repeat biopsy but were subsequently found to have lymphoma. Two of the patients with aspirates that were negative for malignancy were believed to have inflammatory changes secondary to pancreatitis. One patient was lost to follow-up evaluation. No complications were recorded. Percutaneous fine-needle aspiration of gastric and bowel lesions is a simple and safe procedure and may be particularly useful with poor candidates for endoscopy or for lesions that are difficult or impossible to reach endoscopically. Diagnostic yield is high, particularly in documenting malignancy, although in suspected stromal tumors a core biopsy often is required.

Intravenous gamma-globulin treatment and retreatment in Kawasaki disease. US/Canadian Kawasaki Syndrome Study Group

OBJECTIVE

To determine the prevalence and outcome of intravenous gamma-globulin (IVIG) retreatment in patients with Kawasaki disease (KD).

METHOD

Multicenter, retrospective survey of all children with KD evaluated at nine clinical centers across North America during a 15-month period.

RESULTS

Data were available for 378 patients. At 48 h after completion of the initial IVIG infusion, 50 patients (13.2%) remained febrile, 29 (58.0%) of whom were retreated with IVIG, including 4 (13.8%) with coronary artery abnormalities before their first IVIG infusion. Among 25 retreated patients with a normal baseline echocardiogram, 5 (20.0%) developed coronary abnormalities and were termed "treatment failures." Among the 323 patients with a normal baseline echocardiogram, only 9 (2.8%) were treatment failures; treatment failure occurred in 4 of 282 (1.4%) patients who became afebrile post-IVIG and in 5 of 41 (12.2%) patients with persistent or recrudescent fever after their first course of IVIG therapy (P=0.002).

CONCLUSIONS

The overall prevalence of new coronary abnormalities in KD patients treated with IVIG and aspirin remains low. Persistent or recrudescent fever after the first course of IVIG was associated with an increased risk of treatment failure (P=0.002). IVIG retreatment in patients who remain febrile after the first course of IVIG is now common (58.0%), although the efficacy of this practice requires assessment with a randomized trial.

HIV-1 tat binds TAFII250 and represses TAFII250-dependent transcription of major histocompatibility class I genes

HIV Tat, a transactivator of viral transcription, represses transcription of major histocompatibility (MHC) class I genes. Repression depends exclusively on the C-terminal domain of Tat, although the mechanism of this repression has not been known. We now show that repression results from the interaction of Tat with the TAFII250 component of the general transcription factor, TFIID. The C-terminal domain of Tat binds to a site on TAFII250 that overlaps the histone acetyl transferase domain, inhibiting TAFII250 histone acetyl transferase activity. Furthermore, promoters repressed by Tat, including the MHC class I promoter, are dependent on TAFII250 whereas those that are not repressed by Tat, such as SV40 and MuLV promoters, are independent of functional TAFII250. Thus, Tat repression of MHC class I transcription would be one mechanism by which HIV avoids immune surveillance.

The MHC class II transactivator (CIITA) requires conserved leucine charged domains for interactions with the conserved W box promoter element

The class II transactivator CIITA is required for transcriptional activation of the major histocompatibility complex (MHC) class II genes. Aside from an N-terminal acidic transcriptional activation domain, little is known about how this factor functions. Extensive mutagenesis of CIITA was undertaken to identify structural motifs required for function. The ability of mutants to activate a reporter gene under the control of MHC class II conserved W-X-Y or X-Y regulatory elements was determined. Two mutants displayed differential activity between the two promoters, activating transcription with the W-X-Y but not the X-Y elements. All mutants were tested for their ability to interfere with wild-type CIITA activity. Five CIITA mutant constructions were able to down-regulate wild-type CIITA activity. Three of these mutants contained targeted disruptions of potential functional motifs: the acidic activation domain, a putative GTP-binding motif and two leucine charged domains (LCD motifs). The other two contained mutations in regions that do not have homology to described proteins. The characterization of CIITA mutants that are able to discriminate between promoters with or without the W box strongly suggests that CIITA requires such interactions for function. The identification of LCD motifs required for CIITA function brings to light a previously undefined role of these motifs in CIITA function.

Psychopharmacologic treatment of acquired attention disorders in children with brain injury

This investigation examined the efficacy of psychostimulant therapy in alleviating neurobehavioral dysfunction attendant to pediatric brain injury. The most commonly reported neurobehavioral sequelae associated with head injury in the pediatric population involve deficits along the attentional matrix. This is also the most common objectively documented neurobehavioral finding among children as well as adults. There are several investigations in the adult literature which have employed the use of psychostimulants in treating both psychiatric and neuropsychological residua associated with head injury. Overall, the results of these studies are equivocal, but suggest a beneficial impact on general functioning. The present prospective investigation utilized a double-blind, placebo-controlled, cross-over experimental design to examine the efficacy of methylphenidate in treating children with acquired attentional disorders secondary to brain injury. A cohort of 14 children with varying degrees of head injury were recruited for participation. As expected, differences between drug and placebo conditions uniformly achieved statistical significance. Additionally, there were no differences in performance between baseline and placebo conditions on neurobehavioral tasks of attention and concentration. Current findings suggest that methylphenidate (and probably other psychostimulants such as Cylert, Adderal, Wellbutrin and dextroamphetamine sulfate) is an extremely effective agent in treating attentional disorders secondary to brain injury in children.

Erythropoietin-induced recurrent veno-occlusive priapism associated with end-stage renal disease

This is the first report of a male hemodialysis patient experiencing recurrent dialysis-associated priapism that resolved when his concurrent erythropoietin dose was reduced from 2000 to 1500 U one time per week and held if his hemoglobin was greater than 10 g/dL. We discuss dialysis-associated priapism and the effects of erythropoietin on the coagulation cascade and male hormone levels in an effort to elucidate the etiology of priapism in this patient.

Work time estimates for ophthalmic diagnoses and procedures. Results from the Eye Care Workforce Study

OBJECTIVE

To provide estimates of patient-level annual ophthalmologist work times for the care of common ophthalmic conditions and patient-level global surgical care time for common or important ophthalmic procedures.

METHODS

A random sample of the domestic membership (excluding members-in-training) of the American Academy of Ophthalmology, stratified by self-designated practice concentration, was surveyed in 1994 to provide estimates of work times for common ophthalmic services.

RESULTS

Comprehensive and subspecialty-specific results were obtained for ophthalmic diagnoses, services, and surgical procedures. For ophthalmic diagnoses and services, initial and follow-up visit work times are reported for comprehensive and subspecialty ophthalmologists separately. For common surgical procedures, aggregate results based on comprehensive and subspecialist survey responses are reported.

CONCLUSIONS

These ophthalmology-specific survey results can be used for a variety of purposes, including practice management, "benchmarking," health plan administration and national workforce planning. Such surveys should be repeated as techniques and practice patterns change over time.

Fielding standardized patients in primary care settings: lessons from a study using unannounced standardized patients to assess preventive care practices

OBJECTIVES

To document detection and suspicion rates of unannounced standardized patients visiting community-based practices.

DESIGN

Primary care physicians were recruited to participate in a study using standardized patients. Four standardized patient scenarios were used.

SETTING

Community-based primary care physicians' practices in southern Ontario between September 1994 and August 1995.

STUDY PARTICIPANTS

Sixty-two primary care physicians.

MAIN OUTCOME MEASURES

A 'believability' questionnaire completed after all four standardized patients had visited the practices.

RESULTS

Of the primary care physicians approached, 50% (62) agreed to participate. Twenty-one per cent of all visits were suspected as standardized patient encounters. Forty-six per cent suspected one or more standardized patients. Only five physicians (8%) suspected all four standardized patients. Reasons for suspecting standardized patients were associated with the characteristics of the physician's practices, the physician's practice profile and the standardized patient cover story.

CONCLUSION

The portrayal of asymptomatic patients seeking a new primary care physician presents unique challenges. Carefully constructed cover stories, and detailed knowledge of the local area and of the practices of the participating physicians is required to allow standardized patients cases to be tailored to fit into primary care settings without arousing suspicion.

CIITA stimulation of transcription factor binding to major histocompatibility complex class II and associated promoters in vivo

CIITA is a master transactivator of the major histocompatibility complex class II genes, which are involved in antigen presentation. Defects in CIITA result in fatal immunodeficiencies. CIITA activation is also the control point for the induction of major histocompatibility complex class II and associated genes by interferon-gamma, but CIITA does not bind directly to DNA. Expression of CIITA in G3A cells, which lack endogenous CIITA, followed by in vivo genomic footprinting, now reveals that CIITA is required for the assembly of transcription factor complexes on the promoters of this gene family, including DRA, Ii, and DMB. CIITA-dependent promoter assembly occurs in interferon-gamma-inducible cell types, but not in B lymphocytes. Dissection of the CIITA protein indicates that transactivation and promoter loading are inseparable and reveal a requirement for a GTP binding motif. These findings suggest that CIITA may be a new class of transactivator.

Postprostatectomy urinary incontinence: a comparison of the cost of conservative versus surgical management

OBJECTIVES

Post-radical prostatectomy stress incontinence occurs in up to 20% of patients. Postprostatectomy incontinence is initially treated with undergarments, pads, or drip collectors. Patients with persistent leakage are often treated with a transurethral bulking agent (Contigen) or placement of an artificial genitourinary sphincter (AGUS). We have compared the direct costs of each treatment at our institution over 10 years.

METHODS

The Mayo Clinic estimating office provided the Medicare and non-Medicare charges for patients receiving both collagen injection (outpatient) and AGUS placement (2-day hospitalization) during August 1995. The Mayo Store provided the current price of all undergarments, pads, and drip collectors carried. Two local grocery stores provided the cost of Depends undergarments.

RESULTS

The following items were the least expensive carried at the Mayo Clinic Store: Entrust undergarments, Active Style pads, and Conveen drip collectors at $0.99, $0.52, $1.05 each, respectively. The average cost of Depends undergarments was $0.52 each. The cost of wearing 5 of the least expensive undergarments or pads per day for 10 years is $9497. The average estimated Medicare and non-Medicare cost for outpatient (general anesthesia) collagen injection is $4300 and $5625, respectively. The average Medicare and non-Medicare cost for AGUS placement is $15,400 and $20,300, respectively. Factoring in our current 22.4% reoperation rate, the average per patient Medicare and non-Medicare cost for AGUS placement is $18,850 and $24,847, respectively.

CONCLUSIONS

The cost of the AGUS placement compares favorably with the cost of transurethral collagen injection (under general anesthesia) in patients requiring several (more than three) collagen injection treatments or requiring the continued use of undergarments after collagen injection. Whereas the cost of transurethral collagen injection, when effective, compares favorably with conservative treatment, AGUS placement is significantly more expensive than conservative management for almost all patients except the exceedingly rare patient wearing more than 9 undergarments or pads per day. When the psychosocial benefit of urinary continence is considered, however, transurethral injection of collagen or AGUS placement often becomes the preferred treatment.

Member ratings of health care provided by 48 physician groups

BACKGROUND

Satisfaction with health plan performance has been assessed frequently, but assessment of physician group performance is rare.

OBJECTIVE

To present ratings of the care provided by physician groups to enrollees in a variety of capitated health maintenance organization plans.

METHODS

A random sample was drawn of adult enrollees receiving managed health care from 48 physician groups in a group practice association. Each individual in the sample was mailed a 12-page questionnaire and 7093 were returned (59% response rate). The mean age of those returning the questionnaire was 51 years; 65% were women.

RESULTS

Reliability estimates for 6 multi-item satisfaction scales were excellent, and noteworthy differences in ratings among groups were observed. In particular, ratings of overall quality ranged from a low of 28 to a high of 68 (mean, 50; SD, 10). Average scores for physician groups were strongly correlated across all scales, but no single group scored consistently highest or lowest on the different scales. Negative ratings of care were significantly related to the following: intention to switch to another physician group, difficulty in getting appointments, lengthy waiting periods in the reception area and examination room, the inability to get consistent care from one physician for routine visits, and not being informed by the office staff when there was a delay in seeing the primary care provider.

CONCLUSIONS

Monitoring of health care quality at the physician group level is possible, and could be used for benchmarking, internal quality improvement, and for providing information to the public about how these physician groups will meet its needs.

The effects of menopausal status and exercise training on serum lipids and the activities of intravascular enzymes related to lipid transport

The study purpose was to compare the effect of exercise training on serum lipid and apolipoprotein concentrations and the activities of intravascular enzymes related to lipid transport in previously untrained eumenorrheic, premenopausal (PRM) women (n = 21; mean age, 36 +/- 3 years) and estrogen-free postmenopausal (POM) women (n = 16; mean age, 68 +/- 8 years). Subjects trained at a progressive intensity and duration (50% to 75% maximal O2 consumption [VO2max], 200 to 300 kcal/session) 4 d/wk for 12 weeks. Before and after training, VO2max, body weight, relative body fat, and fasting blood samples were obtained following 2 weeks on a standardized diet designed to maintain body weight and during the early follicular stage for the PRM group. Blood samples were analyzed for serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), the cholesterol content of the HDL3 subfraction, apolipoprotein (apo)A-I and apoB, lipoprotein(a), and the activity of lecithin:cholesterol acyltransferase (LCAT). Total and hepatic triglyceride lipase activity (HTGLA) were determined from plasma samples obtained after heparin administration. The cholesterol content of the low-density lipoprotein (LDL) and HDL2 subfractions and endothelial-bound lipoprotein lipase activity (LPLA) were calculated. A two (group) x two (time) multivariate ANOVA (MANOVA), with repeated measures for time indicated that the exercise-induced changes in physiological measurements, serum lipid or apolipoprotein concentrations, or enzyme activities did not differ between groups. Serum concentrations of TC, LDL-C, and HDL3 cholesterol, TG, and apo A-I and apoB were higher in POM women compared with the PRM group (P < .05 for all). For the combined groups, body weight and relative body fat did not change with training, but VO2max increased an average of 18.5% (P < .05). LPLA, HTGLA, and LCAT activity were unaltered with exercise training. Except for a small but significant decrease in HDL-C (-5.5%) and an elevation in apoB (4.3%; P < .05 for both), the concentrations of serum lipids and apolipoproteins did not change over the training period. We conclude that in previously untrained women, menopausal status does not influence the exercise training response of serum lipids or apolipoproteins or activities of intravascular enzymes related to lipid transport.

Pressure-permeability relationships in basement membrane: effects of static and dynamic pressures

The glomerular basement membrane (GBM) is an important component of the filtration barrier that is the glomerular capillary wall. Previously GBM permeability has been investigated only under static pressures and often within a supraphysiological range. We used Matrigel as a model of GBM and formed membranes at the base of filtration chamber. We measured membrane permeability under static and dynamic pressures. Matrigel membranes were size and charge selective toward neutrally and negatively charged dextrans. Their permeability (as measured by hydraulic conductivity) was found to decrease from 1.61 +/- 0.06 to 0.75 +/- 0.07 x 10(-6) cm.s-1.cmH2O-1 as static pressure increased from 6 to 78 cmH2O, an effect attributed to membrane compression. In comparison to static pressure, sinusoidal pressure waves with a mean pressure of 50 cmH2O decreased membrane permeability, e.g., fluid flux was reduced by a maximum of 2% to a value of 5.47 +/- 0.38 x 10(-5) cm/s; albumin clearance was reduced by a maximum of 5.2% to a value of 9.63 +/- 1.06 x 10(-6) ml.cm-2.s-1. Such changes were affected by the frequency of pressure wave application and could be attributed to a switching on and off of the membrane compression effect.

Carotenoid pigments in seafoods and aquaculture

Color plays a major role in the overall acceptability of food products. It is considered one of man's basic experiences that a particular foodstuff has to be of a distinct color in order to be edible. The color of a seafood is the first characteristic noted by the consumer and is directly related to the subsequent acceptance or rejection of it. Carotenoids contribute to the yellow, orange, and red colors of the skin, shell, or exoskeleton of aquatic animals. Indeed, they are the most widespread pigments found in nature, as they occur in bacteria, yeasts, mold, all green plants, and many animals, and therefore various functions have been attributed to them. From anthropocentric consideration, the most significant aspect of carotenoids is the color they impart to our food and environment. In animals, the carotenoids are also associated with reproductive organs and hence the hatching success and survival of alevins.

Cost-efficient localization of seizures of mesiotemporal onset with foramen-ovale electrodes

Foramen ovale (FO) electrodes can identify mesiotemporal lobe (MTL) seizure onsets but are infrequently used in the USA. Ten patients with presumed MTL ictal onset, unlocalized noninvasively, had FO electrodes inserted during long term monitoring for epilepsy. Placement was facilitated by intraoperative use of oblique submental and modified Caldwell view fluoroscopy. Eighty percent of patients had ictal localization by FO electrodes. This led to anterior temporal lobectomy in six with 83% being seizure free after follow-up of 20-32 months. The mean total costs of placing these electrodes was approximately half that of subdural strips and a quarter that of depth electrodes. Foramen ovale electrodes represent a cost-effective and efficient method of seizure localization when noninvasive workup suggests but is not definitive for MTL origin.

What factors influence primary care physicians' charges for their services? An exploratory study using standardized patients

OBJECTIVE

To determine the extent of variation in physicians' charges for health care encounters with unannounced standardized patients and factors associated with the variation.

DESIGN

Cross-sectional study.

SETTING

Family practices open to new patients within 1 hour's drive of Hamilton, Ont.

PARTICIPANTS

A stratified random sample of 125 physicians who had responded to an earlier survey regarding preventive care were invited to participate. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew because they closed their practices to new patients. Sixty-two physicians thus participated in the study.

INTERVENTION

Unannounced standardized patients posing as new patients to the practice visited study physicians' practices between September 1994 and August 1995, portraying 4 scenarios: 28-year-old woman, 52-year-old woman, 48-year-old man and 70-year-old man.

OUTCOME MEASURES

Physician characteristics, encounter characteristics and charges made for services.

RESULTS

The 62 physicians had 246 encounters with the standardized patients. Charges were made to the health insurance plan for services by 59 physicians for up to 4 encounters (215 encounters in all). Charges varied considerably both within and across patient scenarios. Time spent with the patient was an important factor predicting charges made (p < 0.01), although the effect of time spent on charges varied across scenarios (p < 0.01). Fee-for-service physicians charged more for their services than physicians who usually had alternative billing arrangements (p < 0.01). Female physicians charged more for their services than their male colleagues (p = 0.03). No relation was found between quality of preventive care and charges made (p = 0.15).

CONCLUSIONS

Physician-related factors are better able to account for the variability in charges for their services than patient-related factors. Physicians seeing comparable patients may earn much more or less than their colleagues because of differences in the services they provide and the way they apply the fee schedule. Quality-assurance techniques are likely needed to reduce the variability in charges seen and increase value for money spent in health care.

Provision of preventive care to unannounced standardized patients

OBJECTIVE

To examine the relation between physician, training and practice characteristics and the provision of preventive care as described in the guidelines of the Canadian Task Force on the Periodic Health Examination.

DESIGN

Cross-sectional study.

SETTING

Family practices open to new patients within 1 hour's drive of Hamilton, Ont.

PARTICIPANTS

A total of 125 family physicians were randomly selected from respondents to an earlier preventive care survey. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew when they closed their practices to new patients. Sixty-two physicians thus participated in the study.

INTERVENTION

Unannounced standardized patients posing as new patients to the practice visited study physicians' practices between September 1994 and August 1995, portraying 4 scenarios: 48-year-old man, 70-year-old man, 28-year-old woman and 52-year-old woman.

OUTCOME MEASURES

Proportion of preventive care manoeuvres carrying grade A, B, C, D and E recommendations from the Canadian Task Force on the Periodic Health Examination that were performed, offered or advised. A standard score was computed based on the performance of grade A and B manoeuvres (good or fair evidence for inclusion in the periodic health examination) and the non-performance of grade D and E manoeuvres (fair or good evidence for exclusion from the periodic health examination).

RESULTS

Study physicians performed or offered 65.6% of applicable grade A manoeuvres, 31.0% of grade B manoeuvres, 22.4% of grade C manoeuvres, 21.8% of grade D manoeuvres and 4.9% of grade E manoeuvres. The provision of evidence-based preventive care was associated with solo (v. group) practice and capitation or salary (v. fee-for-service) payment method. Preventive care performance was unrelated to physician's sex, certification in family medicine or problem-based (v. traditional) medical school curriculum.

CONCLUSIONS

Preventive care guidelines of the Canadian Task Force on the Periodic Health Examination have been incompletely integrated into clinical practice. Research is needed to identify and reduce barriers to the provision of preventive care and to develop and apply effective processes for the creation, dissemination and implementation of clinical practice guidelines.

A giant left renal cyst presenting as obesity: a unique presentation

OBJECTIVE

Benign renal cysts are commonly found in adult patients. However, giant renal cysts measuring more than 15 cm in greatest diameter or containing more than 1500 cc of fluid are rarely seen. A giant renal cyst presenting as obesity, a unique form of presentation, is described herein.

METHODS/RESULTS

We report the unique case of 78-year-old male who was diagnosed with a 25 cm left renal cyst after presenting solely with diffuse progressive abdominal distention. He had no other signs or symptoms and had been followed at our institution for seven years with a diagnosis of obesity. The patient was effectively treated by open renal cyst decortication.

CONCLUSIONS

Giant renal cyst measuring > or = 15 cm or containing more than 1500 cc of fluid rarely occur. This case is unique in that unlike other adult patients, this patient presented with no sign or symptom other than diffuse, nonlateralizing, abdominal distension.