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Physician claims can provide clues to causes
of postoperative complications
Physician claims submitted to Medicare could be used by
professional review organizations (PROs) and others to identify
hospitals or surgeons who have a high complication rate for
surgeries such as carotid endarterectomy, according to a recent
study by the Stroke Prevention Patient Outcome Research Team
Led by David B. Matchar, M.D. of Duke University, the PORT
investigators extracted physician claims data from a random 20
percent sample of Medicare patients undergoing carotid
endarterectomy (surgical removal of plaque deposits from the
carotid artery) between January 1, 1991 and November 31, 1991.
The study, which involved claims for 8,345 patients, was
supported by the Agency for Health Care Policy and Research
The Stroke PORT researchers found that by following claims for
certain services indicative of complications, they could identify
those patients who had problems following carotid
endarterectomy—approximately 10 percent of all patients
undergoing the procedure. Characteristics of these patients,
including their costs and outcomes, were compared with the
characteristics of patients whose records implied that they
underwent the surgery without complications.
Results indicated that patients who developed complications were
not only more likely to die within a month but also were eight
times more likely to be discharged to a rehabilitation hospital
or nursing home than to their homes (25 percent vs. 3 percent)
and three times more likely to be readmitted to an acute care
hospital (27 percent vs. 8 percent). Few differences in
complication rates were attributable to the patient's age, sex,
race, or medical condition; the rural or urban location of the
hospital; or the surgeon's specialty.
These findings suggest that the identity of the hospital and the
operating surgeon may be key factors in predicting the patient's
chance of recovering from carotid endarterectomy without
complications. Lead author Janet Mitchell, Ph.D., cautions,
however, that the use of claims data as a screening tool for
complications should be clinically validated before its use
For more information, see "Using physician claims to identify
postoperative complications of carotid endarterectomy," by Dr.
Mitchell, David J. Ballard, M.D., Ph.D., Jack P. Whisnant, M.D.,
and others, in the June 1996 issue of Health Services
Research 31(2), pp.141-152.
Current health, race, and age predict future
prescription drug use
While people typically use more medications as they age, a
person's current health and race are also important predictors of
later medication use, according to a new study supported in part
by the Agency for Health Care Policy and Research (HS07819). It
shows further that elderly blacks are less likely than elderly
whites to take prescription drugs, even though previous studies
have reported that blacks are more apt to be given a drug
prescription. This may reflect poorer communications between
typically white physicians and their black patients, greater
reliance of black patients on nontraditional healing methods (for
example, faith healing and folk remedies), noncompliance, or
inappropriate treatment of disease, notes Joseph T. Hanlon,
Pharm.D., of Duke University Medical Center.
Information was gathered through Duke University's Established
Populations for Epidemiologic Surveys of the Elderly (EPESE) on
1,778 elderly black and 1,446 elderly white North Carolina
community residents in 1986-1987 and 1989-1990. Dr. Hanlon and
colleagues then designed a model of health service use to analyze
which factors would predict changes in medication use 3 years
later. About 74 percent of these elderly persons were taking
prescription medications at the outset, compared with about 79
percent 3 years later, a statistically significant increase. The
average number of prescription drugs taken increased from 2.12 to
2.49. Older persons were more likely than younger ones to become
users of prescription drugs and to increase the number of drugs
used, but race and health were better predictors of future
prescription drug use than age.
Blacks were less likely than whites to become prescription drug
users or to increase the number of these drugs they used. Initial
severity of chronic disease and health care visits during the
year prior to the first interview also predicted use of
prescription drugs 3 years later. The model used was unable to
explain why the proportion of nonprescription drug users declined
from 73.4 percent to 71 percent, or why the average number of
nonprescription drugs decreased from 1.31 to 1.24 during the
For more information, see "Factors predicting change in
prescription and nonprescription drug use in a community-residing
black and white elderly population," by Gerda G. Fillenbaum,
Ph.D., Ronnie D. Horner, Ph.D., Dr. Hanlon, and others, in the
Journal of Clinical Epidemiology 49(5), pp. 587-593,
Elderly private patients are less apt to wait
admission than those eligible for Medicaid
Medicaid-eligible elderly persons seeking nursing home care are
considerably less likely than private payers to gain admission to
nursing homes, according to a recent study. It suggests that this
difference is due to the low reimbursements nursing homes receive
from Medicaid for these patients and State limits on the number
of nursing home beds. Based on a statistical model using data
from the National Long Term Care Channeling Demonstration, the
typical private-pay patient who sought nursing home care was able
to gain admission to a nursing home during the 1-year duration of
the demonstration. In contrast, the typical Medicaid-eligible
person who sought nursing home care had only a 71 percent chance
of gaining admission.
The findings suggest that increasing Medicaid reimbursements and
relaxing controls on bed supplies would increase access to care
for Medicaid-eligible people. Increasing reimbursements to
improve access would be expensive, however, and other research
suggests that, under some conditions, higher reimbursements may
lead to lower quality care, since nursing homes would then have
less incentive to compete for higher paying private payers. The
study was conducted by James D. Reschovsky, Ph.D., formerly with
the Agency for Health Care Policy and Research.
Details are in "Demand for and access to institutional long-term
care: The role of Medicaid in nursing home markets," by Dr.
Reschovsky, in Inquiry 33, pp. 15-29, 1996. Reprints
(AHCPR Publication No. 96-R104) are available from the AHCPR Publications Clearinghouse.
Physician retention continues to be
problematic in rural areas
Rural areas typically have fewer health care providers than more
urbanized parts of the country and it is difficult for rural
communities to keep their physicians. For example, rural areas
are rapidly losing obstetric providers. Even retention of
National Health Service Corps (NHSC) physicians, after they have
paid back their NHSC scholarship obligation, is difficult. Two
recent studies supported by the Agency for Health Care Policy and
Research (HS06544) demonstrate the influence of rural
characteristics on retention of physicians.
The first study shows that black NHSC physicians placed in rural
areas were much more dissatisfied with their work and personal
lives than other NHSC physicians, primarily because they
preferred urban life. Thomas R. Konrad, Ph.D., of the University
of North Carolina at Chapel Hill, and coinvestigators surveyed
NHSC physicians involved in the program from 1987 through 1990
who had been placed in rural sites. Minority physicians were more
apt to prefer access to urban cultural activities and placed less
value on living in a small community or an area where they had
access to outdoor sports such as fishing and skiing.
Despite similar hours of work, number of nights on call, patient
volumes, and incomes, minority physicians had lower work
satisfaction scores (2.13 vs. 2.30) and personal life
satisfaction scores (2.75 vs. 2.99) than other NHSC physicians.
These lower ratings were due almost entirely to the low ratings
provided by black physicians. Hispanic physicians did not differ
from white physicians in work or personal life satisfaction
In the second study, Dr. Konrad and colleagues examined the
migration of obstetrician-gynecologists into and out of rural
areas from 1985 to 1990. During the study period, a total of 962
ob-gyns moved out of 531 nonmetropolitan counties and 979 ob-gyns
moved into 528 counties. These physicians were more likely to
leave rural areas that were near metropolitan counties and that
had a low number of hospital beds. A sufficient population to
support health care providers and adequate hospital resources
were important to retaining physicians.
Of greater potential importance were factors related to
State-level policies, such as malpractice premiums, Medicaid
reimbursement, or the activity of State offices of rural health.
For example, North Carolina, the biggest gainer in the change,
made significant changes in its Medicaid program to improve
payments for prenatal care and delivery.
For more details on both studies, see "Minority physicians
serving in rural National Health Service Corps sites," by Donald
E. Pathman, M.D., M.P.H., and Dr. Konrad, and "Migration of
obstetrician-gynecologists into and out of rural areas,
1985-1990," by Thomas C. Ricketts, Ph.D., M.P.H., Sarah E.
Tropman, M.P.H., Rebecca T. Slifkin, Ph.D., and Dr. Konrad, which
appear in Medical Care 34(5), pp. 439-454 and 428-438,
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