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Racial differences in nicotine metabolism mean that blacks take in more nicotine per cigarette than whites

Black cigarette smokers take in 30 percent more nicotine per cigarette than white smokers and take nearly 2 hours longer to clear cotinine, a nicotine metabolite, from the bloodstream, concludes a study supported in part by the Agency for Health Care Policy and Research (HS07373). This means that blacks who smoke 12 to 15 cigarettes a day get as much nicotine as whites who smoke a full pack of 20 cigarettes a day. These findings of racial differences in nicotine metabolism may help explain why blacks tend to suffer more from tobacco-related disease and have more trouble kicking the habit than whites.

As of 1994, about the same proportion of blacks and whites smoked cigarettes (27 to 28 percent). However, one-third (34 percent) of black men smoked compared with 28 percent of white men; fewer black than white women smoked (22 vs. 25 percent). Cigarette smokers tend to regulate their tobacco consumption to gain the desired effects of nicotine (relaxation and increased concentration), which are related to the levels of nicotine in the body. Since whites metabolize nicotine more rapidly, they need to smoke more than blacks to maintain the same level of nicotine in their body, explains Eliseo J. Perez-Stable, M.D., of the AHCPR-funded Medical Effectiveness Research Center for Diverse Populations, University of California, San Francisco.

To separate smoking behavior from nicotine metabolism, the researchers simultaneously infused nicotine and cotinine into the bloodstream of 40 black and 39 white smokers of similar age at San Francisco General Hospital Medical Center. The researchers collected smokers' urine to determine rates of nicotine metabolism. They used these data on metabolism to estimate the smokers' daily intake of nicotine from cigarette smoking.

Blacks had blood levels of cotinine that were 50 percent higher per cigarette than whites. Also, blacks cleared cotinine significantly more slowly, with cotinine half-life (time remaining in the body) of nearly 18 hours (1,064 minutes) in blacks compared with 16 hours (960 minutes) for whites. In addition, the nicotine intake per cigarette was 30 percent greater in blacks than whites (1.41 vs. 1.09 mg per cigarette). Most blacks (78 percent) smoked mentholated cigarettes, compared with only two whites (5 percent). Blacks also smoked cigarettes with a higher content of nicotine, tar, and carbon monoxide. The higher intake of nicotine among blacks, which is highly correlated with exposure to tar and oxidant gases, may help explain the higher smoking-related risks of lung cancer and reproductive disorders in blacks compared with whites, note the researchers.

These findings suggest that there may be a racial genetic difference in cotinine metabolism. On the other hand, smoking mentholated cigarettes may influence cotinine metabolism. The reasons why blacks take in more nicotine and more cigarette smoke per cigarette are unclear. The most obvious possibility is that menthol, via its cooling action, facilitates deep inhalation, but this explanation has not been confirmed by research.

More details are in "Nicotine metabolism and intake in black and white smokers," by Dr. Perez-Stable, Brenda Herrera, M.S., Peyton Jacob III, Ph.D., and Neal L. Benowitz, M.D., in the July 8, 1998 Journal of the American Medical Association 280(2), pp. 152-156.

Editor's Note: Another new study also supports these findings of higher blood cotinine levels in black compared with white and Mexican-American smokers. See Carballo, Giovino, Pechacek, and others, JAMA 280 (2), pp. 135-139, July 8, 1998.

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Clinical Decisionmaking

Women with chronic disease are less likely than other women to undergo screening for breast and cervical cancer

Although screening for breast or cervical cancer reduces death from those diseases by 20 to 60 percent, such screening is underused. Women with chronic conditions—such as diabetes in particular—do not make adequate use of this screening, according to a study supported in part by the Agency for Health Care Policy and Research (HS09446).

Catarina I. Kiefe, Ph.D., M.D., of the University of Alabama, and fellow researchers reviewed the medical records of 1,764 women aged 43 and over who were followed for about 3 years in two of the university's primary care clinics. They determined whether a woman had been screened according to recommendations of the U.S. Preventive Services Task Force: mammography within the past 2 years for women aged 50 to 74 years; a clinical breast exam (CBE) within the past year for women of all ages; and a Pap smear within the past 3 years for women younger than 65.

The researchers correlated existence of chronic conditions with screening, after accounting for other determinants of screening. With each additional chronic condition, a woman was 17 percent less likely to have had a mammogram, 13 percent less apt to have had a CBE, and 19 percent less likely to have had a Pap smear within the recommended timeframe.

Conditions that were significantly and negatively related to screening included chronic stable angina, rheumatoid arthritis, congestive heart failure, and myocardial infarction. One exception was women with hypertension, who were 32 percent more likely to have had a Pap smear than other women. These findings suggest that women followed in a primary care setting are screened less frequently for breast or cervical cancer as their burden of chronic disease increases. In some cases, care associated with the chronic diseases may be competing with clinical screening, explains Dr. Kiefe. On the other hand, some physicians may be less likely to use cancer screening in elderly patients or in patients whose life expectancy has been shortened by disease.

See "Chronic disease as a barrier to breast and cervical cancer screening," by Dr. Kiefe, Ellen Funkhouser, Dr.P.H., Mona N. Fouad, M.D., M.P.H., and Daniel S. May, Ph.D., in the June 1998 Journal of General Internal Medicine 13, pp. 357-365.

More checkpoints are needed to prevent overdosing errors in administering high-dose chemotherapy

High-dose chemotherapy followed by bone marrow or peripheral blood stem cell transplantation is widely used to treat blood disorders and cancers. But chemotherapy overdosing occurs, usually due to nursing infusion errors or cumulative drug doses given as a daily dose. In fact, several blood and marrow transplant units surveyed had prior overdosing incidents, and overdosing appeared likely in recently established units, says a study supported in part by the Agency for Health Care Policy and Research (HS09407).

Multidisciplinary checkpoints should be established at the physician, pharmacist, nursing, and institutional levels to curb this problem, recommends Keith M. Sullivan, M.D., of the Fred Hutchinson Cancer Research Center in Seattle.

The researchers analyzed results of an anonymous national survey by the American Society for Blood and Marrow Transplantation (ASBMT) of 115 blood and marrow transplant centers in the United States. Fifteen (13 percent) of the centers reported a total of 18 patients inadvertently given overdoses of cisplatin, carboplatin, busulfan, cytosine arabinoside, cyclophosphamide, interleukin-2, or other high-dose chemotherapy agents between 1989 and 1994. The overall rate of chemotherapy overdoses for the 5-year study period was 0.06 percent, or 6 cases per 10,000 transplants.

Errors were due to cumulative drug doses given as a daily dose (six cases), nursing infusion errors (six cases), ambiguous orders without attending co-signatures (two cases), and pharmacy or staff error (one each). To reduce these errors the ASBMT suggests guidelines for standardizing safety practices at all transplant centers. These include preprinted order sheets that specify the date and daily doses of a drug to prevent doctors from prescribing the cumulative drug treatment as the daily dose and verification of patient and drug identification against orders and protocols by two nurses to reduce the incidence of nursing infusion errors.

Details are in "Safeguarding the administration of high-dose chemotherapy: A national practice survey by the American Society for Blood and Marrow Transplantation," by Chien-Shing Chen, M.D., Kristy Seidel, M.A., James O. Armitage, M.D., and others, in Biology of Blood and Marrow Transplantation 3(6), pp. 331-340, 1997.

Treating acute asthma attacks in special ER observation units is more effective and costs less than inpatient care

Many poor, urban individuals, whose asthma is frequently out of control due to poor self-management and inadequate primary care, often end up at public hospital emergency departments (EDs) with an acute exacerbation of their illness. Typically, if their asthma episode is not resolved after 3 hours of treatment in the ED, they are admitted to the hospital, a costly and disruptive approach. However, observation and treatment of these same patients for up to 12 hours in a hospital Emergency Department Observation Unit (EDOU) is a less costly and more effective treatment alternative, concludes a study supported in part by the Agency for Health Care Policy and Research (HS07103 and HS07969).

Robert J. Rydman, Ph.D., of Chicago's Cook County Hospital, and his colleagues assigned 113 eligible adult asthma patients randomly to a hospital EDOU or inpatient care from a consecutive sample of 250 acute care asthma patients arriving at an urban hospital ED whose acute asthma episode was not resolved after 3 hours of ED therapy. Patients assigned to the EDOU had lower mean costs of treatment compared with those treated as inpatients ($1,202 vs. $2,247) and higher quality-of-life outcomes in five of eight health status areas measured in a post-treatment questionnaire.

EDOU treatment was consistently predictive of higher quality of life in domains of physical functioning, physical role functioning, emotional role functioning, social functioning, and mental health. There was no difference between the groups in peak flow rates (a measure of lung capacity) and relapse rates during 8 weeks of followup after the study. The researchers conclude that extending the amount of time that patients remain under observation in the ED to a maximum of 12 hours before a decision to admit them to the hospital is made allows enough time to reverse the acute asthma episode in many cases.

See "Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population," by Dr. Rydman, Miriam L. Isola, Dr.P.H., Rebecca R. Roberts, M.D., and others, in Medical Care 36(4), pp. 599-609, 1998.

Carotid endarterectomy is being performed more often on asymptomatic patients to prevent stroke

Carotid endarterectomy is increasingly being performed on patients who have no symptoms of blocked carotid artery, such as mini-strokes, in order to prevent stroke. Also, patients who undergo the procedure (surgical removal of plaque from the carotid artery in the neck) at hospitals performing many carotid endarterectomies fare better than those who undergo the procedure at low-volume hospitals, concludes a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00059).

Randall D. Cebul, M.D., of Case Western Reserve University, and colleagues retrospectively analyzed Medicare files and medical records on a random sample of 678 Ohio Medicare beneficiaries who underwent carotid endarterectomy at 115 acute care hospitals in Ohio during 1993 or 1994 to calculate uses and outcomes of the procedure. Almost half (47.5 percent) of the carotid endarterectomies among Ohio's Medicare population were performed on individuals who were asymptomatic or had nonspecific symptoms. Among these patients, indications for surgery were asymptomatic carotid stenosis in 25 percent, transient ischemic attack (TIA, mini stroke) in 43 percent, completed stroke in 9 percent, and nonspecific symptoms in 23 percent.

Nearly 5 percent died or suffered nonfatal strokes by 1 month after surgery. Patients at higher and lower volume hospitals had similar indications for surgery and coexisting illnesses. However, after controlling for factors affecting adverse outcomes, researchers found that patients operated on in a higher-volume hospital had a 71 percent reduction in risk for 30-day stroke or death (odds ratio 0.29); 30-day stroke or death rates ranged from 7.7 percent in hospitals in the lowest quartile of procedure volume to 2.5 percent in hospitals in the highest quartile. Stroke or death rates ranged from 2.4 percent among asymptomatic patients to 7.1 percent among those who had suffered TIAs. Patient age was not associated with stroke or death rates.

See "Indications, outcomes, and provider volumes for carotid endarterectomy," by Dr. Cebul, Richard J. Snow, D.O., M.P.H., Richard Pine, M.D., and others, in the April 22, 1998 Journal of the American Medical Association 279(16), pp. 1282-1287.

Missed detection of depression in the elderly might be reduced by screening with a simple questionnaire

Primary care physicians (PCPs) miss identifying depressive feelings in half of elderly community-dwelling patients they see, especially men. Their failure to recognize the possibility of depression among white elderly men suggests a serious public health problem, concludes a study supported by the Agency for Health Care Policy and Research (HS07772). Elderly white men are at the highest risk for completed suicide, and three-fourths of all elderly suicide victims visit a PCP within the month before their death, according to previous studies.

In this study, Judith Garrard, Ph.D., of the University of Minnesota, and her colleagues administered a 30-item screening questionnaire on depression symptoms, the Geriatric Depression Scale (GDS), to 3,410 elderly people who belonged to a health maintenance organization. They then correlated individuals' GDS scores with their PCP's diagnosis of depression, which they identified either by notation in the patient's chart, a visit to a mental health specialist, or treatment with antidepressant medication. Over a 2-year period, about half of the elderly people with depressive feelings (based on a GDS score of 11 or higher) were identified by their PCPs as possibly depressed.

Overall, 16 percent of all elderly patients in this study had an indication of depression based on the standardized GDS cut-off score of 11 or greater. PCPs were most likely to identify the most depressed patients, that is, those with the highest GDS scores. For instance, PCPs were seven times more apt to recognize a patient's feelings of depression if their GDS score was 26 to 30 versus 6 to 10. Also, doctors were over 2.5 times more likely to detect depressive feelings in elderly women than in elderly men aged 65 to 74 and 1.5 times more likely to detect it in women than men in the 75 to 84 year age group. One way to improve clinical detection of depression and hence the quality of life of community-dwelling elderly people might be periodic screening for depression using an instrument such as the GDS, conclude the researchers.

See "Clinical detection of depression among community-based elderly people with self-reported symptoms of depression," by Dr. Garrard, Sharon J. Rolnick, Ph.D., Nicole M. Nitz, M.S., and others, in the April 1998 Journal of Gerontology: Medical Sciences 53A(3), pp. M92-M101.

Pilot program leads to a healthier lifestyle for Mexican-American children at risk for type 2 diabetes

Type 2 (adult-onset) diabetes is more prevalent and occurs at a younger age among Mexican Americans compared with non-Hispanic whites. A new pilot study shows that a culturally and age-appropriate educational program can improve the diet and exercise habits of Mexican-American children at high risk for type 2 diabetes, which will decrease their risk of developing the disease later in life. The free eight-session program, conducted over 3.5 months, was aimed at 37 Mexican-American children 7 to 12 years of age. These children had at least one parent or grandparent with type 2 diabetes, 50 percent were obese, and 45 percent had a poor to fair diet prior to starting the program.

The program focused on teaching children the importance of good nutrition and exercise to decrease the risk of diabetes and increasing their understanding of diabetes and its risk factors (obesity, high sugar and fat intake, low fiber and complex carbohydrate intake, and insufficient exercise). The program incorporated the group's ethnic food types and eating patterns in age-appropriate, hands-on activities, such as using the food groups to prepare healthy snacks and meals. The program also taught children how to read food labels and provided homework with monetary incentives. Parents attended the sessions with the children and received certificates for groceries as an incentive.

The study was conducted at the Mexican-American Medical Treatment Effectiveness Research Center at the University of Texas Health Science Center and was supported by the Agency for Health Care Policy and Research (HS07397). Results were promising. After the program, 94 percent of parents and 67 percent of children had begun to read food labels; 83 percent of the parents had begun to use fat-modified recipes; and 83 percent of children were exercising regularly. In addition, children's health profiles tended to be more normal 4 months after program completion than prior to the program, supporting parents' reports that they had indeed changed eating and exercise habits.

For details, see "A primary intervention program (pilot study) for Mexican-American children at risk for type 2 diabetes," by Shirlyn B. McKenzie, Ph.D., Janelle O'Connell, Ph.D., Linda A. Smith, Ph.D., and William E. Ottinger, Ph.D., in the March 1998 issue of The Diabetes Educator 24(2), pp. 180-187.

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Outcomes/Effectiveness Research

Prostatitis is a common problem that is often treated unnecessarily with antibiotics

Doctors see about 2 million men each year for prostatitis (infection or inflammation of the prostate gland). Many of these men leave the doctor's office with a prescription for antibiotics that are of uncertain benefit. For instance, one study has shown that only 10 percent of prostatitis is caused by bacteria and therefore would be treatable by antibiotics. Primary care physicians (PCPs) are more likely than urologists to prescribe antibiotics for prostatitis, according to a national survey by the Prostate Patient Outcomes Research Team (PORT), which is supported by the Agency for Health Care Policy and Research (HS08397 and HS07892).

Led by Mary McNaughton Collins, M.D., M.P.H., of Massachusetts General Hospital, the researchers used a national data base to analyze 58,955 visits to physicians for genitourinary symptoms or prostatitis by men 18 years of age or older from 1990 to 1994. Analysis revealed that 5 percent of all outpatient visits by these men were for genitourinary symptoms. In almost 2 million visits each year, prostatitis was listed as a diagnosis, with 46 percent of these visits to urologists and 47 percent to PCPs. The odds of a prostatitis diagnosis were about two-fold greater in the South than in the Northeast. Prostatitis was more commonly diagnosed in men aged 36 to 65 than in younger men.

Antibiotics were prescribed for 45 percent of men diagnosed with prostatitis with genitourinary symptoms and for 27 percent of men without genitourinary symptoms. Also, visits to PCPs were more often associated with antibiotic use than visits to urologists. These varied approaches to prostatitis treatment partially reflect that a specific treatment has yet to be convincingly proved effective in controlled trials or uniformly accepted as the treatment of choice. Ongoing research on the pathophysiology of chronic prostatitis will provide a stronger rationale for some treatments than others, concludes Dr. Collins.

See "How common is prostatitis? A national survey of physician visits," by Dr. Collins, Randall S. Stafford, M.D., Ph.D., Michael P. O'Leary, M.D., M.P.H., and Michael J. Barry, M.D., in the April 1998 Journal of Urology 159, pp. 1224-1228.

High rates of sexual, urinary, and bowel dysfunction follow treatment for early prostate cancer

The two treatments commonly used for early localized prostate cancer—radical prostatectomy and radical radiotherapy—leave men with bowel and urinary problems and severe sexual dysfunction 1 year after surgery, according to a study supported by the Agency for Health Care Policy and Research (HS06824 and HS08208).

The level of symptoms after treatment is greater than reported in previous studies based on patients' reports to their physicians. The poorer outcomes reported in this study may be due to the fact that patients reported their problems to third parties instead of their own physicians, suggests James A. Talcott, M.D., S.M., of Massachusetts General Hospital. Dr. Talcott and his colleagues studied 279 men who sought treatment advice for early prostate cancer. The researchers compared self-reported patient symptoms and other measures of quality of life before therapy and at 3 and 12 months afterward.

They found that urinary incontinence (UI) and bowel symptoms were uncommon prior to treatment. UI occurred after radiotherapy infrequently and only in men more than 65 years of age. However, 1 year after surgery one-third of men were still wearing absorptive pads, and 5 percent had used a penile clamp within the past week to control UI. One year after radiotherapy, diarrhea occurred regularly in 12 percent of patients, and 19 percent reported bowel urgency or tenderness. Bowel symptoms were infrequent after prostatectomy.

Impotence was assessed in both functional and absolute terms. At baseline, among the men who would receive radiotherapy (median age 68 years), 45 percent reported erections usually inadequate for sex, including 18 percent with no erections in the preceding 4 weeks; 12 months after radiotherapy, the corresponding percentages were 67 and 33. Among the prostatectomy group (median age 62 years), at baseline 32 percent reported erections inadequate for sex, including 17 percent with none in the preceding 4 weeks; 12 months after surgery, these percentages were 93 and 75. The rates of impotence among radiation therapy patients rose gradually over the first year, suggesting that differences in impotence between the surgery and radiotherapy groups may diminish with longer followup.

Details are in "Patient-reported symptoms after primary therapy for early prostate cancer: Results of a prospective cohort study," by Dr. Talcott, Patricia Rieker, Ph.D., Jack A. Clark, Ph.D., and others, in the Journal of Clinical Oncology 16(1), pp. 275-283, 1998.

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Health Care Organization and Delivery

Employer-sponsored coverage for chiropractic care is now commonplace

Coverage for chiropractic care in employer-sponsored health insurance plans is commonplace, with three out of four of 68.8 million U.S. insured workers receiving such benefits in 1993. With the exception of health maintenance organizations—which are as likely to exclude the coverage as they are to include it—most plans provide coverage for chiropractic care, according to a study supported by the Agency for Health Care Policy and Research (HS07915). This AHCPR grant was awarded to Daniel C. Cherkin, Ph.D., of Group Health Cooperative of Puget Sound. In 1992, all but six States required that commercial health insurers include chiropractic coverage in the group indemnity policies that they sell. Also, most States now authorize chiropractic services as part of State worker compensation programs, notes Gail Jensen, Ph.D., of Wayne State University.

Self-insured plans, which are totally exempt from State requirements for chiropractic coverage, are more likely to include chiropractic coverage than are indemnity (fee-for-service) plans that are subject to existing mandates. Thus, it is not the case that employers provide such benefits only when forced to do so. Also, where chiropractic benefits have been mandated for conventional health insurance, most—but not all—plans comply with the law. The study shows that among insured workers entitled to chiropractic coverage because of a mandate, about one in five were not receiving such benefits, although they should have been.

When chiropractic care was covered, most insurance plans had explicit limitations clearly stated on the use of chiropractic services, which were separate from the limits placed on the use of other medical services. Most common were ceiling-type limits, such as limits on the number of chiropractic visits covered under a plan per week, per year, or per benefit period. And finally, with the exception of HMOs, most insurance plans do not require prior authorization for use of chiropractic care. Provided the plan's limits have not been exceeded, chiropractic care initiated by the patient will be covered in most cases.

In conclusion, this study revealed a wide diversity in the actual benefit provisions of plans and no clear consensus among plans about how chiropractic services should be covered. Drs. Jensen and Cherkin call for further studies to examine how the complex benefit limits being imposed by different plans influence the use and cost of services and patients' health outcomes.

These findings are based on a 1993 Survey of Employer-Sponsored Health Benefits covering 3,829 employers, as a nationally representative sample of all private and public non-Federal employers in the United States, and a 1995 mini random survey of 200 employers across the country (80 responded), who in 1993 said they covered chiropractic services.

See "Employer-sponsored health insurance for chiropractic services," by Dr. Jensen, Canopy Roychoudhury, Ph.D., and Dr. Cherkin, in Medical Care 36(4), pp. 544-553, 1998.

Certain factors increase the likelihood that Medicaid HMO enrollees will visit the ER for nonurgent care

Low-income individuals often use the emergency department (ED) inappropriately for nonurgent care. Because ED use is usually more costly and does not permit the followup care available from a primary care doctor's office, Medicaid health maintenance organizations (HMOs) would like to reduce inappropriate ED use in favor of visits to HMO primary care doctors. However, certain psychological and social barriers may stand in the way, finds a new study supported by the Agency for Health Care Policy and Research (HS08934).

People enrolled in Medicaid HMOs who have had more hospital admissions and who live farther from their physicians are more likely to visit the ED for nonemergency care and on the weekends. In contrast, females and individuals who are older, more satisfied with the HMO and their doctor, and enrolled longer in the HMO are less likely to visit the ED for nonemergency care.

Physical distance from the primary care physician or dissatisfaction with one's HMO make it difficult to use a medical care system, leaving an emergency department as a logical alternative for HMO Medicaid enrollees, explains study author Patricia A. Butler, J.D., of the University of Michigan at Ann Arbor. On the other hand, she points out that only 6 percent of total outpatient visits over a year's time were made to the ED for nonemergency care by Medicaid enrollees in the Rocky Mountain HMO studied. This suggests that the vast majority of this HMO's enrollees made the "right" decision when choosing between EDs and primary care physicians to obtain nonemergency care. She concludes that if the marginal cost of nonemergency ED visits is as low as some analysts have reported, it may be difficult to justify expensive services to reduce a relatively low level of nonemergency ED use. These findings are based on analysis of data from one Colorado HMO on all outpatient visits over 1 year and a biennial State survey of HMO enrollees conducted by the State's Medicaid agency in 1994.

See "Medicaid HMO enrollees in the emergency room: Use of nonemergency care," by Ms. Butler, in the March 1998 Medical Care Research and Review 55(1), pp. 78-98.

Model outpatient program helps keep high-risk elderly people out of the hospital at a reasonable cost

A major portion of the Nation's healthcare budget for the elderly is consumed each year by a small group of chronically ill Medicare enrollees who undergo repeated hospitalizations. A new model program for providing outpatient care to the elderly could change this, according to a study jointly sponsored by the National Institute on Aging and the Agency for Health Care Policy and Research (AG/HS11047).

The Outpatient Geriatric Evaluation and Management (GEM) care model was tested for 6 months. It was able to provide elderly patients at high risk for hospitalization with targeted outpatient intensive care at a reasonable cost ($1,540 for GEM personnel for each patient treated). In addition, patients and their primary care physicians were very satisfied with the program.

The goal of the GEM program is to help high-risk older adults living in the community preserve their remaining health and avert the need for expensive institutional care, explain the University of Minnesota researchers who developed the model program and initially tested it. They enrolled in the study 248 community-dwelling Medicare beneficiaries with one or more of five chronic conditions that are the most frequent causes of hospital admission among Medicare beneficiaries: congestive heart failure, cerebrovascular disease, coronary atherosclerosis, chronic pulmonary disease, and cardiac dysrhythmias. The average patient was 79 years of age, had been in the hospital the previous year, took five long-term prescription medications, and was unable to perform many activities of daily living.

Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse, and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients.

On average, during the 6-month study, patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers such as specialist physicians, physical therapists, or dietary counselors. The full impact of this model of care will be known next year, when the study is completed.

For more information, see "Outpatient geriatric evaluation and management," by Chad Boult, M.D., M.P.H., Lisa Boult, M.D., M.P.H., Lynne Morishita, M.S.N., and others, in the March 1998 Journal of the American Geriatric Society 46, pp. 296-302.

Most physicians are satisfied with their practices and income

The majority of physicians are satisfied with their overall practices and income, if a survey of physicians in one Midwestern city is any indication. It shows that about 73 percent of Indianapolis physicians surveyed were satisfied with their overall practice, and 59 percent were satisfied with their income. However, the source and extent of physician satisfaction depended on the physician's specialty, practice setting, and financial arrangements, according to a study conducted by William M. Tierney, M.D., of the Regenstrief Institute for Health Care and the Indiana University School of Medicine, and his colleagues. The study was supported in part by the Agency for Health Care Policy and Research (HS07632, HS07763, and HS07719).

Overall, doctors who were surveyed expressed the greatest satisfaction with the relationships they had with patients and peers and the least satisfaction with their autonomy in clinical decisionmaking. Doctors in private practice were most satisfied with their overall practice and office resources. However, doctors in health maintenance organizations (HMOs) were most satisfied with their autonomy in clinical decisionmaking. Doctors not working in HMOs but having a large percentage of patients with capitated reimbursement were not enthusiastic about the effect of managed care on their medical practices.

Family practitioners and general internists—who have been much more affected by Medicare, managed care, and competition than other primary care doctors—were generally less satisfied, and general pediatricians were more satisfied with most aspects of their medical practices. Older physicians were less satisfied with their overall practices and leisure time than younger physicians but more satisfied with their autonomy, patient relationships, and office resources. Doctors with predominantly fee-for-service reimbursement were most satisfied with every practice dimension except their leisure time. Overall, 49 percent of surveyed physicians were satisfied with the amount of leisure time they had. These findings are based on a 1993 questionnaire completed by 1,855 doctors in Indianapolis, IN.

See "Dimensions and correlates of physician work satisfaction in a midwestern city," by Ann S. Bates, M.D., M.P.H., Lisa E. Harris, M.D., Dr. Tierney, and Fredric D. Wolinsky, Ph.D., in the April 1998 Medical Care 36(4), pp. 610- 617.

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