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Health Care Delivery

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One-third of back pain sufferers seek care from chiropractors instead of physicians

Back pain episodes of care among adults in the United States are usually brief and recur infrequently (within 3 to 5 years). One-third of all patients suffering from back pain choose chiropractors over physicians to treat them, and chiropractors provide 40 percent of primary care for back pain. These are the results of two studies supported in part by the Agency for Health Care Policy and Research (HS06920).

Paul G. Shekelle, M.D., Ph.D., of the West Los Angeles Veterans Affairs Medical Center and the University of California, Los Angeles, and his colleagues analyzed data from the RAND Health Insurance Experiment (HIE), a community-based study of the use of health services from 1974 to 1982. The HIE enrolled randomly selected families from six sites chosen to represent the U.S. census regions, as well as urban and rural sites: Dayton, OH; Seattle, WA; Fitchburg and Franklin County, MA; and Charleston and Georgetown County, SC.

The researchers examined all insurance claims forms for episodes of patient-specified back pain and identified 1,020 episodes of back pain experienced by 686 different nonelderly persons (22 percent). Of these patients, 26 percent saw a general practitioner, and about 40 percent saw a chiropractor as the first or primary care provider.

Patients most likely to choose a chiropractor were white men with a high school education. Geographic site was also important. Patients were more likely to go to a chiropractor than a medical doctor if they lived in Georgetown County, Fitchburg, Franklin County, or Seattle, than if they lived in Dayton or Charleston.

General satisfaction with health care and level of pain were not associated with provider choice. About 10 percent of patients initially seeing other providers switched to a chiropractor to receive the majority of their back pain care. Moreover, chiropractors retained a greater proportion (92 percent) of their patients for subsequent episodes of back pain care than did other providers. This coincides with other findings that low back pain patients of chiropractors are more satisfied with their care than those of other providers.

See "An epidemiologic study of episodes of back pain care," by Dr. Shekelle, Martin Markovich, M.B.A., and Rachel Louie, M.S., in Spine 20(15), pp. 1668-1673, 1995; and "Factors associated with choosing a chiropractor for episodes of back pain care," by Dr. Shekelle, Mr. Markovich, and Ms. Louie, in Medical Care 33(8), pp. 842-850, 1995.

Use of formal home care depends on level of impairment and presence of family support

How severely a person is impaired in ability to function and the availability of informal home care (family or friends) determine the use of formal (paid) home care services. Even for persons with moderate or severe impairment, the use of formal home care remains relatively low with greater involvement of family caregivers. These are the findings of a study supported by the Agency for Health Care Policy and Research, (HS06925), led by Linda Grabbe, Ph.D., R.N., of Abt Associates.

The investigators analyzed a national sample of persons who died in 1986 to estimate the relationship between functional status and use of formal home care during the last year of life. They found that 30 percent of those who died were cared for exclusively by informal caregivers in the community during the year before their deaths. Mildly impaired persons (a walking limitation) with one or more informal caregivers were 1.5 to 3 times more likely and those living alone were nearly 4 times more likely than unimpaired persons to obtain formal home care. Moderately impaired persons (bathing or dressing limitation) with one or more informal caregivers were about 2.5 to 3 times more likely to receive formal care than were unimpaired persons. However, those with no informal caregivers were more than 10 times as likely to obtain formal care.

Severely impaired persons (difficulty eating or toileting) living with others had nearly double the odds of using formal home care than severely impaired persons living alone (4.2 vs. 2.4 for those with two or more informal caregivers and 11.5 vs. 6.5 for those with no caregivers). This is probably because family members who assist and live with severely impaired individuals may be particularly stressed by the burden of care, notes Dr. Grabbe. At a point where the burden to the family exceeds the family's emotional or physical resources, they usually seek formal help.

Finally, 45 percent of persons who used formal home care reported difficulty in obtaining these services. This underscores the lack of policy and structures to adequately meet the needs of individuals who need formal care in the community, conclude the researchers.

Details are in "Functional status and the use of formal home care in the year before death," by Dr. Grabbe, Alice S. Demi, D.N.Sc., R.N., F.A.A.N., Frank Whittington, Ph.D., and others, in the August 1995 Journal of Aging and Health 7(3), pp. 339-364.

Physician practice style determines the number of patients seen per hour

Physicians vary from two- to four-fold in the number of patients they see per hour, a measure of "physician productivity" by which some managed care systems judge them. A recent study shows that physician practice style, not clinic support systems or patient characteristics, accounts for most of the variation in physician productivity. Thus, interventions to increase the number of patients a physician sees each hour need to consider methods to change physician behavior, suggest researchers who were supported in part by the Agency for Health Care Policy and Research (HS06173).

The investigators observed 2,520 patients during 2,721 consecutive outpatient visits to 56 physicians at a general medicine clinic and found that physicians spent an average of 17.3 minutes in direct contact with each patient and saw a mean of 1.62 patients per hour. A model of overall physician productivity, using physician characteristics, explained 84.9 percent of the variance in physician productivity.

Clinic characteristics explained 8.2 percent of physician variability, while patient characteristics (number of chronic conditions, new patient, current number of medications, etc.) accounted for only 7 percent of the variability. Increased clinic staff support was positively related to productivity, but the relationship was not significant. Delegating some tasks, such as vaccinations, to nurses may improve physician productivity, and automated record systems may reduce time spent charting, retrieving information, writing notes, and writing prescriptions, according to the researchers, who note that monetary incentives also seem to increase productivity.

Details are in "Primary care physician productivity: The physician factor," by David M. Smith, M.D., Douglas K. Martin, M.D., Carl D. Langefeld, M.S., and others, in the September 1995 Journal of General Internal Medicine 10, pp. 495-503.

Half of physicians relocate to other States after completing residency training

Recently, a number of State legislatures have introduced bills to expand the supply of primary care physicians in their States through incentives for graduate medical education. Yet, following residency training in a State, about half of physicians (49 percent) relocate to other States to practice medicine, according to a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00044). This leaves the State they trained in with the challenge of balancing its supply of specialty and primary care physicians.

Extremes range from a low of 6 percent of Nevada medical graduates remaining in that State to 71 percent of California residents electing to remain in the State. Generalist physicians are more likely than specialists to remain in their States after graduation (57 percent vs. 48 percent). The more physicians in training per capita in a State, the less likely they are to remain in the State to practice. These findings suggest that most medical training locations function as a national rather than State market for physicians.

This study was based on a cross-sectional analysis of physicians in active practice in 1993. California researchers classified physicians by State of graduate medical education and stratified them by specialty and professional activity. They used logistic regression analysis to examine predictors of physicians remaining to practice in the same State in which they trained.

For more information, see "Graduate medical education and physician practice location," by Sarena D. Seifer, M.D., Karen Vranizan, M.A., and Kevin Grumbach, M.D., in the September 6, 1995, Journal of the American Medical Association 274(9), pp. 685-691.

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