Charles F. Federspiel

Reducing antipsychotic drug prescribing for nursing home patients: a controlled trial of the effect of an educational visit.

We conducted a statewide, controlled trial of the efficacy of an educational visit in reducing antipsychotic drug prescribing for nursing home patients. Frequent antipsychotic drug prescribers were visited by a trained physician counselor who stressed known drug risks for elderly patients and suggested techniques for reducing antipsychotic drug use. Although well-received, the visit did not reduce antipsychotic drug prescribing. This negative finding suggests that future interventions address factors within the nursing home which encourage antipsychotic drug use.

Medicaid records as a valid data source: the Tennessee experience.

Health care researchers rarely employ Medicaid claim files as a data base, in part because they are designed to serve fiscal and administrative ends. Indeed, some investigators have emphasized the deficiencies in such records. In contrast, we have found Tennessee Medicaid data to be suitable for research. A statewide automated data processing system reduces the occurrence of many of the errors noted by others. Further, analysis of the July 1974 month of payment file illustrates the accuracy and internal consistency of Tennessee Medicaid data. Specimen legend drug results for ambulatory patients suggest investigations of physician prescribing patterns. Evaluation of the Medicaid claims processing system suggests other applications in health care administration and research. In a time when available resources are dwindling, the incisive use of Medicaid claims files offers an attractive alternative to expensive new systems of data collection and analysis.

Incidence of Myocardial Infarction and Sudden Death from Coronary Heart Disease in Nashville, Tennessee

The incidence rates for myocardial infarction and sudden death attributable to coronary heart disease for adults between the ages of 35 and 74 years for black and white populations were studied in Nashville, Tennessee, for a l-year period, July 1, 1967 to June 30, 1968. The overall incidence rate for myocardial infarction was 3.42 and for sudden coronary death, 1.55 per 1,000 population. The male-to-female ratio for the white population for myocardial infarction was 3:1, and for the black population 2:1. Similar male-to-female ratios were found for those dying suddenly for both races. However, both black males and females died suddenly at a higher rate than did the white.Over half of the sudden deaths occurred within a 2-hour period after onset of symptoms. Fifty-two percent were dead on arrival at a hospital, 31% died at home, and 6% in a public place. Only 4% had either no contact with a source of medical care or had negative disease histories prior to sudden death. Thus, it would seem possible in further studies to identify a group of individuals at high risk of sudden death from coronary heart disease.

Prescribing of Chloramphenicol in Ambulatory Practice: An Epidemiologic Study Among Tennessee Medicaid Recipients

During the 1-year period from July 1973 through June 1974, 1761 chloramphenicol prescriptions were written for 992 outpatients in the Tennessee Medicaid program. Sxi percent (250 of 3409) of participating physicians prescribed chloramphenicol; 20 physicians wrote 55% of the prescription. Both family practice and rural location were independently associated with increased rates of prescribing chloramphenicol for outpatients. Among rural family practitioners, 21% prescribed chloramphenicol. Physicians graduating since 1955 were as likely to have prescribed chloramphenicol as were earlier graduates. Almost half the adult patients received 6 grams or less, while 2 received more than 250 grams. Approximately half of the prescriptions were for treatment of upper respiratory infections. Most prescriptions were interdicted by good medical practice. Analysis of the prescribing of chloramphenicol (and perhaps other drugs) in ambulatory practice will help identify those physicians most in need or remedial medical education.

Prescribing of Tetracycline to Children Less Than 8 Years Old: A Two-Year Epidemiologic Study Among Ambulatory Tennessee Medicaid Recipients

The committee on Drugs of the American Academy of Pediatrics finds virtually no indications for administering tetracyclines to children less than 8 years old. This study analyzes tetracycline prescribing to ambulatory children less than 8 years of age in the Tennessee Medicaid program during a two-year period. Of the nearly 59,000 children in the study, 4,026 (7%) received 7,046 tetracycline prescriptions. Twenty-seven percent (527) of 1,947 participating physicians prescribed tetracycline; 26 physicians (5%) wrote 54% of the prescriptions for 45% of the children. Physicians in family practice prescribed the greatest quantity of tetracycline. Surgeons and internists prescribed more tetracycline to young children than did pediatricians. Rural location of practice was independently associated with increased tetracycline prescribing for all specialties. Recent graduates from medical school were less apt to prescribe tetracycline than were earlier graduates.

Development of an Early Identification and Response Model of Malpractice Prevention

The dramatic rise in the incidence of malpractice claims over the past thirty years has revealed several problems with the U.S. system of medical dispute resolution. First, the sudden and unexpected increase in claims has created an insurance crisis wherein various medical specialists have had difficulty obtaining affordable insurance coverage.1 One such crisis occurred in Florida in the mid-1980s, when an inability of many physicians to procure medical malpractice coverage caused some to limit or curtail their practice. This resulted in access problems for the public. This phenomenon has disproportionately befallen physicians practicing obstetric medicine.2 Second, besides contributing to periodic crises of access, the current medical dispute resolution system is often responsible for long delays in resolving claims and in compensating victims.3

Factors Associated with Early Demise in Nursing Home Residents: A Case Control Study

A case‐control study was performed to identify factors differentiating nursing home residents who die within 12 months of admission (decedents) and those who survive for at least four years (survivors). Using Tennessee Medicaid data, 49 decedent/survival pairs admitted during the same year were matched for age, race, sex, nursing home, and diagnosis. There were no significant differences between the decedent and survivor groups in demographic factors, sensory impairments, physical handicaps, or number of drugs prescribed. Assessments of the ability to perform activities of daily living were found to be strongly associated with survival, providing a valuable prognostic tool. The authors suggest that personnel providing care for patients of advanced age would benefit from instruction in making such assessments

Identifying medical center units with disproportionate shares of patient complaints.

BACKGROUND A pilot study was conducted to learn whether an academic medical centers database of patient complaints would reveal particular service units (or clinics) with disproportionate shares of patient complaints, the types of complaints patients have about those units, and the types of personnel about whom the complaints were made. RESULTS During the seven-year (December 1991-November 1998) study period, Office of Patient Affairs staff recorded 6,419 reports containing 15,631 individual complaints. More than 40% of the reports contained a single complaint. One-third of the reports contained three or more complaints. Complaints were associated with negative perceptions of care and treatment (29%), communication (22%), billing and payment (20%), humaneness of staff (13%), access to staff (9%), and cleanliness or safety of the environment (7%). Complaints were not evenly distributed across the medical centers various units, even when the data were corrected for numbers of patient visits to clinics or bed days in the hospital. The greatest proportion of complaints were associated with physicians. DISCUSSION Complaint-based report cards may be used in interventions in which peers share the data with unit managers and seek to learn the nature of the problems, if any, that underlie the complaints. Such interventions should influence behavioral and systems changes in some units. SUMMARY AND CONCLUSIONS Further experience should indicate how different types of complaints lead to different kinds of interventions and improvements in care. Tests of the system are also currently under way in several nonacademic community medical centers.

Maternal Mortality in Michigan: An Epidemiologic Analysis, 1950-1971

An analysis was performed of direct maternal mortality over 22 years (1950 through 1971) in the state of Michigan. The overall direct maternal mortality rate fell from 5.0/10,000 live births in 1950 to 1.5 in 1971. The rate among nonwhites was more than four times greater than among whites and the difference in relative risk did not narrow over the 22 years. Mortality rates increased with increasing maternal age but not with increasing parity. Nulliparous women had a significantly higher mortality rate than did parous women, particularly those over 25 years of age. when the white gravida of urban Wayne County were compared with the white gravida of 33 rural counties, no difference in direct maternal mortality rates could be attributed to rurality per se. Hemorrhage, infection, and toxemia were the leading causes of direct maternal death. The data suggest that hospitals with less active obstetrical services were associated with a higher risk of direct maternal mortality than were hospitals whose obstetrical services were more active. An increasing proportion of the direct maternal deaths was designated as preventable over the study period. It is believed that analyses of maternal mortality have led to improved perinatal and obstetrical care and that further advances require their continued support. (Am. J. Public Health 67:821-829, 1977)

SIMULTANEOUS MEASURE OF GENERAL ACTIVITY AND EXPLORATORY BEHAVIOR.

Housemice of five strains were tested repeatedly in a runway apparatus so arranged that both dimensions of gross activity could be measured. Exploratory performances showed the expected decline both within and among days of testing. On the other hand, general activity did not decrease among days. Moreover, the magnitude of correlation between the two behaviors was minimal except for one strain. These data are construed as definitive in establishing the separateness of the two categories of gross activity: general activity and exploratory behavior. Moreover, these data indicate that maze learning drug response differences reported for these strains cannot be explained by differences in activity variables.