Gary Hart

Metropolitan, Urban, and Rural Commuting Areas: Toward a Better Depiction of the United States Settlement System.

Discontent with the current definition of metropolitan areas and the lack of differentiation within nonmetropolitan territory provided the incentive for the research presented here. Census tracts rather than counties were used as the building blocks for assignment of tracts, not just to metropolitan areas, but also to larger towns (10,000 to 49,999) and to smaller urban places (2,500 to 9,999). The analysis used 1990 census-defined urbanized areas and tract-to-tract commuter flows. Results include a modest shift of population from metropolitan to nonmetropolitan, as well as a significant reduction in the areal size of metropolitan areas, disaggregation of many areas, and frequent reconfiguration to a more realistic settlement form. [Key words: metropolitan, urban-rural, commuting.]

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care

A clustering method for the analysis of ambulatory morbidity data is presented. This approach reduces spurious variations resulting from idiosyncratic diagnosis labeling and coding habits of physicians and facilitates the analysis of the content of ambulatory medical care through the use of aggregate morbidity data. The clusters provide a tool that allows for the comparison of the content of practice based on different factors such as provider training, practice organization, and patient characteristics. Ninety-two diagnosis clusters were derived using the 1977 and 1978 National Ambulatory Medical Care Survey (NAMCS). These clusters incorporate 86 per cent of all ambulatory visits to office-based physicians in the contiguous United States. The clusters were constructed based on the consensus of a group of clinicians including both generalists, as well as selected subspecialists representing the spectrum of ambulatory medical practice. The diagnosis clusters presented are compatible with the International Classification of Diseases (ICDA-8 and ICD-9-CM) and the International Classifications of Health Problems in Primary Care (ICHPPC and ICHPPC-2). Several applications demonstrating the utility of the method are presented, and directions for future applications are suggested.

A Description Of The Content Of Army Family Practice

Background: For decisions about residency curricula and downsizing the US Army medical corps, decision makers must know the practice content of the various specialties. Little is known about the content of Army family practice. The purpose of our study was to describe the content of Army family practice. Methods: We analyzed a random sample of 28,849 family practice encounters from the US Army Ambulatory Care Data Base Study. Variables included patient demographics, diagnoses, visit duration, procedures, and medical facility. Patient age and visit duration were compared using analysis of variance; facility profiles were compared by age category and sex of patients, family member position, and procedure frequency using chi-square analysis. Diagnostic content of the facilities was compared by both chi-square and Kendall’s tau B tests. Results: The typical patient was a 26-year-old woman. The 25 most frequent diagnoses accounted for three-fourths of all encounters, with variation by patient age. The majority of visits did not include a procedure, but procedure frequency varied by patient age and diagnostic certainty. Mean visit duration was 16.4 minutes and varied by age. There were differences among the sites for all variables. Conclusions: Army family physicians see patients of all ages, of whom more are the family members of soldiers than the soldiers themselves; they frequently do procedures and are usually certain of their diagnoses, which include a broad spectrum of illnesses. Army family physicians are flexible, adapt to local patient and environmental needs, and are uniquely qualified to form the basis of Army medicine.

The Effect of Including Secondary Diagnoses on the Description of the Diagnostic Content of Family Practice

The diagnoses that physicians record are an important part of the mosaic that describes what they do. Various classifications are used to code the recorded diagnoses to permit the identification of specific conditions. The more specific the classification, the more readily this can be achieved, and for all its faults the International Classification of Diseases1 is the most widely used classification of both hospital and ambulatory diagnoses. For the purposes of describing and comparing the practices of individual or groups of physicians, it is desirable to aggregate diagnostic data in clinically meaningful ways. One dilemma facing researchers is whether to use only the primary diagnosis or to include all the diagnoses recorded for

Influenza Vaccinations of Washington State Medicare Beneficiaries Seen by Physiatrists in the Outpatient Setting in 1994

OBJECTIVE To compare influenza vaccination billing rates for patients seen by physiatrists with those of four other specialties: neurology, rheumatology, family practice, and internal medicine. DESIGN Retrospective cohort analysis using Medicare billing data. PATIENTS 234,164 Medicare outpatients seen in Washington state between September 1 and December 31, 1994. RESULTS Based on Medicares billing data, only 6 of 99 physiatrists ordered vaccinations, and they immunized only 159 (6%) of the patients seen. An additional 1,109 (42%) patients seen by physiatrists were vaccinated by other physicians. Physiatric patients were less likely to have been vaccinated than those seen by internists, family practitioners, or rheumatologists (p < .002), but equally likely as those seen by neurologists (p = .07). A significantly smaller percentage of physiatrists ordered vaccinations than all other specialties (p < .04). Utilizing pre-existing survey data, the misclassification rate (those immunized but not billed) was estimated at 22% of our original cohort. Thus, approximately 800 patients, one third of those seeing physiatrists, may not have been immunized. We estimated the increase in hospitalization costs to be

Low-bandwidth, low-cost telemedicine consultations in rural family practice.

117 per nonvaccinated patient (total >

Can Physicians Be Induced To Resume Obstetric Practice

90,000). CONCLUSIONS Missed opportunities for vaccination by physiatrists appear to be more frequent than in other specialties and have potentially large health and economic costs.