Lawrence Kahn

Comparability of two methods of time and motion study used in a clinical setting: work sampling and continuous observation.

Two methods of time and motion study, continuous observation and work sampling, were used to measure physician behavior in a prepaid group practice. Results of the two methods were compared to determine whether differences occurred because of method. No significant differences appeared in time/unit of patient service for 82 per cent of physicians studied, nor did the presence of the continuous observer affect the number of units of patient service/half day of observation. Nonpatient activities showed a slightly larger number of differences although 74 per cent of comparisons of mean activity times still showed none. Suggested causes for noted discrepancies may be circumstantial dissimilarities in the two study periods or observer proximity. Nonetheless, overall the two methods show a high degree of similarity. Unless there is particular interest in the exact content of the physician-patient encounter, when continuous observation is required, work sampling is preferred because of time, cost, and possible observer influence on nonpatient activities.

Patient's perceptions and uses of a pediatric emergency room

Abstract The patient population utilizing the emergency room (ER) of St. Louis Childrens Hospital (StLCH) was analyzed for social attributes relating to ER utilization. Contrary to prevailing belief, concern that the patients condition was worsening governed selection of the time of visit for the majority (63%), not availability of transportation nor other enabling factors. Families headed by single women were especially likely to identify the ER as their regular source of care in contrast to two parent families. Escorts perceptions of the illness differed markedly from those of physicians. Increased understanding of this area may help solve problems of ambulatory care.

The Effects of an Experimental Prepaid Group Practice on Medical Care Utilization and Cost

Rates of utilization and costs of medical care by a study group in a prepaid group practice, the Medical Care Group of Washington University (MCG), were compared prospectivcly over a three-year period with those of a demonstrably similar control group cared for by fee-for-service private physicians. MCG enrollees used twice the ambulatory services control enrollees did (p= <0.01), but used 23 per cent fewer hospital days (p= <0.01). Cost per diagnostic and therapeutic visit was similar for both groups; MCG preventive visits cost more. Increased numbers of MCG services provided led to increased ambulatory care costs for MCG over controls. Hospital utilization savings did not compensate for these increased costs. Thus prepayment in an organized setting did change hospital and ambulatory care utilization but did not reduce medical care costs. Other changes in medical care besides those which result from a different organization of medical care are discussed which might make control of medical care costs more likely.

The Cost of a Primary Care Teaching Program in a Prepaid Group Practice

Costs were determined for a teaching program in general pediatrics and general internal medicine for advanced residents in a prepaid group practice, the Medical Care Group of Washington University. A time and motion study was conducted to measure the productivity of faculty physicians before and after the establishment of the teaching program. There was a statistically significant loss in productivity for internists and an apparent loss, though not significant, for pediatricians as a result of their teaching effort, but the productivity of the residents more than compensated for the loss. The residual positive value of a full time equivalent (FTE) pediatric resident after reimbursement of all possible lost productivity by faculty pediatricians represented 43.9 per cent of a FTE pediatrician. For a FTE resident in internal medicine the residual positive value was 49.7 per cent of a FTE internist.

Medical Care Utilization in an Experimental Prepaid Group Practice Model in a University Medical Center

Medical care utilization is reported for the first two years of an experimental prepaid group practice, the Medical Care Group of Washington University (MCG). Methodologic considerations are emphasized and comparison is made between prospectively selected study and control families. Overall, MCG children were admitted to hospitals less often than control children for surgical and nonsurgical conditions. For adults, reduced admission rates were found only for nonsurgical conditions. In contrast, surgical utilization by MCG enrollees was somewhat higher than control utilization in both years, but utilization of surgical services by both study and control enrollees was closer to that characteristic of prepaid group practice than it was to that of the general population. MCG members used significantly fewer hospital days than controls in year 2. In both years, members utilized ambulatory services at a rate about twice that of controls. Thus, the combination of a prepayment mechanism for ambulatory services with a system which guarantees provision of those services was associated with changes in the pattern of medical care delivery. Some, but not all, of these changes were characteristic of those predicted for prepaid group practice.

From the Clinical Conference St. Louis Children's Hospital: Rocky Mountain Spotted Fever Successful Application of New Insights Into Physiologic Changes During Acute Infections to Successful Management of a Severely-Ill Patient

* Assistant Professor of Pediatrics, Washington University School of Medicine. Address for correspondence: Lawrence I. Kahn, M.D., Division of Health Care Research, Washington University School of Medicine, 4550 Scott Avenue, St. Louis, Mo. 63110, DURING the past several decades, the metabolic changes associated with many different hereditary and acquired diseases have been described in detail. Only recently have the metabolic changes during the course of infection been subjected to analysis in depth. The value of such an analysis has been well justified by some recent studies. Austrian 1

Wetzel grid analysis of rheumatic children

Summary 1. The distribution of 157 childrenon the Wetzel Grid in their initial episode of acute rheumatic fever is presented and compared with the distribution of 3,366 grade school children. The comparison of the two series points definitely to the presence of growth failure in the series of rheumatic children as compared to the childhood population of the same age range at large. 2. Follow-up Grid position determinationsof 130 of the 157 rheumatic children show a shift in the Grid positions demonstrating marked improvement in growth and development. 3. The application of the Wetzel Grid as an instrument in following the course of the individual child with rheumatic fever is suggested.

Patterns of Pediatric Practice by the Same Physicians in a Prepaid and a Fee- for-Service Setting How the Organization of the Delivery of Health Services Influences Physician Behavior

A study is reported of the ambulatory services provided by four pediatricians who practice both in their own fee-for-service practice (FFS) and in an experimental prepaid group practice model (PPGP). Differences were noted in the two prac tices. There were more infants in the fee-for- service practice and more adolescents in the pre paid practice. Likewise, a nurse provided follow- up medical services in the prepaid practice but not in the fee-for-service practice. These factors explained some of the results observed. Even allowing for these practice differences, however, the same physicians prescribed more laboratory tests, consultations, and follow-up visits in the prepaid as opposed to the fee-for-service prac tice. This study suggests that observed differences in medical care utilization between PPGP and FFS are associated with the organizational, staffing, and financial aspects of prepaid practice contrasted to fee-for-service practice, rather than with physician differences per se.

A Comparison Between the Pediatric Nurse Practitioner (PNP) and the Pediatric Resident in an Out-Patient Department: A Pilot Study

Haggcrty2 ’-’ found that ancillary personnel could perform almost 50 per cetrt of pediatricians’ office work, and Yankauer et aP showed pediatricians were still performing many routine tasks in and out of office settings which could be performed as well by other personnel. The development of programs to train Pediatric Nurse Practitioners (PNP) are a direct result of such studies. The role of the PNP

The Hematological Aspects of a Case of Systemic Lupus Erythematosus

Prepared while Instructor in Pediatrics and Senior Clinical Trainee in Cancer Control, Washington University School of Medicine. (Present address, Department of Pediatrics, Wayne University College of Medicine.) Assistant Professor of Medicine, Washington University School of Medicine. † Assistant Professor of Pediatrics and Medicine, Washington University School of Medicine. ‡ Assistant Professor of Medicine, Washington University School of Medicine. Assistant Clinical Professor of Pediatrics, Washington University School of Medicine. Request for reprints: Lawrence I. Kahn, M.D., Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri 63110. Dr. Jeanne Lusher: Susan G., a 14-yearold white child from Clayton, Missouri, was admitted to St. Louis Children’s Hospital for the first time on November 19, 1965. Two days prior to admittance she developed nausea, low grade fever, and lethargy. The following morning there were several episodes of epistaxis followed by hematemesis. That after-