Melissa H. Roberts

Patient Satisfaction With Primary Care: Does Type of Practitioner Matter?

Objective:The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO). Study Design:We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics. Results:Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ. Conclusions:Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.

How clean must our drinking water be: the importance of protective immunity.

BACKGROUND Cryptosporidium parvum is an important cause of epidemic diarrhea. Few studies have assessed whether serological evidence of prior infection in adults is related to a reduced occurrence of enteric illness. METHODS Serum samples and enteric illness event data were obtained in 2000 and 2001 from 326 people served by 1 of 2 unfiltered surface sources or 1 groundwater source. In 2001, filtration was initiated at 1 of the surface sources. Poisson regression related illness episodes with serological responses to the 15/17- and 27-kDa Cryptosporidium antigen groups. RESULTS Subjects with moderately strong responses to the 15/17-kDa antigen had <65% of the risk of all 1-3-day episodes of diarrheal or gastrointestinal illness and <40% of the risk of all >/=4-day episodes, compared with subjects without a moderately strong response. Water source, change in water treatment, and very weak responses were unrelated to illness events. CONCLUSIONS Endemic Cryptosporidium infections are a common cause of diarrheal and gastrointestinal illness in persons without a moderately strong response to the 15/17-kDa antigen group. Users of surface-derived drinking water are more likely to have strong serological responses to this antigen group and may be at a lower risk of endemic gastrointestinal illness caused by Cryptosporidium infection.

Laboratory safety monitoring of chronic medications in ambulatory care settings.

AbstractOBJECTIVE: To evaluate laboratory safety monitoring in patients taking selected chronic prescription drugs. DESIGN: Retrospective study using 1999–2001 claims data to calculate rates of missed laboratory tests (potential laboratory monitoring errors). Eleven drugs/drug groups and 64 laboratory tests were evaluated. SETTING: Two staff/network model health maintenance organizations. PATIENTS: Continuously enrolled health plan members age≥19 years taking ≥1 chronic medications. MEASUREMENTS AND MAIN RESULTS: Among patients taking chronic medications (N=29,823 in 1999, N=32,423 in 2000, and N=36,811 in 2001), 47.1% in 1999, 45.0% in 2000, and 44.0% in 2001 did not receive ≥1 test recommended for safety monitoring. Taking into account that patients were sometimes missing more than 1 test for a given drug and that patients were frequently taking multiple drugs, the rate of all potential laboratory monitoring errors was 849/1,000 patients/year in 1999, 810/1,000 patients/year in 2000, and 797/1,000 patients/year in 2001. Rates of potential laboratory monitoring errors varied considerably across individual drugs and laboratory tests. CONCLUSIONS: Lapses in laboratory monitoring of patients taking selected chronic medications were common. Further research is needed to determine whether, and to what extent, this failure to monitor patients is associated with adverse clinical outcomes.

Chronic Pain and Pain Medication Use in Chronic Obstructive Pulmonary Disease. A Cross-Sectional Study

RATIONALE Pain is a common problem for patients with chronic obstructive pulmonary disease (COPD). However, pain is minimally discussed in COPD management guidelines. OBJECTIVES The objective of this study was to describe chronic pain prevalence among patients with COPD compared with similar patients with other chronic diseases in a managed care population in the southwestern United States (age ≥ 40 yr). METHODS Using data for the period January 1, 2006 through December 31, 2010, patients with COPD were matched to two control subjects without COPD but with another chronic illness based on age, sex, insurance, and healthcare encounter type. Odds ratios (OR) for evidence of chronic pain were estimated using conditional logistic regression. Pulmonary function data for 200 randomly selected patients with COPD were abstracted. MEASUREMENTS AND MAIN RESULTS Retrospectively analyzed recurrent pain-related utilization (diagnoses and treatment) was considered evidence of chronic pain. The study sample comprised 7,952 patients with COPD (mean age, 69 yr; 42% male) and 15,904 patients with other chronic diseases (non-COPD). Patients with COPD compared with non-COPD patients had a higher percentage of chronic pain (59.8 vs. 51.7%; P < 0.001), chronic use of pain-related medications (41.2 vs. 31.5%; P < 0.001), and chronic use of short-acting (24.2 vs. 15.1%; P < 0.001) and long-acting opioids (4.4 vs. 1.9%; P < 0.001) compared with non-COPD patients. In conditional logistic regression models, adjusting for age, sex, Hispanic ethnicity, and comorbidities, patients with COPD had higher odds of chronic pain (OR, 1.56; 95% confidence interval [CI], 1.43-1.71), chronic use of pain-related medications (OR, 1.60; 95% CI, 1.46-1.74), and chronic use of short-acting or long-acting opioids (OR, 1.74; 95% CI, 1.57-1.92). CONCLUSIONS Chronic pain and opioid use are prevalent among adults with COPD. This finding was not explained by the burden of comorbidity.

Limited Lung Function: Impact of Reduced Peak Expiratory Flow on Health Status, Health-Care Utilization, and Expected Survival in Older Adults

The authors examined whether peak expiratory flow (PEF) is a valid measure of health status in older adults. Survey and test data from the 2006 and 2008 cycles of the Health and Retirement Study, a longitudinal study of US adults over age 50 years (with biennial surveys initiated in 1992), were used to develop predicted PEF regression models and to examine relations between low PEF values and other clinical factors. Low PEF (<80% of predicted value) was prevalent among persons with chronic conditions, including frequent pain, obstructive lung disease, heart disease, diabetes, and psychological distress. Persons with higher physical disability scores had substantially higher adjusted odds of having low PEF, on par with those for conditions known to be associated with poor health (cancer, heart disease, and stroke). In a multivariate regression model for difficulty with mobility, PEF remained an independent factor (odds ratio (OR) = 1.69, 95% confidence interval (CI): 1.53, 1.86). Persons with low PEF in 2006 were more likely to be hospitalized (OR = 1.26, 95% CI: 1.10, 1.43) within the subsequent 2 years and to estimate their chances of surviving for 10 or more years at less than 50% (OR = 1.69, 95% CI: 1.24, 2.30). PEF is a valid measure of health status in older persons, and low PEF is an independent predictor of hospitalization and poor subjective mortality assessment.

Comparative cost-effectiveness of a fluticasone- propionate/salmeterol combination versus anticholinergics as initial maintenance therapy for chronic obstructive pulmonary disease

Purpose Relative costs and utilization-related outcomes of a fluticasone propionate 250 μg + salmeterol 50 μg combination (FSC), tiotropium bromide, and ipratropium as initial maintenance therapy in COPD have not been compared in a commercially-insured population. Methods This retrospective, observational cohort study used health care claims data from January 2004 to June 2009 from a large administrative database for patients aged ≥40 years with COPD. Time-to-first COPD-related health care event beginning 30 days following therapy initiation with FSC (n = 16,684), ipratropium alone or in fixed dose combination with albuterol (n = 14,449), or tiotropium (n = 12,659) was estimated using Cox proportional hazard models that controlled for differences in patient demographic characteristics, health care utilization, and comorbidities at baseline. Mean adjusted costs and numbers of COPD-related health care encounters and prescription medication fills were compared among patients with 12 months of follow-up (FSC, n = 12,595; ipratropium, n = 10,617; tiotropium, n = 9126). Results With FSC as the reference, risk for a COPD-related hospitalization and/or emergency department visit was significantly higher for ipratropium (hazard ratio [HR] 1.64, 95% confidence interval [CI] 1.50–1.79) and tiotropium (HR 1.29, CI 1.17–1.41). Mean adjusted 12-month COPD-related total health care costs were lower for FSC (

New Clinical Insights into Chronic Obstructive Pulmonary Disease and Their Implications for Pharmacoeconomic Analyses

2068, standard deviation [SD]

Economic burden of chronic bronchitis in the United States: a retrospective case-control study

1190) than for ipratropium (

Comparative effectiveness of budesonide/formoterol and fluticasone/salmeterol for COPD management

2841, SD

Cost-effectiveness of combination fluticasone propionate–salmeterol 250/50 μg versus salmeterol in severe COPD patients

1858) and tiotropium (