Steven D. Hillson

Specialty differences in the 'July Phenomenon' for Twin Cities teaching hospitals.

This study evaluated changes over the academic year in the cost and the outcome of inpatient care to investigate the effect of housestaff experience in teaching hospitals. Patients with 25 preselected discharge diagnoses, admitted between January 1,1983 and December 31,1987 to acute-care, nonfederal, nonpediatric hospitals in the Minneapolis/St. Paul metropolitan area (total number available for analysis 240,467) were examined. Level of housestaff experience was measured as the number of days (1 to 365) into the academic year when the patient was admitted. Linear and logistic regression analyses were used to evaluate the different effects of experience on patient care in teaching hospitals compared with nonteaching hospitals. For the subset of patients with internal medicine diagnoses, the expected “July Phenomenon” was observed, with significant relative declines in diagnostic and pharmaceutical charges in teaching hospitals over the academic year. In contrast, surgery patients showed an increase in length of stay and various charges over the academic year in teaching hospitals. There were no meaningful effects of housestaff experience on mortality, operative complications, or nursing home discharge. These results indicate that housestaff training is significantly related to the use of hospital resources for inpatients, but that the degree and direction of the effects differ by specialty. These findings may reflect important differences among training programs in the process of physician education and its effects on patient care.

Call nights and patient care: Effects on inpatients at one teaching hospital

OBJECTIVE To determine whether the timing and number of patients admitted by internal medicine housestaff under a traditional call schedule affect the resource utilization and outcome of care for those patients. DESIGN Retrospective cohort study, using existing computerized records. SETTING University-affiliated 340-bed city/county teaching hospital. PATIENTS/PARTICIPANTS 22,112 patients discharged from the internal medicine service who had been admitted by an on-call first-year resident between January 1, 1980, and December 31, 1987. MEASUREMENTS AND MAIN RESULTS Admission after 5:00 PM was associated with decreased hospital length of stay (8.1%, p less than 0.0001), but increased total charges (3.1%, p = 0.007). The relative risk of inpatient mortality for patients admitted at night was 1.21 (p = 0.03). Patients of busier housestaff, as indicated by a larger number of on-call admissions, had lower total charges (1.7% decreased per admission) and no change in risk of inpatient mortality. While no linear relation was found between number of admissions and length of stay, analysis of nonlinear effects revealed that length of stay first rises, then falls as interns receive more on-call admissions. CONCLUSIONS The number and timing of admissions by on-call internal medicine housestaff are significantly related to length of hospital stay, total charges, and likelihood of inpatient mortality at one teaching hospital. These variations should be considered in planning the reform of residency training programs.

Call nights and patient care

Objective:To determine whether the timing and number of patients admitted by internal medicine housestaff under a traditional call schedule affect the resource utilization and outcome of care for those patients.Design:Retrospective cohort study, using existing computerized records.Setting:University-affiliated 340-bed city/county teaching hospital.Patients/participants:22,112 patients discharged from the internal medicine service who had been admitted by an on-call first-year resident between January 1, 1980, and December 31, 1987.Measurements and main results:Admission after 5:00 PM was associated with decreased hospital length of stay (8.1%, p<0.0001), but increased total charges (3.1%, p=0.007). The relative risk of inpatient mortality for patients admitted at night was 1.21 (p=0.03). Patients of busier housestaff, as indicated by a larger number of on-call admissions, had lower total charges (1.7% decreased per admission) and no change in risk of inpatient mortality. While no linear relation was found between number of admissions and length of stay, analysis of nonlinear effects revealed that length of stay first rises, then falls as interns receive more on-call admissions.Conclusions:The number and timing of admissions by oncall internal medicine housestaff are significantly related to length of hospital stay, total charges, and likelihood of inpatient mortality at one teaching hospital. These variations should be considered in planning the reform of residency training programs.

Competition, professional synergism, and the geographic distribution of rural physicians.

This study provides a theoretical and empirical investigation of competition and synergism among physicians in rural areas. The results show that rural primary care physicians cluster together rather than distribute themselves evenly. This suggests that public policy makers and rural communities must take an active role to ensure provider availability in all rural areas. There is less clustering among subspecialists. The results also reveal a disturbing negative relationship between young children and physician availability in rural areas. Finally, the results provide strong evidence that the relationship between rural physicians and hospitals is synergistic.

An analysis of physician recruitment strategies in rural hospitals

This article analyzes the importance and effectiveness of several physician recruitment strategies in 60 shortterm general hospitals in rural Minnesota. The results suggest that rural hospitals should continue to attract physicians with quality facilities and services, increase efforts to facilitate group practice opportunities, and rely less on direct financial incentives.

Call nights and mortality

coupled with the complexion, focus, and training of the individual provider. However, data generated from an ongoing study of 270 consecutively evaluated patients to determine the incidence of shoulder pain disorders in my practice reveal the complaint of shoulder pain is third (14%), exceeded only by cardiopulmonary/vascular-related disorders (41%) and osteoarthritis (18%). This is in keeping with other investigators who note over 5% of our populat ion has significant shoulder pain each year and European studies showing that about 14% of the population developed significant shoulder pain.9-x Lastly, Chard attempted to discover the prevalence of symptomatic shoulder disorders in both a hospital and community-based study sample of 744 persons. 12, 13 He found a prevalence of 21%, corresponding to the observation that shoulder tendon pathology is found in 20% of persons examined postmortem, t4 I appreciate and, in part, agree with the keen observation of Dr. Feagin, but most importantly our prime goal of this extensive review is to help primary care providers sort out common shoulder complaints in a logical sequence and provide a current, well-referenced discussion on various available treatment methods.--DAVID L. SMITH, MD, StaffPhys# clan, Section o f General Medicine, Associate Professor o f Medicine, Oregon Health Sciences University, Portland, OR 97201

Economies of scope and payment for physician services.

Physician payment reform will base payment largely upon physician work. Current reforms assume that services are provided independently, yet physicians may often perform two or more services at one time. There is evidence from other industries that services provided jointly may not require the same total resources as identical services provided independently. This study evaluated whether physician-reported work and time were the same for some common services when provided jointly and when provided separately. Six case vignettes were constructed consisting of two services each. Forty-four general internists rated the total work and time required for each vignette performed as a whole, and for the two services performed separately. Total work was estimated using a magnitude estimation technique similar to that used in developing the resource-based relative value scale. For five of the six vignettes, the work rating for performing the services together was significantly less than the sum of the ratings for the separate services. The work savings associated with providing services together ranged from 4% to 30% of the total work of the separate services. A similar reduction was observed for the estimated time to perform services jointly in four of the six vignettes. In no case was work or time lower when services were provided separately. Physicians report lower work and time for at least some pairs of services, compared with providing the same services separately. Reimbursement mechanisms that fail to account for these reductions may provide incentives to combine or add services.

Computer-assisted test interpretation: considerations in patient care

Computer-assisted test interpretation (CATI) is a set of developing technologies designed to support medical decision-making. This paper develops a taxonomy of computer-assisted test interpretation, giving specific consideration to the characteristics of the data that are to be interpreted, the nature of the interpretive task, the expected involvement of the health professional in the generation of the interpretation, the inference mechanism used for the interpretation, and the broader context of the interpretation. We go on to examine potential benefits and disadvantages of CATI systems in terms of accuracy, information management, interpretation time, patient management, medical communication, and expense. Finally, we examine electrocardiogram interpretation systems from the perspective of this taxonomy, and offer suggestions regarding areas of further inquiry into the effects of CATI on medical care.

The Effectiveness of Medicare Part B Medical Review: Issues and Alternatives

The part B medical review methods currently used by Medicare carriers to control resource use suffer from a series of problems including failure to reward deter rence of unnecessary claims, failure to detect substitu tion of nonreviewed claims, reliance on average rather than marginal measures of performance, excessive fo cusing of reviews, and the inability to measure effective ness separately from the intervention. This article de scribes these problems and proposes a series of alternative strategies for review that may improve these problems.