William T. Basco

Low Rates of Controller Medication Initiation and Outpatient Follow-Up after Emergency Department Visits for Asthma

OBJECTIVE To determine what proportion of patients who are seen in an emergency department (ED) for asthma receive inhaled corticosteroids or attend follow-up appointments. STUDY DESIGN This was a retrospective cohort study of 2007-2009 South Carolina Medicaid data. Enrollees aged 2-18 years who had an ED visit for asthma were included. Patients admitted for asthma or with an inhaled corticosteroid claim in the 2 months before the month of the ED visit were excluded. Covariates were sex, race, age, rural residence, and asthma severity. Outcome measures were a prescription for an inhaled corticosteroid filled within the 2 months after the ED visit and attendance at a follow-up appointment within the 2 months after the ED visit. RESULTS A total of 3435 patients were included. Out of the study cohort, 57% were male, 76% were of a minority race/ethnicity, 69% lived in an urban areas, 18% had inhaled corticosteroid use, and 12% completed follow-up. Multivariate analyses demonstrated that patients with severe asthma were more likely to receive an inhaled corticosteroid (OR, 2.9; 95% CI, 2.3-3.7) and attend a follow-up appointment (OR, 2.0; 95% CI, 1.5-2.6). Patients aged 2-6 years and those aged >12 years were less likely to attend follow-up (OR, 0.71; 95% CI, 0.56-0.90 and OR, 0.62; 95% CI, 0.47-0.83, respectively) (all models P < .0001). CONCLUSION Children with asthma seen in the ED have low rates of inhaled corticosteroid use and outpatient follow-up. This indicates a need for further interventions to increase the use of inhaled corticosteroids in response to ED visits.

The relationship between the National Board of Medical Examiners' prototype of the Step 2 clinical skills exam and interns' performance.

Purpose To examine the relationship between graduates’ performances on a prototype of the National Board of Medical Examiners’ Step 2 CS and other undergraduate measures with their residency directors’ ratings of their performances as interns. Method Data were collected for the 2001 and 2002 graduates from the study institution. Checklist and interpersonal scores from the prototype Step 2 CS, along with United States Medical Licensing Examination (USMLE) Step 1 and 2 scores and undergraduate grade-point average (GPA), were correlated with residency directors’ ratings (average score for six competencies, quartile ranking, and isolated interpersonal communication competency score). Stepwise linear regression was used to identify the best outcome predictors. Results Quartile ranking was more highly correlated with GPA than Step 2 CS prototype interpersonal score, USMLE Step 2 score, USMLE Step 1 score, and Step 2 CS prototype checklist score. The average score on the residency directors survey was more highly correlated with GPA than USMLE Step 2 score, USMLE Step 1 score, Step 2 CS prototype interpersonal score, and Step 2 CS prototype checklist score. The best predictors for both quartile ranking and average competency score were GPA and Step 2 CS prototype interpersonal score (R2 = 0.26 and 0.28). Conclusion Both scores from the Step 2 CS prototype significantly correlated with the interns’ quartile ranking and average competency score. Only GPA and Step 2 CS prototype interpersonal score accounted for most of the variance of performance in the regression model.

Undergraduate Institutional MCAT Scores as Predictors of USMLE Step 1 Performance

Medical schools using formal undergrad-uate selectivity measures do so to compensate for the psychometricinadequacies of college grade-point averages, believing that moremeaning can be derived from the GPA if it is attached to a measureof institutional performance (academic rigor) or selectivity (strin-gent admission standards).Researchers have reported mixed results on whether formal mea-sures of undergraduate institution selectivity are useful contributorsto predicting medical student performance.

Does institutional selectivity aid in the prediction of medical school performance

Various factors are considered in the decision to offer an admission interview to a medical school applicant, including Medical College Admission Test (MCAT) scores, undergraduate grade-point average (GPA), and the selectivity of the degree-granting undergraduate institution. Admission officers view MCAT scores, undergraduate GPA, and institutional selectivity as having high or moderate importance. Research has indicated that these factors, most notably the MCAT scores and the undergraduate GPA, are reliable in helping predict medical school performance. The strongest association has been shown between MCAT scores and performance on the United States Medical Licensing Examination, Step 1. Institutional selectivity data are used to help control for differences in grading stringency across undergraduate institutions. Previous reports have examined the role of institutional selectivity, or a specific undergraduate institution, as a predictor of performance in the first two years of medical school. With the exception of the study of Zelesnik et al., which examined ten specific undergraduate institutions, these reports have used the Higher Education Research Institute (HERI) Index, also called the ‘‘Astin Index,’’ as a measure of institutional selectivity. Other measures of institutional selectivity or categorization that schools of medicine may employ include the Barron’s Profiles of American Colleges Admissions Selector Rating and the Carnegie Classification from the Carnegie Foundation for the Advancement of Teaching. (These measures are explained in the next section.) Institutional validity studies of admission decision-making data help to determine which characteristics should be accorded highest importance in applicant selection. Given the reliance upon institutional selectivity as an important admission characteristic and the different types of selectivity classifications available for medical schools to use, the purpose of this study was to examine how well three measures of institutional selectivity could predict medical students’ performances, specifically their performances on the USMLE Step 1 and Step 2 and their final medical school GPAs.

Early Adopters of Computerized Physician Order Entry in Hospitals That Care for Children: A Picture of US Health Care Shortly After the Institute of Medicine Reports on Quality

Objective. To determine national estimates of computerized physician order entry (CPOE) use for 2003 in hospitals that care for children. Design. Retrospective cohort analysis. Results. Six percent of the hospitals used CPOE (119 out of 2145). Childrens hospitals are more likely to use CPOE than a childrens unit (odds ratio [OR] = 6; 95% confidence interval [CI] = 1.5-23.9). Private for-profit hospitals are more likely to use CPOE than public hospitals (OR = 26.5; 95% CI = 3.1-224.8). Urban teaching hospitals are more likely to use CPOE than rural hospitals (OR = 3.9; 95% CI = 1.7-8.8). Hospitals in the Northeast, Midwest, and South are more likely to use CPOE than hospitals in the West (OR = 11.2, 95% CI = 4.8-26.5; OR = 4.2, 95% CI = 1.7-10.5; OR = 3.1, 95% CI = 1.5-6.3, respectively). Conclusions. In 2003, 6% of the hospitals that care for children reported using CPOE. Early adoption of CPOE was associated with childrens hospitals, private hospitals, urban-teaching hospitals, and hospitals outside of the western region.

Associations between primary care-oriented practices in medical school admission and the practice intentions of matriculants

PURPOSE: To assess associations of primary-care-oriented medical school admission practices with matriculants practice intentions. METHOD: The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four medical school admission practices. The control variable was school ownership (public vs private). The dependent variables were the proportions of matriculants at each school interested in generalism, rural practice, and locating in a socioeconomically deprived area. RESULTS: One hundred and twenty medical schools (95%) completed the AAMCs Survey of Generalist Physician Initiatives in either 1993 or 1994; 94% of matriculants replied to the AAMCs 1994 Matriculating Student Questionnaire. Twenty-five percent of the schools had admission committee chairs who were generalists, half had over 25% generalists on their admission committees, 64% gave admission preference to students likely to become generalists, and 33% reported premedical recruitment efforts that targeted applicants likely to become generalists. In multivariable analyses, premedical recruitment efforts and public school ownership (all p < .01) were associated with greater interest of matriculants in both generalism and rural practice. CONCLUSIONS: Public medical schools and schools with premedical recruitment activities targeting future generalists admitted greater proportions of students interested in primary care and rural practice.

Performance outcomes associated with medical school community service.

Background Providing medical students with community service opportunities during medical school is believed to foster altruism. Little is known whether voluntary community service is associated with students’ academic and clinical skill performance. This study examined the relationship between students’ volunteer community service hours during medical school and their medical school academic performance, measures of clinical skills, and residency performance. Method Subjects were 2001 and 2002 graduates of the institution. Performance measures were: United States Medical Licensing Examination (USMLE) Step 2 score, grade point average, fourth-year clinical skills examination scores, and two types of residency director assessments. Associations between performance measures and community service hour categories were analyzed using descriptive statistics, chi-square, and t-tests. Results Students in the highest service group (≥18.5 hours) had significantly higher grade point averages, USMLE Step 2 scores, and scores on both residency director assessment when compared to students with no community service hours. Conclusions Community service involvement in medical school appears associated with medical school academic and residency performances.

Asthma medication ratio predicts emergency department visits and hospitalizations in children with asthma.

OBJECTIVE To determine if the asthma medication ratio predicts subsequent emergency department (ED) visits and hospital admissions in children. DESIGN Retrospective cohort with two year pairs. SETTING/PARTICIPANTS 2007-2009 South Carolina Medicaid recipients with persistent asthma age 2-18. MAIN EXPOSURE Controller-to-total asthma medication ratios were calculated for each patient in 2007 and 2008. Ratios range from 0-1 (1 = ideal, 0 = no controller). OUTCOME MEASURES 2008 and 2009 asthma related ED visits, hospitalizations, and a combined outcome of ED visit or hospitalization in the subsequent 3, 6, and 12 month time periods. RESULTS 19,512 patients were included. Mean age 8.9 years, 58% male, and 55% black. The ratio significantly predicted ED visits and hospitalizations over subsequent 3, 6, and 12 month time periods. The cut-point that maximized the ability to predict visits ranged from 0.4-0.6. A cutpoint of 0.5 was used in the final models. After controlling for age, race, gender, and rurality, patients with a ratio <0.5 were significantly more likely to have a subsequent emergent healthcare visit (OR 1.5-2.0). The ratio retained its predictive ability in both year-pairs for all three outcome variables, in all three time periods, with the exception of the 2008 ratio not predicting 2009 3-month and 6-month hospitalizations. CONCLUSIONS The asthma medication ratio is a significant predictor of ED visits and hospitalizations in children. Using a cutoff of <0.5 to signal at-risk patients may be an effective way for populations who would benefit from increased use of controller medications to reduce future emergent asthma visits. CPT only copyright XXXX-2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. See attached CMS CPT 2013 end user license.

Cost effectiveness of an inpatient influenza immunization assessment and delivery program for children with asthma

BACKGROUND Influenza is common in children. Children with asthma are underimmunized. The Centers for Disease Control recommends immunization in an acute-care hospital setting. OBJECTIVE The purpose of this study was to determine the potential clinical benefit and cost savings of delivering influenza vaccination to hospitalized children with asthma. DESIGN The study was designed as a decision and cost-effectiveness analyses. A decision tree was constructed to represent an intervention to assess and deliver influenza vaccinations to hospitalized pediatric patients with asthma. A literature survey provided estimates for the decision tree assumptions. In the decision analysis, various rates of screening for influenza vaccine status were investigated to determine the effects on final up-to-date (UTD) status in a hypothetical cohort. The cost-effectiveness analysis was used to determine potential cost savings resulting from the modeled increase in UTD status. MEASUREMENTS The percentage of children ultimately becoming UTD, direct and indirect costs, and cost savings of the intervention were measured. RESULTS With existing data showing that only 29% of asthmatics receive the influenza vaccine in a given year, our decision analysis demonstrated that even modest increases in the screening rate for influenza vaccine status among hospitalized patients with asthma can result in clinically significant increases in UTD status. For example, screening just 20% of those with asthma who are hospitalized would result in 35% ultimately being UTD for that influenza season; and 100% screening would result in 59% being UTD. The cost savings for this intervention would be

Younger Asthmatics Are Less Likely to Receive Inhaled Corticosteroids and Asthma Education After Admission for Exacerbation

5.45/child assessed and