Biomedical subjects
D G Cave
Publications and source records attributed to D G Cave.
Nonmigraine headaches.
The easiest-to-treat nonmigraine headaches for the 18-to-64 year old population have an average duration of 60 days. The most common diagnostic imaging test used is the computed tomography scan performed on the head or brain. Two out of 1,000 patients have a hospital admission. About 43% of the PTEs are treated without prescription. When a single prescription drug group is used, 56.7% of the prescriptions are for pain relief drugs. Nonsteroidal anti-inflammatory drugs are the most prescribed single drug group for this condition.
Patient care management programs: maximizing efficiency through the use of prevalence rates.
Providers are assuming more risk for patient management than ever before. This has led to more interest in managing patients with high-cost, chronic illnesses. In the following article, the authors discuss how accurate chronic disease prevalence rates can be used to better focus care management efforts, leading to a successful, cost-efficient program.
Vertical integration models to prepare health systems for capitation.
Health systems will profit most under capitation if their vertical integration strategy provides operational stability, a strong primary care physician base, efficient delivery of medical services, and geographic access to physicians. Staff- and equity-based systems best meet these characteristics for success because they have one governance structure and a defined mission statement. Moreover, physician bonds are strong because these systems maximize physicians' income potential and control the revenue stream.
Small-area variations in the treatment of prevalent medical conditions: a comparison of three cities in the Northeast.
This article presents a small-area variation study that examines utilization differences for primary care physicians (PCPs) in treating a homogeneous set of prevalent medical conditions. The study used secondary data collected over a 24-month period from a large, Northeastern region independent practice association. The diagnostic cluster methodology was used to examine geographic differences for PCPs in treating prevalent medical conditions. This methodology groups International Classification of Diseases, 9th revision (ICD-9), codes into diagnostic clusters based on clinical homogeneity with respect to generating a similar clinical response from the physician. For each diagnostic cluster, diagnostic episode clusters (DECs) were formulated. Each DEC links all services incurred in treating a patient's medical condition within a specific period of time. Differences in use rates across small areas were tested using t tests. The data showed little variation in the physician office visit rate across small areas. However, services generated from these office visits exhibited large rate variations. The most significant small-area differences were for hospital inpatient days and surgical procedures. Pattern-of-treatment differences exist across small areas for the homogeneous set of prevalent medical conditions treated by PCPs.
Profiling physician practice patterns using diagnostic episode clusters.
Health plans and providers need to profile current practice patterns to understand better the resources used in managing medical conditions. A profiling system is presented that groups International Classification of Diseases (ICD-9-CM) codes into 125 diagnostic clusters based on clinical homogeneity with respect to physician treatment response. For each diagnostic cluster, diagnostic episode clusters (DECs) are formulated. A DEC links all services incurred in treating a patient's medical condition within a specific period of time. Each DEC is marked with a severity-of-illness, comorbidity, and age indicator. To test the validity of the diagnostic cluster methodology, claims were analyzed from a preferred provider organization (PPO) and an independent practice association (IPA). PPO and IPA DEC charges and utilization were compared with t-tests. Physician practice patterns differed based on patient severity of illness, comorbidities, and age. Both PPO and IPA physicians delivered significantly more resources to patients in higher severity-of-illness categories. PPO physicians generally treated older patients with more resources than younger patients. Patient age did not have the same impact on IPA physicians' practice patterns. IPA physicians' average treatment pattern was about 22% less expensive than that of PPO physicians. IPA physicians decreased average expenses by reducing hospital days by about 73% (P < 0.01) and hospital outpatient visits by about 89% (P < 0.01) compared to the rates of PPO physicians. Ambulatory services among IPA physicians were not significantly higher than rates for PPO physicians. The DEC methodology is a valid approach for profiling patterns of treatment. The style of medicine in the IPA was less hospital intensive and, consequently, less expensive than that practiced by PPO physicians. PPO physicians also had greater practice pattern variations than IPA physicians.
Using diagnostic clusters to evaluate patterns of treatment and develop capitation rates.
Payers and providers of medical services need to understand what is effective in medical care and what determines patient outcomes. The diagnostic cluster methodology offers a way to analyze physicians' overall practice patterns in treating a specific medical condition and provides a good foundation for performing medical outcomes studies.
Pitney Bowes: using comprehensive cost information to build provider networks.
Wishing to develop a work partnership with a managed care organization, Pitney Bowes decided to select its own network providers. The company reached out to the medical community for input and participation in crafting both a clinical and a business partnership that would set new standards for health care delivery in the country. A methodology--described here--was developed for comparing medical plans and selecting providers.
Capitated chronic disease management programs: a new market for pharmaceutical companies.
With corporatism of the medical care delivery system, the pharmaceutical industry is searching for new ways to market prescription drug product lines. A new strategy focuses on developing chronic disease management programs. In doing so, pharmaceutical companies work with clinical leaders of HMOs or large physician groups on disease management guidelines to reduce practice pattern variations and improve the quality of patient care. In addition, pharmaceutical companies capitate payment to physicians treating chronic disease patients to give them financial incentives to comply with the disease management guidelines.
Distributing full-risk capitation revenues among providers.
What are the predominant types of vertical-integration models used to form health systems? The author describes these and the most common approaches employed by health systems to distribute full-risk capitation revenues between their primary care physicians, specialists, and hospitals.
Analyzing the content of physicians' medical practices.
For many large physician groups, about 75% of all revenues come from capitation contracts. These groups may reduce the variable expenses of patient care by conducting medical outcome studies. Physician groups will obtain the most benefit for their limited research dollars by focusing outcomes research on prevalent medical conditions. The purpose of this study is to provide a comprehensive analysis of the content of physicians' medical practices. We found that 21 diagnostic clusters defined 70% or more of the episodes treated by primary care physicians. For specialists, no more than eight diagnostic clusters were needed to define the majority of their practices. Outcomes research should initially focus on abdominal pain, acute lower respiratory infections, cataracts, cholelithiasis, congestive heart failure, diabetes mellitus, external abdominal hernias, ischemic heart disease, low back pain, maternity care, menstrual disorders, otitis media, peptic diseases, prostate cancer, psychotic episodes, renal calculi, seizure disorders, and thyroid diseases.
Caesarean section rate reduced.
The Caesarean section rate in consecutive years was decreased from 20.5% to 11.1% of total public deliveries (p < 0.0001). On retrospective analysis the emergency Caesarean section rate decreased from 10.9% to 6.0% (p < 0.0001) and elective Caesarean section rate from 9.6% to 5.1% (p < 0.0001) in consecutive years. Interventions which have accounted for the decrease were 3-fold. Firstly, vaginal birth after Caesarean delivery was encouraged, secondly, the active management of labour and thirdly, extensive, regular peer review were introduced as unit policy. The decrease in the Caesarean section rate was not achieved at the expense of the fetus as judged by perinatal mortality rates and 5-minute Apgar scores of less than 7.
Ureaplasma urealyticum chorioamnionitis.
Controversy reigns over the role of Ureaplasma urealyticum in determining pregnancy outcome. U. urealyticum infection of the chorioamnion is strongly associated with chorioamnionitis (1-3), premature birth (2-4), and perinatal morbidity (4-6). We present 4 cases of U. urealyticum chorioamnionitis and associated morbidity and mortality.
Capitation adjustments for physician risk.
Based on available data from the Health Insurance Association of America and the Group Health Association of America, about 9% of all primary care physician-based compensation was through capitation in 1990. By the turn of the century, more than 20% of such payment will be in the form of capitation. The author discusses how capitated arrangements can be negotiated so that the fairest rates result. Also described is the importance of developing practice pattern guidelines to ensure that capitation payment does not adversely affect patient quality of care.
Who treats medical conditions more cost efficiently?
Total costs in HMOs are 10% to 40% below those in indemnity plans; however, investigators have not examined the types of medical conditions that HMO providers treat more cost efficiently than indemnity providers. The present study was designed to evaluate if managed care health plan specialists treat complex conditions as cost efficiently as the HMO primary care providers treated the less-complex conditions and, if not, why?
Analyzing patterns-of-treatment data to provide feedback to physicians.
Physicians' practice patterns can be influenced through feedback programs. The purpose of this article is to define a methodology that provides the feedback information necessary to affect physicians' practice patterns, using data collected by a large multispecialty physician group and individualized feedback plans for primary care physicians.