Search PubMed⌕ Search

Biomedical subjects

G E Kikano

Publications and source records attributed to G E Kikano.

At least 19 recordsLinked to original sources
PubMed2000

Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

OBJECTIVE: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. DESIGN: Multi-method, cross-sectional observation study. SETTING: Eighty-four family practices in northeast Ohio. PARTICIPANTS: Four thousand fifty-four outpatients visiting 138 family physicians. MAIN OUTCOME MEASURE: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits. RESULTS: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients. CONCLUSIONS: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.

Cross-Sectional Studies↗
PubMed1999

Direct observation of exercise counseling in community family practice.

BACKGROUND: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood. METHODS: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis. RESULTS: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor. CONCLUSIONS: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.

Adult↗
PubMed1998

Physician employment status and practice patterns.

BACKGROUND: Many physicians today are employed by another physician, group, hospital, HMO, or other organization. However, the differences in the characteristics, practice patterns, and patient outcomes of self-employed and employed physicians are not well understood. METHODS: The practices of 108 community family physicians in northeast Ohio were assessed using a multimethod cross-sectional design. Physician characteristics were assessed by questionnaire. Direct observation of 3536 consecutive patient visits was used to measure time use and the delivery of preventive services recommended by the US Preventive Services Task Force. Patient satisfaction was assessed with the Medical Outcomes Study (MOS) 9-item Visit Rating Form. RESULTS: Employed physicians were more likely to be female, in group practice, work fewer hours, and see fewer patients. Job satisfaction was similar between the two groups, but employed physicians reported greater satisfaction with leisure and family time. Employed physicians spent more time per patient visit, scheduled a larger percentage of well-care visits, and were more likely to refer to specialists. Employed physicians also spent a greater proportion of their patients' visit time performing history-taking and eliciting family information, and a lesser proportion of time on physical examination, planning treatment, providing health education, and chatting. Recommended screening and health habits counseling preventive services were more likely to be delivered by employed physicians. Patient satisfaction was similar for the two groups. CONCLUSIONS: Primary care physician characteristics and practice patterns differ by employment status. The consequences of the trend toward a largely employed physician workforce as reported in this study should be carefully considered.

Adult↗
PubMed1998

Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation.

BACKGROUND: Little is known about the accuracy of family physicians' use of the Current procedural Terminology (CPT) coding scheme for office visits, despite increased administrative oversight of Medicare billing practices. In addition, the patient and visit characteristics that are associated with over- and undercoding are not well understood. METHODS: This study compared coding for evaluation and management (E&M) services billed for 3791 visits to 138 family physicians with the codes assigned by trained research nurses using direct observation. We calculated the degree to which the codes for E&M were concordant with the observer-assigned codes. Analysis of variance and logistic regression were used to examine the association of visit and patient characteristics with discordance between billed and observer-assigned CPT codes. RESULTS: Billing codes were concordant for 55% of encounters. Discordance was evenly distributed between under- and overcoding. Concordance of billed and observed codes was greatest for patients with indemnity insurance. Undercoding increased with longer visit length and a smaller percentage of the visit spent planning treatment. Overcoding was more common during visits with a greater percentage of time spent chatting, planning treatment, and delivering preventive services. CONCLUSIONS: Family physicians are generally accurate in their billing procedures. The findings on patient and visit characteristics associated with over- or undercoding may be used by practicing clinicians to enhance the accuracy of their coding and billing procedures.

Adult↗
PubMed1996

Medical decision making and perceived socioeconomic class.

OBJECTIVE: To examine the effects that a physician's knowledge of a patient's socioeconomic status or profession has on clinical decision making in an outpatient setting. METHODS: We mailed a survey to all 336 members of the Academy of Medicine of Cleveland who are general internists, family practitioners, or general practitioners. Physicians were randomized before the initial mailing to receive one of the two questionnaires. Physicians in group A were given two simulated clinical scenarios in which the socioeconomic status or profession of the patient was identified, followed by management options. Physicians in group B were given the same scenarios without any suggestion of the patient's profession or social standing. Outcomes that reflect decision making, intensiveness of evaluation, and treatment course were compared for the two groups. Data were analyzed using t tests and chi 2. After Bonferroni correction, a P < or = .01 was considered significant. RESULTS: The response rate was 60%. For clinical scenario 1, no difference was noted in the number of tests ordered. However, physicians in group A responding to clinical scenario 2 ordered more total tests than did physicians in group B (P = .03), including complete blood cell counts (45% vs 29%, P = .01). In both scenarios, earlier follow-up visits were scheduled by physicians in group A compared with those in group B (P = .01). CONCLUSION: Our results do not support findings by other investigators that more tests are ordered when physicians perceive their patients to be of higher socioeconomic status. Intensity of follow-up, however, was greater when physicians believed the patient was in a more prominent profession or was of higher socioeconomic status.

Adult↗
PubMed1994

Methods of recruiting and selecting residents for U.S. family practice residencies.

PURPOSE: To describe the strategies used by family practice program directors to recruit and select residents. METHOD: The residency directors of all 361 U.S. accredited nonmilitary family practice programs in 1992-93 were asked to complete three-page questionnaires regarding program descriptors, curriculum, benefits offered, interview process, and factors affecting their selection of residents. Each program was categorized into one of nine geographic regions. Variation of program characteristics across the regions was assessed using chi-square. RESULTS: A total of 282 directors (78%) returned usable questionnaires. The programs did not differ in benefits offered except that (1) those with low fill rates in the 1992 Match of the National Resident Matching Program were more likely to have additional financial incentives and (2) the programs in areas of high competition went to extra effort and expense to market their residencies through the use of advertising materials (e.g., pens, mugs). The most important factor in selecting applicants was listed as the personal interview by 51% of the directors and performance on clinical rotations by 36%. CONCLUSION: The residency directors' selection decisions were highly influenced by candidates' performances in interviews and on clinical rotations. The programs in the most competitive areas were characterized by greater efforts and increased expenditures of resources for recruiting. More research is needed to assess the values of the different strategies used by programs to recruit and select residents.

Family Practice↗
PubMed1994

The clinical utility of a day of hospital observation after switching from intravenous to oral antibiotic therapy in the treatment of pyelonephritis.

BACKGROUND: This study was undertaken to investigate the clinical utility of a widespread practice: the 24-hour in-hospital observation period that commonly follows when the treatment of patients hospitalized with acute pyelonephritis is switched from intravenous to oral antibiotics. A preliminary survey of infectious disease specialists confirmed the pervasiveness of this practice and the lack of scientific evidence to support it. METHODS: The clinical utility of in-hospital observation was examined by means of a retrospective chart review of 138 consecutive nonpregnant adult patients who were between the ages of 17 and 65 and had been admitted to a university hospital with a diagnosis of acute pyelonephritis. The progress notes, temperature charts, and laboratory test results were reviewed for any evidence of clinical relapse or adverse reaction to the antibiotic that occurred in the 24-hour period after the switch from intravenous to oral antibiotic therapy. RESULTS: Only two (1%) patients had evidence of clinical relapse within the study period. Five (4%) patients had adverse reactions to their oral antibiotic, none of which were serious. The 95% confidence interval for the percentage of patients who might experience a clinical relapse was from 1% to 5%; for adverse antibiotic reaction, 1% to 8%. CONCLUSIONS: This study shows the limited usefulness of an in-hospital observation period. Savings resulting from avoiding an extra day of hospitalization could amount to millions of dollars annually in the United States.

Acute Disease↗
PubMed1994

Markers of successful recruitment of students to family practice residency programs.

BACKGROUND AND OBJECTIVES: With limited numbers of medical students choosing a primary care specialty, family practice residency programs have had to complete to fill available residency positions. The purpose of this study was to determine the characteristics of the recruiting process used by US family practice residencies and to compare recruiting strategies used by successful and unsuccessful programs. METHODS: We surveyed program directors of all 361 nonmilitary, accredited, US family practice residency programs in existence for more than 2 years. The questionnaire elicited information on program descriptors, recruitment process, and fill rate in the National Resident Matching Program. RESULTS: Seventy-eight percent (282) of the program directors returned usable questionnaires. Success in filling available positions through the Match was significantly associated with high quality of current housestaff and faculty and current residents' positive feelings about the program (P < .01). Program directors perceived successful programs as having an outstanding reputation and being regarded positively by other departments within the institution (P < .01). Programs in the Pacific and Mountain regions of the United States are more successful in recruitment. Programs not filling available positions through the Match spent more effort in recruiting strategies such as mailing and marketing materials (P < .01). CONCLUSION: Having high-quality faculty, housestaff, and residents with good attitudes are markers of success in the Match. Less successful programs appear to try harder to attract residents.

Academic Medical Centers↗
PubMed1993

Lead poisoning in children.

In October 1991, the Centers for Disease Control issued new recommendations lowering the acceptable blood lead level. This change was based on data indicating that irreversible adverse neurodevelopmental effects occur in children with chronic low-level exposure to lead. The primary source of lead poisoning is still lead-based paint, particularly in older urban housing. Other sources of lead poisoning are also common. Almost all U.S. children are considered at risk of lead poisoning and should be screened for lead poisoning. Parents should be provided with information about potential sources of lead during routine well-child visits. Multidisciplinary efforts should be made to reduce all lead exposure. Oral chelation therapy on an outpatient basis is now available to treat less severe cases of lead poisoning.

Ambulatory Care↗
PubMed1992

Lead poisoning in a child after a gunshot injury.

Lead poisoning is a common disease that, if not detected, can lead to developmental delay and other serious sequelae. We report the case of a child with retained intracranial lead pellets from a gunshot injury, in whom elevated blood lead levels were detected approximately 1 year after the injury. No environmental source of lead was found, and a twin sister living in the same dwelling had considerably lower lead levels. The patient's lead levels diminished after each of four courses of chelation, but rebounded each time to potentially toxic levels after termination of therapy. Physicians should be particularly alert in screening for elevated lead levels in children with retained bullet fragments. In patients in whom removal of the bullet fragments is impractical, the potential risks of long-term chelation therapy must be weighed against the risks of lead toxicity.

Chelation Therapy↗
PubMed1991

Effect of the white blood count on the clinical management of the febrile infant.

BACKGROUND: The white blood count is commonly used in the evaluation of the febrile infant without a focal source of infection. This study describes the physician's use of diagnostic tests in this clinical situation and also evaluates the effect of an elevated white blood count (WBC) on diagnostic test ordering and patient management. METHODS: A case scenario describing a febrile infant was mailed to all 294 pediatric, family, general, and emergency physician members of the Academy of Medicine of Cleveland. Questions about test ordering and case management were asked, both before and after the patient's WBC was known. Physicians were randomly assigned to receive a case scenario with either a normal or an elevated WBC. RESULTS: Of the 294 physicians contracted, 196 (67%) returned usable questionnaires. Physicians ordered an average of 1.4 tests in the initial management of the case, for an average cost of $82. Emergency physicians ordered more tests than other physicians (2.4 vs 1.2 tests, P = .001). Once the WBC was known, physicians in the high WBC group ordered more additional tests than the normal WBC group (0.89 vs 0.33 tests, P less than .001), and were more likely to change to a more aggressive therapeutic management strategy (P less than .001). CONCLUSIONS: The cost of physician-ordered laboratory testing is significant for the clinical scenario of a febrile infant without a localizing source. An elevated WBC affects physician management by causing more tests to be ordered and by influencing some physicians to choose more aggressive management strategies.

Clinical Laboratory Techniques↗
PubMed1989

Brain perfusion in acute and chronic hyperglycemia in rats.

Recent studies show that acute and chronic hyperglycemia cause a diffuse decrease in regional cerebral blood flow and that chronic hyperglycemia decreases the brain L-glucose space. Since these changes can be caused by a decreased density of perfused brain capillaries, we used 30 adult male Wistar rats to study the effect of acute and chronic hyperglycemia on 1) the brain intravascular space using radioiodinated albumin, 2) the anatomic density of brain capillaries using alkaline phosphatase histochemistry, and 3) the fraction of brain capillaries that are perfused using the fluorescein isothiocyanate-dextran method. Our results indicate that acute and chronic hyperglycemia do not affect the brain intravascular space nor the anatomic density of brain capillaries. Also, there were no differences in capillary recruitment among normoglycemic, acutely hyperglycemic, and chronically hyperglycemic rats. These results suggest that the shrinkage of the brain L-glucose space in chronic hyperglycemia is more likely due to changes in the blood-brain barrier permeability to L-glucose.

Animals↗