POTENTIALLY AVOIDABLE HOSPITALIZATION DAYS: A PROSPECTIVE ANALYSIS. A. Torn 1 , A. Pichon-Riviere 2 , C. Romero 1 ; 1 Sanatorio de la Trinidad, Capital Federal, Buenos Aires; 2 Programa de Efectividad Clinica -Argentina, Capital Federal, Buenos Aires PURPOSE: Analyze the distribution and causes of the potentially avoidable additional hospitalization days (PAAD) in an institution that has a hospitalist program. METHODS: From 06/99 to 01/00 the surgical and medical admissions of adult patients to a private hospital in Buenos Aires, Argentina were followed prospectively to detect PAAD. The additional days were defined using the Milliman and Robertson's Optimal Recovery Guidelines. The case management nurse assigned a cause from a set of 16 possibilities to each additional day and categorized the admissions in 5 severity levels. RESULTS: There were 1812 medical and surgical admissions of adult patients; 626 (34.55%) were medical and 1186 (65.45%) surgical from which 27.4% were emergency and 72.6% programmed procedures. The mean age was 56.3 years with a 25% of the patients older than 74 years; 58.5% were women. The average length of stay (ALOS) was 4.1 days with a median of 2.1; 5.8 for the medical admissions and 3.2 for the surgical ones. The difference between the programmed and emergency operations was significant: 2.6 vs. 4.9. There was also a significant increase of the ALOS with categories of age and severity. The inpatient mortality was 3.5%, 93.4% were discharged and 3% were transferred to a rehabilitation center or to home care. A total of 723 PAAD, representing a 9.64% of the hospitalization days, were generated by 600 admissions. The physicians were responsible of 668 PAAD (92.40%). Inappropriate admission (potentially ambulatory procedures), was the cause of 392 (54.22%) PAAD, 181 (46.17%) were due to gynecological procedures, 73 (18.62%) to general surgical and 62 (15.82%) to traumatological ones. Prolongation of hospital stay was the cause of 331 (45.78%) PAAD divided in 55 days (16.62%) attributed to the health care system and 276 (83.38%) to the physicians. Of the latter 106 (38.40%) were responsibility of traumatology and 82 (29.71%) of gynecology. A logistic regression model adjusted for severity, age, sex, type of admission and specialty was analyzed. The following specialties were positive predictors of PAAD compared to general surgery: gynecology (OR 7.84), traumatology (OR 2.75) and neurosurgery (OR 4.58) . Emergency surgery (OR 0.61) was a negative predictor of PAAD and age (OR 1.01) was a positive one. CONCLUSION: Even though this study was conducted in an institution where a hospitalist program is in place, there are still a significant number of potentially avoidable additional days. They are concentrated in programmed surgical procedures mainly gynecological and orthopedic, and in the lower levels of severity. PURPOSE: Primary care physicians (PCPs) are often required to act as gatekeepers and or patient advocates for mental health services in an extremely complex administrative environment that includes managed care organizations with and without mental health carve-outs. This analysis addresses two aspects of this environment: (1) number of managed care contracts per practice (2) percentage of patients for whom the physician serves as managed care gatekeeper. METHODS: Data from the 1996 ± 97 Physician Community Tracking Study performed by the Center for Studying Health System Change were analyzed. This cross-sectional survey consisted of telephone interviews of 12,385 physicians (5,583 primary care physicians caring for adults) and had a response rate of 65 percent. Access to high quality mental health services was defined as PCPs indicating that they always or almost always could obtain high quality mental health services for their patients. RESULTS: Perceived availability of high quality services was much lower for outpatient mental health than for outpatient medical specialists (30% vs. 81 %, p-value < 0.001). Perceived access to high quality outpatient mental health services declined with increasing numbers of managed care contracts: zero (44%, Odd Ratio 2.3, CI 1.8, 3.1), one (37%, OR=1.8), two to ten (27%, OR=1.1), eleven to twenty-five (29%, OR=1.2) and more than twenty five (25%, OR=1.0). These findings persisted after adjustment for patient demographics (Medicare percentage, Medicaid percentage), physician demographics (age, gender, foreign vs. US medical graduate and overall career satisfaction) and practice characteristics (type of practice and concern about financial penalties for practice decisions) using multiple logistic regression analysis. An adjusted OR of 1.9 (p-value of < 0.001) was observed for zero contracts compared to twenty-five or more. A U-shaped distribution in perceived access was observed for the percent of patients in the practice for whom physician served as gatekeeper: three percent or fewer patients in gatekeeper status (42%, OR 2.6), more than ninety percent of patients (43%, OR 2.6) and fiftytwo to sixty percent of patients were in gate-keeping status (22%, OR 1.0). These findings persisted after adjustment using the same model described above (p-value < 0.001). The same patterns were observed for inpatient psychiatric services. The same relationships between access to high quality services and number of managed care contracts and gatekeeper percentage were not observed for medical services. CONCLUSION: The mental health referral process may be uniquely vulnerable to the administrative burdens imposed by the current managed care environment. Paradoxically, while large numbers of managed care plans with a variety of options are thought to increase choice, they may actually decrease access to high quality mental health services. PURPOSE: For many chronic diseases, effective drug therapy is now available. However, patients often fail to adhere to prescribed regimens with suboptimal clinical results. We surveyed resident and faculty physicians (MD) of a university-based internal medicine clinic serving an indigent population to determine MD attitudes, beliefs and behaviors with respect to patient drug adherence (DA). METHODS: One hundred two MDs completed a 14 question survey asking them to definè good' adherence, estimate the proportion of their patients who achieve 'good' patient DA, and to respond to a series of statements regarding DA. Two mailings produced an 86% response rate. At least 20 responses were obtained from each of PGY1,2,3 and attending MD levels. RESULTS: Seventy nine percent of MDs defined`good' adherence' as patients taking at least 80% of prescribed doses. However, MDs estimated that only 66+/À15% (mean/SD) of their patients acheived`good' adherence. In the prior 6 months, 50% of MDs discussed DA with at least 80% of patients, and 91% of MDs reported discussing DA with at least 50% of patients. Despite these discussions, only 32% of MDs felt that at least half of their patients had a good understanding of the importance of drug therapy to avert adverse outcomes. Almost all (97%) MDs felt that DA assessment and intervention was an important component of the office visit and 100% felt that prescription refill feedback would help them target patients for adherence intervention. There was no association between year of training and DA responses. CONCLUSION: In this indigent care setting, MDs indicated that they frequently discussed DA with patients but felt that patients lacked a good understanding of the role of their medication and that many were not adherent to their prescribed regimens. All MDs felt that specific DA feedback based on prescription refill data would assist them to identify and manage non-adherent patients. Since automated pharmacy claims systems cover the majority of the US population, such feedback is feasible and worthy of future study in both indigent and more affluent populations.