In linear regression analyses, LOS was nearly identical in major, minor, and non-teaching hospitals (relative LOS 1.01, 1.00, and 1.00 respectively). CONCLUSION: Patients admitted to ICUs in major teaching hospitals early or late in a month have a modestly higher risk of death, even after adjusting for admission severity of illness. A similar pattern was not observed in minor teaching and non-teaching hospitals. These findings may reflect the discontinuity of care that typically occurs when housestaff and attending teams rotate on and off service. PURPOSE: To explore the extent to which physicians agree that their main responsibility is to individual patients rather than to society, to understand which physician and practice characteristics may influence this attitude, and to examine how this attitude affects physicians' career satisfaction. METHODS: We surveyed 500 primary care providers from 80 outpatient clinics in 11 managed care organizations (MCOs) and received 414 completed surveys (response rate 83%). We used t-tests, chi-squared tests and logistic regression to compare the socio-demographic and practice characteristics of physicians who strongly agreed versus all other responses with the statement``The practitioners main responsibility is to each individual patient rather than to society'' (the individual-patient ethic). We then examined the relationship between the individual-patient ethic and career satisfaction using chi-squared tests and logistic regression with career satisfaction as the dependent variable. RESULTS: 28% of physicians strongly agreed, 42% somewhat agreed, 13% were neutral and 17% somewhat or strongly disagreed that their main responsibility was to each individual patient rather than society. Physicians with the individual-patient ethic were older (43% physicians > 50 years vs 21% physicians < 35 years, p = .009), spent more hours/week in direct patient care (36 vs 32 hours, p = .048), and tended to practice in network rather than staff model MCOs (33% vs 24%, p = .077). There was no difference in gender, race, specialty, or geographic region between physicians with or without the individual-patient ethic. In multivariate analyses, physician age remained the only significant predictor of the individualpatient ethic after controlling for all other physician and practice characteristics. When examining the relationship of the individual-patient ethic to career satisfaction, physicians with the individual-patient ethic were more satisfied with their ability to provide good quality care (38% vs 19% very satisfied, p = .000) and more satisfied with their ability to serve enrollee needs (28% vs 12% very satisfied, p = .000) but were not significantly more satisfied with their overall careers (20% vs 14%, ns). After controlling for physician age, gender, specialty, number hours/ week in direct care, type of MCO and geographic region, physicians with the individual-patient ethic were more likely to be very satisfied with their ability to provide good quality patient care (AOR 3.16, 95% CI 1.88 ± 7.75), to serve enrollee needs (AOR 3.81, 95% CI 1.87 ± 7.75) and more likely to be very satisfied with their overall career (AOR 2.13, 95% CI 1.04 ± 4.39). CONCLUSION: Physicians who strongly agree that their main responsibility is to each individual patient rather than society are older and more satisfied with their careers. The extent to which this attitude impacts patient care is unknown. PURPOSE: Fragmentation of health services may hamper women's ability to obtain comprehensive, coordinated healthcare. The Veterans Administration (VA) has encouraged its medical facilities to create specialized women's health clinics (WHC) to meet these needs. This study compares patient perceptions of the quality of primary care delivery in WHC versus traditional VA general medicine or primary care clinics (PCC). METHODS: We mailed an anonymous survey to women veterans from the 10 VA facilities in the Mid-Atlantic region. For the 8 facilities with a WHC code, we randomly sampled 170 veterans who used the WHC, and 80 who used a PCC from March 1, 1999 , to March 1, 2000 At the other 2 sites, we selected 250 women who visited a PCC. The initial mailing was followed at one week intervals by a reminder postcard then a repeat survey. Patient perceptions of primary care were measured using the original 19-item Components of Primary Care Index (CPCI) by Flocke (1997 . Additionally, other provider characteristics significantly influenced patient ratings. The presence of a regular VA provider was associated with higher ratings on all four subscales (OR 2.53, 1.53, 2.44, and 3.26 respectively, p < 0.001). Among the women who had a regular provider, those who used a female practitioner also rated their care significantly higher on all subscales (OR 1.67, 1.80, 2.16, and 1.83, p < 0.001) . CONCLUSION: Female veterans using specialized women's clinics perceive a higher quality of primary care delivery even after controlling for demographics, health status, and provider characteristics. Further details about model of care, type of provider, and health outcomes for women veterans need to be examined. Since WHC appear to differ from PCC on some factors, one may infer that selection bias accounts for the differences in patient ratings between clinics. Further analyses will account for selection bias through Heckman models or other methods. PURPOSE: Waiting lists for coronary revascularization are frequently managed without any explicit queuing criteria. Patients may thus not receive priority based on the severity of their clinical symptoms. This is of particular concern in Europe. We therefore convened a European expert panel to develop criteria for maximum acceptable waiting times for coronary revascularization. We assessed the applicability of this criteria and compared Dutch patients' waiting times with the panel's recommendations. METHODS: A panel of 13 cardiothoracic surgeons and cardiologists from Spain, the Netherlands, Sweden, Switzerland and the United Kingdom was convened to assess the appropriateness of, and priority for, a set of hypothetical scenarios for coronary revascularization. They rated the appropriateness of these scenarios using a modified delphi process and then assigned a maximum waiting time, on a scale of 7 time frames, for 200 indications that were not judged inappropriate. We then measured the waiting time for coronary revascularization (i.e. the number of days between when a recommendation was made that a patient should undergo revascularization and the time the procedure was performed) for 1713 chronic stable angina patients who were treated at one of 10 hospitals in the Netherlands. We also collected data on how the patient's clinical data was presented at the meeting where the recommendation was made for revascularization: (1) direct presentations occurred when the referring cardiologist attended the meeting; and (2) indirect presentations occurred when the patient's clinical data was provided by telephone, letter or facsimile. We assessed the proportion of patients who underwent revascularization within the maximum recommended time. RESULTS: There was significant variation in the maximum recommended waiting time among the panelists (mean maximum recommended waiting time 96 days; standard deviation 85 days). Angioplasty patients waited fewer days than bypass patients (48 vs. 83 days, p < 0.001). Thirtyseven percent of patients waited longer than the maximum recommended waiting time. The majority of patients with excess waiting times were referred for bypass surgery rather than angioplasty (e.g., 83% vs. 17%, respectively). Patients whose cases were discussed during a direct presentation waited fewer days than those patients whose cases were presented indirectly (61 vs. 74 days). CONCLUSION: One-third of patients referred for coronary revascularization waited for periods longer than those recommended by a multinational panel. Two contributing factors were the type of revascularization procedure the patient was referred for and how the patient's case was presented, factors not considered by the panel as they felt a patient's waiting time should be determined by clinical symptoms. was convened to assess the appropriateness of, and priority for, a set of hypothetical scenarios for coronary revascularization. They rated the appropriateness of these scenarios using a modified delphi process and then assigned a maximum waiting time, on a scale of 7 time frames, for all non-inappropriate indications. They also assessed the impact of social factors on a subset of 45 scenarios in which the patient was considered to have mild-moderate angina, moderate left ventricular function, and had a low-moderate operative risk. The scenarios varied in the patients ability to work, live independently or care for dependents which was categorized as being: (1) not threatened, but more difficult; (2) threatened, but not immediately; and (3) immediately threatened. The time frame was converted to a linear scale and multiple regression was performed on the 540 individual panelist's ratings to assess the impact of each factor on waiting time. RESULTS: Twelve of the 13 panelists responded. Large shifts in (p < 0.001) occurred in ratings of waiting time, with the order of priority being those whose ability to work, live independently or care for dependents was immediately threatened first, those whose activities were threatened but not immediately second, and those whose activities were not threatened last. The overall mean shift in maximum recommended waiting time due to a threat to ability to work, live independently or care for dependents (37 days longer wait for those who were not threatened vs. those immediately threatened) was less than the mean shift due to extent of coronary disease (e.g., 93 days longer wait for those with 1 or 2 vessel nonproximal left anterior descending artery disease compared to those with left main disease) or stress test results (62 days longer for those with a negative compared to very positive stess test). CONCLUSION: Cardiovascular specialists may place considerable weight on the threat of cardiovascular disease on a patient's ability to perform their usual social activities. However, the impact of this factor varies according to clinical presentation. The impact of these factors should be assessed in actual practice. PURPOSE: Teaching hospitals, due to their size, expertise, and location may find themselves in a position to treat alcohol and drug related diagnoses more often than their community counterparts. Previous studies have shown the existence, in some cases, of a volume-to-outcome relationship. Thus, though past research has shown that overall teaching hospitals may be less efficient, they may experience efficiencies in uniquely qualified or niche areas. This study examines the relationship of hospital resource use and the treatment of alcohol and drug diagnoses. Specifically the study tests the hypothesis that teaching hospitals will have greater efficiency than other community hospitals in the treatment of alcohol or drug related diagnoses. This study also examines the hypothesis that hospitals with more experience in treating alcohol and drug related diagnoses would experience greater efficiencies than hospitals with less experience. METHODS: This is a retrospective cross-sectional study that examines the association of hospital resource use and the treatment of alcohol and drug related diagnoses. The population for this study comes from the 1996 Healthcare Costs and Utilization Project's National Inpatient Sample. The final sample consisted of patients with the appropriate alcohol and drug related diagnosis (n = 9,528 patients). Data from the American Hospital Association, the Area Resource File, InterStudy, and the Health Care Financing Administration supplemented the patient level data from NIS. Teaching hospitals were identified using the Council of Teaching Hospital designation. Hospital experience was measured by the number alcohol and drug related admissions relative to the hospital's total admissions. Hospital resource use was measured by taking both the log of length of stay and total hospital charges. Least square regression was used to analyze hospital resource use while controlling for hospital, patient, and market characteristics. RESULTS: The average age of the sample was 39 with 68% of the patients being male and 66% of them white and 23% black. Twenty percent of the admissions were to teaching hospitals. Teaching hospitals had significantly lower charges (p = 0.029) than non-teaching hospitals and shorter lengths of stay (p = 0.042) than their community hospital counterparts. When examining the hospitals relative experience, hospitals with greater experience had significantly lower total charges (p < 0.001); however, contrary to our hypothesis they had significantly longer lengths of stay (p < 0.001). CONCLUSION: Though previous studies have shown teaching hospitals, as compared to non-teaching hospitals, are less efficient overall, the results of this study show that they are able to experience certain efficiencies in niche areas. Specifically, teaching hospitals are more efficient at treating alcohol and drug related diagnoses. As teaching hospitals continually find themselves competing for managed care contracts, finding and documenting niche areas in which they excel becomes increasingly important. PURPOSE: Routine screening for domestic violence (DV) is increasingly recommended in outpatient healthcare settings. However, little is known about the screening process. The purpose of this study was to document the screening process for women counseled for DV in a primary care setting. METHODS: We identified pregnant women who were counseled for DV between 8/98 ± 6/99 at a university obstetrics clinic. The DV protocol at this clinic, similar to national guidelines, recommends that women be asked about DV at every visit. Identified women are offered counseling using a specific form (usually performed by a social worker). Data were collected from the DV counseling form and from medical records for the previous 6 months. We assessed how the women were screened, who had counseled the women, and what types of abuse led to the counseling. We compared demographic and health characteristics of counseled women to a control group of pregnant women, matched on race, age and type of visit, who were not counseled for abuse. RESULTS: Of 63 pregnant women counseled for abuse, 53 had complete medical records available for review. Fourteen (26%) of the women were identified as victims at their first clinic visit. Thirty-three (62%) of women denied abuse in at least one previous screening attempt. Eighteen (67%) of the 27 women who were asked about abuse by their physician on the same day that they received counseling denied abuse to their physician. Of the 48 women (91%) referred by an MD/RN to social work for counseling, only 25 (52%) were referred for DV. Twenty-three (48%) were referred for non-DV reasons with the social worker subsequently identifying the abuse. Women referred for DV were more likely to be seen within a month of referral than women referred for other reasons (72% vs. 39%, p=0.01). The majority of abuse reported was physical (96%) and recent (83% with event within past month); 37% had been experienced abuse for more than 2 years. In the 40 cases we were able to match to controls, women counseled for abuse were more likely to be depressed (51% vs. 29%, p < 0.05), to be currently using drugs (20% vs. 6%), p < 0. Bivariate analysis revealed that physicians with a higher score on the SWB scale and more frequent church attendance were more likely to hold beliefs that health outcomes are improved with patient and physician prayer and that faith alone can cure disease. There were no associations between physician sex, age, race, or spirituality training and these attitudes. CONCLUSION: A large number of physicians believe religious and spiritual behaviors by patients will improve health outcomes. A smaller but significant number believe that physician prayer will improve patient outcomes. These findings suggest that there is a need for more rigorous examination of the connection between health outcomes and spirituality as many physicians seem willing to incorporate aspects of spiritual behavior into their practices. 1995) . Little is known about the impetus to develop a separate WHC, especially within the VA, where issues of access to care, privacy, and quality of care for women veterans have often been of concern. We examined organizational, provider, and patient-level determinants of developing a separate WHC for delivery of gender-specific and primary care services. METHODS: We used data from the 1999 VHA Primary Care Practices Survey, a national survey of senior VA primary care leaders at all VA health care facilities with > 4,000 unique patients and > 20,000 outpatient visits during fiscal year 1998 (response rate 93%, n = 219). Analysis of facility characteristics associated with a self-reported WHC for delivering primary care was performed using bivariate analysis and independent predictors were determined using logistic regression. RESULTS: Nationally, 62% of facilities reported having a separate WHC to provide primary care for women. WHC's tended to reside in urban locations (p < 0.05) and in more complex facilities (p < 0.05). Facilities with WHC's had more female patients (p < 0.001) with more visits (p < 0.001), but comparable visits-per-patient (7.1 vs. 7.4). Facilities with team-based primary care that integrated providers from multiple disciplines were more likely to have developed a WHC (p < 0.05). WHC's were more likely where primary care leadership was distinct from subspecialty care (p < 0.001) and a separate budget existed for primary care (p < 0.05). In addition, WHC's were more common in academic facilities (69% vs. 56%, p = 0.09) with higher numbers of internal medicine houseofficers (43.5 vs. 26.9, p < .05) and longer outpatient block rotations (p < .05). Having separate primary care leadership, and higher women veteran caseload remained significant predictors of WHC development after adjusting for other variables. CONCLUSION: Separate WHC's were present in larger, complex, more intensively academic medical centers with more established and authoritatively independent primary care programs. As a cross-sectional study, it is unclear whether WHC development occurred as a result of or resulted in a higher female patient volume. The implications of separate service delivery for women with respect to clinical quality, and patient satisfaction are still unclear and somewhat controversial; assessing WHC performance is a crucial next step. 1.14 ± 1.25), and for all encounters combined (RR 1.07; 1.04 ± 1.09). As compared to their use of Outpatient services, PDs were especially more likely than non-PDs to use high cost Emergency Department and Inpatient services. CONCLUSION: Using CAGE results and objective encounter data from continuity patients in a large group practice, problem drinking was common and associated with higher overall utilization as well as use of higher cost sites for specific alcohol-related conditions. These findings support initiatives to screen and intervene for problem drinking in primary care practices. Respondents were asked to rate how important it is for asymptomatic men to know each of the 17 facts about PSA screening using a 5-point Likert scale ranging from``not at all important'' to``extremely important.'' Because internists and family physicians had similar responses, they were combined as non-urologists and compared to urologists. We used logistic regression to compare differences between urologists and non-urologists and adjusted for the effects of age and gender. RESULTS: Urologists and non-urologists differed in rating how important it is for men to know 9 of the 17 facts. Urologists considered it extremely or very important for men to know that it is unclear whether regular PSA screening will reduce prostate cancer mortality, that done together the PSA and digital rectal exam (DRE) can screen for prostate cancer, and that PSA and DRE are most appropriate for men whose life expectancy is at least 10 years. Non-urologists considered it extremely or very important for men to know that PSA screening is controversial, that there are risks and benefits to PSA screening, that prostate cancer may grow slowly without symptoms, that it is unclear whether treatment of early, localized prostate cancer is helpful, that there are side effects to treatment, and that a man over age 70 is less likely to die from prostate cancer even though he has a higher risk of having it. RESULTS: Faculty and resident patients were similar with respect to sex, race, weight, years of diagnosis of diabetes mellitus and type of diabetes therapy. However, resident patients were slightly older than faculty patients were (mean age 63 vs. 57, p = 0.008). Residents and faculty were no different in frequency of adherence to the ADA Clinical Practice Guidelines for visits per year, HbgA1C testing, lipid profile testing, and foot exam. Faculty were significantly more adherent to urine evaluation (44% vs. 26%, p = 0.04) and referral for dilated eye exam (54% vs. 39%, p = 0.02). There were no differences between residents and faculty patients with respect to mean HbgA1C levels, mean control of blood pressure, use of ACE inhibitors and use of lipid lowering therapy. Resident patients were more likely than faculty patients to have LDL levels controlled to less than 100 (42% vs. 25%, p = 0.03). CONCLUSION: Residents and faculty provide primary care for similar groups of diabetic patients at this academic health center. Adherence to ADA Clinical Practice Recommendations was similar between faculty and residents for many, but not all areas. Outcomes such as HbgA1C levels and blood pressure control were similar for both groups, though more resident patients had better LDL cholesterol control. Though resident continuity practices are faculty supervised and often in the same setting as faculty practices it cannot be assumed that quality outcomes are the same for patients of these two groups. Interventions to improve rates of adherence to specific recommendations should be geared towards both faculty and residents at this academic health center. Younger generation for females and males were significantly less likely to receive primary care compared to older generation males and females (females p < .001 and males p < .006). Male relatives are significantly less likely to access primary care compared to females, 57% vs. 70% (p < .015) and are less likely to access the Charity system compared to females 20% vs. 34% (p < .014). Male relatives are more likely to obtain the majority of their health care in the ER and Walk-in Clinic compared with female relatives 20% vs. 8% (p < .001). There was no difference between work status, age distribution, and health care coverage between male and female relatives. CONCLUSION: The barriers to health care access in both males and females were Full/Part time-work status, younger generation, and lack of health care coverage. Our patients' male relatives are less likely to have a regular source of primary care compared to female relatives. Offering evening and weekend hours in our indigent continuity clinics may possibly reduce this barrier. Further studies are needed to better assess this inequality of primary care access between males and females. PURPOSE: Decreasing waiting times to next available appointment involves evaluation of the physian appropriateness and effectiveness of practice in the clinic system. Some studies have shown that patients receive``better'' care from a sub-specialist than those followed by a generalist. The appropriateness and variability of this care, however, has not been well scrutinized. The purpose of this study, was to identify if patients enrolled in the cardiology clinic belong there based on a set of criteria agreed between internal medicine and cardiology. Also, to assess the variation among cardiology fellow's discharge rates and revisit interval assignment. METHODS: Data was extracted from 194 cardiology clinic notes between 1/14/00 ± 2/27/00. Providers were cardiology fellows practicing at an urban VA. The main outcomes of interest were appropriate discharge from the cardiology clinic (per criteria established by the authors) and assigned revisit interval. Predictors of interest included provider data and patient level information such as a severity of illness score and ejection fraction. RESULTS: Overall, discharge rate was 24/194 (12.4%) . Of the 161 remaining in the clinic, 74 (46%) could have been discharged to their primary provider by the agreed criteria. In logistic regression, disease severity was correlated with discharge from clinic (r =0 .69). The more stable patients were more likely to be discharged from clinic. Overall, average clinic revisit interval was 3.8 months. There was a large amount of variability among providers. Individual provider average follow up time ranged from 2.2 ± 7.7 months. Individual discharge rates ranged from 0 ± 26%. Individual clinic appropriateness ranged from 0 ± 90%. There was no correlation of revisit intervals with severity of illness score (r = .021, p = 0.794) or with ejection fraction (r = .013, p = 0.91). At best, patient severity of disease accounted for only 4% of the variance. Individual providers saw patients back at a consistent length of time regardless of the needs of the individual patients for instance, provider #10 saw every patient back in 6 months and provider #31 saw every patient back in 3 months.