To provide some perspective on the disease burden, we also calculated the ratio of DSM to ACM in the control groups for each cancer type. RESULTS: The RR's were discrepant in 5 of 14 trials. See table for details of RR and disease burden for each screening test. In addition, in one of the trials in which the RR's were both less than 1.0 (Edinburgh mammography trial), the observed difference in ACM was far greater than could be expected on the basis of decreased breast cancer mortality (5 times larger than the observed difference in DSM). CONCLUSION: ACM should be considered in randomized trials of cancer screening because it helps to identify threats to validity (such as the randomization flaws in the Edinburgh trial) and because it provides needed perspective on the magnitude of the benefit of screening. RR's based on ACM and DSM are often discrepant, raising questions about the validity of DSM and the potential for unrecognized harm from screening. For each study, we calculated the absolute difference in mortality rate between the highest and lowest volume strata reported and the number needed to treat (NNT) to prevent one death attributable to low volume. Two investigators independently abstracted each article using a standard form. RESULTS: Of 257 studies reviewed, 128 met inclusion criteria covering 27 procedures and clinical conditions. The methodological rigor of most studies was modest. Few studies used clinical data for risk-adjustment or examined hospital and physician volume effects simultaneously. Overall, 70% of all hospital volume and 74% of physician volume studies reported a significant association between higher volume and better outcomes. The strongest associations were for surgery on pancreatic cancer, esophageal cancer, abdominal aneurysm, and pediatric cardiac problems, and treatment of AIDS (median, 8 to 14 excess deaths per 100 cases attributed to low volume; NNT, 7 to 12). Although statistically significant, the magnitude of the volume-outcome relationships for CABG, PTCA, MI, carotid endarterectomy, other cancer surgery, and orthopedic procedures was much smaller (median, 0.2 to 3 deaths per 100; NNT, 35 to 500). CONCLUSION: High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of this finding is complicated by many methodological shortcomings. Differences in processes of care between high and low volume providers may explain much of the relationship between volume and outcome. (10):769) met all important quality criteria. In that study, 90% of total costs were attributable to drug costs alone, and the cost-effectiveness ratios were > $50,000/QALY for all 240 sub-groups analyzed. The statin dosage range used in that study is achieved at our institution by using half tablets of currently available preparations, and the actual VA costs for statins were 14% of those drug costs assumed in this study. When the VA costs were applied to this analysis, the cost-effectivneness of using statins for primary prevention was < $50,000/QALY for the majority of patient subgroups. CONCLUSION: In at least one large health care system, statins are available at acquisition costs considerably lower than assumed in published CEAs. These acquisition costs permit statin use for primary prevention of CAD to have an acceptable cost-effectiveness ratio. If these drug prices were widely available to consumers, this important category of medication would have great potential for improving the nation's health at reasonable cost. Mechanisms for creating a uniform pricing structure for these widely used medications should be explored. . Qualitative studies suggest that DCs give patients more information and more control over their treatment. Among primary care patients, information and control generally lead to greater satisfaction. We estimate the effects of provider type, explanation of treatment, and self-care advice on satisfaction in a randomized trial of DC vs. MD treatment for low back pain. METHODS: 681 adult low back pain patients were randomly assigned to treatment by either a DC or a MD and were surveyed at baseline, 2, and 4 weeks; follow-up was 99.7%. We used ordinary least squares linear regression to estimate the effects of provider type, explanation, selfcare advice, and other factors on satisfaction with provider. Explanation of treatment was reported as``yes'' or``no.'' Self-care advice was the number of items of advice (0 ± 10) the patient reported receiving. Satisfaction was measured on a 10-item scale (5 = low to 50 = high). RESULTS: The mean satisfaction score was 36.1 for patients in the DC group and 30.6 in the MD group; the crude difference was 5.5 (95% confidence interval [CI] = 4.5, 6.5). Adjustment for sociodemographic and baseline illness characteristics alone did not substantially change these estimates. The mean number of items of self-card advice was 2.3 in the DC group and 1.6 in the MD group (p < 0.001). Sixty-one percent of patients in the DC group vs. 16% in the MD group received an explanation of treatment (p < 0.001). In a regression model that included provider type, explanation, self-care advice, improvement in disability, prior experience with and confidence in treatment, baseline sociodemographic and illness characteristics, and interaction terms, the DC-MD difference in satisfaction was 4. PURPOSE: Although patient demand is high, physicians have not widely adopted use of e-mail with patients. Our purpose was to explore the experiences of physicians frequently using e-mail with their patients, as a window to the future. METHODS: To identify the rare``vanguard'' physicians who frequently use e-mail with their patients, we recruited 11,859 physicians using Physicians' Online, an Internet professional information portal, to participate in a survey. To identify frequent users of e-mail, we asked``In a typical day, please estimate the average number of e-mails you and your immediate staff receive from patients who are currently in your care.'' Additional questions assessed common clinical topics in e-mail, physician's adherence to published guidelines from the AMA and American Medical Informatics Association, and physician satisfaction, measured by``Would you recommend to a colleague use of e-mail with patients.'' RESULTS: Among the 1,325 physicians responding (including individuals from all 50 states), we identified 204 frequent users who received one or more e-mails from patients daily. The mean age was 49 years, 82% were male, and 35% were primary care providers. Participants were from a variety of specialties including adult medical subspecialties(9%), pediatrics(11%), surgery(11%), and psychiatry(7%). Common clinical topics, received frequently or sometimes by over 40% of physicians, include: non-urgent new symptoms, questions about lab results, and questions about information on the Internet. Although infrequent, 7% of our sample did report frequently or sometimes receiving e-mails about urgent issues such as chest pain. The most common practice adherent with published guidelines was including the e-mail in the medical record (38%), but they rarely incorporated other guideline issues such as educating patients about appropriate topics (10%). Despite daily use of e-mail with patients, 25% of the 204 were not satisfied. Physicians who were not satisfied more frequently (80%) reported``patient request'' as the most important reason for using e-mail, compared with those who were satisfied (39%). (p < 0.01). Compared with dissatisfied physicians, physicians who were satisfied with e-mailing patients more frequently noted a decrease in their amount of telephone medicine (29% versus 2%; p < 0.001), and were more likely to use the emails to educate their patients (25% versus 14% p < 0.01). CONCLUSION: Experiences of these``vanguard'' physicians were mixed. Although patient demand is high, physician satisfaction of e-mail with patients may also be important to sustained use of e-mail with patients. Our data suggest that increased dissemination/adherence of published guidelines and increased perception of the efficiency of e-mail communication may improve acceptance. PURPOSE: Continuity of care is a highly desirable characteristic that may be threatened by recent changes in the health care system. We sought to assess patients' perceptions of continuity of care and the relationship between continuity and satisfaction in a managed care organization. METHODS: Within a randomized controlled trial of a patient-provider matching intervention in a group model health maintenance organization (HMO), we evaluated whether subjects reported usually seeing their own primary care provider (PCP), and the association of this perception with satisfaction and trust. Between October 1999 and September 2000, 2501 (64%) subjects completed a mailed, self-administered questionnaire, one year after receiving a new PCP. RESULTS: Among patients who had seen their PCP at least once during the study period, the majority (76%) reported usually seeing their own PCP during their visits. These subjects tended to be older (58 v. 52 yo, p < 0.0001), white (75% v. 69%, p < 0.02), and had more visits during the past year to their PCP (3.6 v. 3.2 visits, p < 0.04) than subjects who reported usually seeing another provider, i.e. lacking continuity of care. Moreover, compared to subjects without continuity, subjects perceiving that they had continuity reported greater satisfaction with their PCP and the health system. For example, subjects reporting that they usually saw their PCP had significantly higher levels of satisfaction with their PCP (72% v. 38% reporting excellent or very good overall satisfaction, p < 0.0001). These subjects were more likely to recommend their PCP to others (82% v. 52%, p < 0.0001), reported greater trust in their PCP (p < 0.0001), and in the health system (p < 0.0001). In addition, these subjects also were less likely to perceive that the PCP created barriers to access, such as with specialist referrals (p < 0.0001). CONCLUSION: In short, the majority of subjects in this study perceived that they usually saw their own PCP during visits. Furthermore, the perception of continuity of care with one's PCP was associated strongly to satisfaction and trust in the PCP, and also in the health system. Further research is needed to assess the direction of this association, as well as to identify potential areas for organizational improvements. Despite a growing focus on this problem many health care organizations provide inadequate interpreter services. A principal reason is the concern that uncertain benefits do not justify the costs of adequate services. The objective of this study was to assess the impact of an interpreter service program on the utilization and cost of health care services at a staff model HMO. METHODS: We conducted a 2-year cohort study of continuously enrolled adult members of a staff model HMO where new comprehensive interpreter services for Spanish and Portuguesespeaking ambulatory patients were implemented in year 2 of the study. Two groups were studied: an interpreter service group (ISG, n = 380) consisting of members who used the new interpreter services and a comparison group (CG, n = 4119) consisting of a 10% random sample of all other members who received ambulatory care in year 2. We abstracted demographic information and utilization of primary health care services (preventive services and outpatient services) and hospital-based services (ED visits and hospitalizations) from the HMO's administrative database. We calculated the unit cost per interpretation based on the cost of the services (salaries, fringe benefits, supervision, and overhead) and reported volume of use of services. We calculated induced costs of interpreter services by multiplying the change in utilization for each health care service by its 1997 fee-for-service reimbursement rate from the Massachusetts' Division of Medical Assistance. RESULTS: Utilization of primary health care increased in both groups after implementation of interpreter services. The changes (yr2-yr1) in utilization of preventive services (p < 0.05), utilization of office visits (p < 0.01), prescriptions filled (p < 0.01) and prescriptions written (p < 0.01) were significantly greater in the ISG compared to the CG. Utilization of hospitalbased services remained the same for both groups, except for a reduction in ED use by the ISG. The change in rate of ED use (yr2-yr1) was not significant when compared to the CG. However, relationships between patient satisfaction and other performance measures are poorly studied. The goal of this study was to examine the relationship between patient satisfaction and severity-adjusted mortality rates. METHODS: The current study used data from a regional initiative to measure performance in 31 hospitals in Northeast Ohio during 1991 ± 1995. Satisfaction was assessed using the Patient Judgement System, a 41 item survey mailed to patients after discharge. Responses were obtained from 40,344 medical patients (response rate 48%). We utilized 5 scales (physician care, nursing care, coordination of care, information provided, and discharge instructions) and 1 single item assessment (overall quality). For each hospital, mean scores were determined, adjusting for self-reported health status, age, gender, education and other demographic factors. Severity-adjusted mortality was determined for patients with 6 medical diagnoses. For each hospital, observed mortality was compared to predicted mortality derived from validated disease-specific multivariable models that were based on data abstracted from medical records. Comparisons of observed and predicted mortality rates were summarized using the z-statistic. RESULTS: Mean satisfaction scores for the 5 scales and 1 single-item indicator ranged from 68.0 (information provided) to 72.6 (physician care). Z-statistics for mortality rates ranged from -7.6 to 4.6. In analyses including data for all 5 years (1991 ± 95), patient satisfaction scores, at a hospital level, were inversely correlated with mortality for each of the 6 measures of satisfaction. from each group who met these criteria: > half-time practice for the last 2 years, > 40% minority patients, and providing primary care of HTN. The 2-hour sessions with 2 ± 4 observers were audiotaped. A facilitator elicited comments and discussion on JNC6 recommendations, perceived barriers, efficacy of traditional guideline interventions, and recommended solutions for future HTN care. One investigator analyzed tapes for emerging themes and concepts. The resulting summaries were distributed to the research team to discuss alternative interpretations. All focus group observers did a final reading of the summary to confirm the validity of the themes and conclusions. RESULTS: Similar themes emerged in the two groups. Physicians felt the JNC6 recommendations were realistic but that physician behavior was not the problem with implementation. Physicians outlined the barriers to optimal control of HTN: poor office systems for tracking care, inability to address lifestyle modification in office visits, impracticality of self-monitoring, the disincentive of co-pays, lack of generic samples for cost-effective prescribing. There was no interest in traditional physician directed interventions such as seminars, academic detailing, incentives for chart review to change therapy, pocket or wall versions of the guidelines, or practice profiling. Physicians suggested making monitoring more practical, providing generic samples, and utilizing group appointments, pharmacies, the internet, and ethnically sophisticated mass-media campaigns for patient education. CONCLUSION: Physicians agreed with the goals and recommendations of the JNC6 HTN guidelines but felt that existing efforts to improve guideline compliance by changing their behavior are bothersome and ineffective. They suggest intervening with the patient to address barriers outside the control of their practices. Future research should examine patients' perceptions of the acceptability and efficacy of these interventions. METHODS: This retrospective cohort study evaluated consecutive ICU admissions to a VA hospital (n = 1,142) and 27 private sector hospitals (n = 51,249) serving the same health care market in 1994 ± 95. Mortality and ICU LOS were adjusted for severity of illness using APACHE III, a validated method that considers age, comorbidity, ICU admission diagnosis, admission source, and abnormalities in 17 physiologic variables during the first 24 hours of ICU admission. We used two multivariable statistical methods to estimate the risk of death in VA patients, relative to private sector patients. 1) Logistic regression provided the odds of inhospital death in VA patients. 2) Cox proportional hazards regression was used to account for potential differences in LOS and in the timing of death by censoring patients at the dime of discharge. RESULTS: Unadjusted in-hospital mortality was higher in VA patients (14.5% vs. 12.0%; p = .01), as was hospital (28.3 vs. 11.3 days; p < .001) and ICU (4.3 vs. 3 .9 days, p < .001) LOS. Using logistic regression to adjust for admission severity of illness, the odds of death was similar in VA patients, relative to private sector patients (OR 1.16, 95% C.I. 0.93 ± 1.44; p = .18). However, a higher proportion of VA deaths occurred after 21 hospital days (33% vs. 13%; p < .001). Using proportional hazards regression, the risk of death was actually lower in VA patients (hazard ratio, 0.70, 95% CI, 0.59 ± 0.82; p < .001). This result was consistent in stratified analyses of medical (hazard ratio, 0.80, p = .02) and surgical (hazard ratio, 0.46, p = < .001) patients. After adjusting for severity using linear regression, differences in ICU LOS were no longer significant (p = .19). CONCLUSION: Severity-adjusted mortality in ICU patients was lower in a VA hospital than in private sector hospitals in the same health care market, based on proportional hazards regression. This finding differed from logistic regression analysis, in which mortality was similar. This difference suggests that comparisons of hospital mortality between systems with different hospital utilization patterns may be biased if LOS is not considered. Moreover, if generalizable to other markets, our findings suggest that ICU outcomes are at least similar in VA hospitals compared to private sector hospitals. BACKGROUND: The evidence to support colorectal cancer (CRC) screening has become definitive though it is well known that most adults do not receive the screening that is recommended. METHODS: We merged patient self-report data from 1998 for respondents > =50 years (n=20,199) with surveys of medical directors of 53 medical organizations [29 medical groups (MG) and 24 Independent Practice Associations (IPAs)] from 3 west coast states to evaluate rates of CRC screening and patient and organizational predictors of those rates. We used logistic regression adjusted for intra-organization clustering of patients within medical organizations to estimate CRC screening rates as a function of patient demographic and comorbid characteristics, receipt of care within a MG or IPA, receipt of care within an organization that uses their corporate structure to implement guidelines, tracking, or feedback of CRC screening results, and the unique identity of each of the medical organizations. RESULTS: Overall, screening rates were modest [45% for sigmoidoscopy or colonoscopy during the last 5 years (SIG), 43% for fecal occult blood tests by the patient at home (FOBT), 64% for either SIG or FOBT, and 24% for both]. Screening rates varied by demographic characteristics. After adjustment for comorbidity, use of any CRC screen was significantly lower for females (OR 0.69 *** ), Asians (OR 0.73 *** ), Hispanics (OR 0.86 * ), and those from other nonwhite race (OR 0.76 * ); screening rates were higher for African Americans (OR 1.3 ** ). Respondents receiving care in IPAs reported less screening than those in MGs (OR 0.83 * ) after adjustment for patient characteristics as well as use of guidelines, tracking and feedback pertinent to CRC screening, and clustering of patients within organizations. In addition to the amount of variation in CRC screening explained by patient characteristics alone, receipt of care in a MG or IPA and corporate policy for use of guidelines, tracking or feedback for CRC screening explained 8% of the unique variation in CRC screening rates, while the unique identity of the 53 medical organizations explained 51% of the unique variation. CONCLUSION: Although there is no clinical reason demographic characteristics should influence rates of CRC screening, they do. In addition to demographics, the corporate structure of the medical organization is associated with rates of patients receipt of CRC screening such that screening occurs more frequently within MGs than IPAs. Even after adjustment for patient characteristics, the use of guidelines, feedback, and tracking of guideline performance, and whether the patient received care in a MG or IPA, most of the variation in screening is explained by the unique identity of their medical organization. PURPOSE: State medical associations may choose to participate in public debates surrounding physician-assisted suicide (PAS). However, physicians lack consensus on the ethics of PAS and its legalization. We examined physician attitudes about PAS and the prospects for consensus regarding its legalization. METHODS: Anonymous questionnaires were mailed to all (1456) members of the Connecticut Chapter, ACP-ASIM. The survey instrument measured attitudes toward PAS; consensus on health policy issues generally; participation in public discussions about PAS; prospects for consensus on its legalization; demographic data including age, gender, experience caring for terminally ill patients, religious affiliation, and religious service attendance. The proportion of foreign-born residents in the United States is at its highest point in over 100 years. Provision of interpreter services for non-English speaking patients is now a federal requirement and general internists will need to use interpreters to care for these patients. We surveyed clinicians in three academic generalist practices to describe how interpreters are being used. METHODS: We surveyed all of the primary care internists and nurse practitioners (n=194) in three academic outpatient settings in San Francisco regarding their most recent patient encounter which involved an interpreter. Questionnaires were self-administered and took about 10 minutes to complete. RESULTS: 158 questionnaires were completed (81% response rate). Among the respondents, 53% were women, 64% White, 66% residents, 78% spoke and understood a language other than English, and 60% had some prior training regarding working with interpreters. Reflection of the most recent patient encounter requiring an interpreter showed that 67% used professional interpreters, 49% felt that not enough time was allotted for the appointment, 90% felt satisfied that they had accomplished their own goals during the encounter, and 83% felt satisfied that the patient had accomplished his/her goals. Most respondents (78%) were very satisfied or satisfied with the medical care they provided, 85% felt satisfied with their ability to diagnose a disease and treat a disease, but only 45% were satisfied with their ability to empower the patient with knowledge about their disease, treatment or medication. Even though 71% felt they were able to make a personal connection with their patient, only 33% felt they had learned about another culture as a result of the encounter. Clinicians had trouble eliciting exact symptoms (70%), explaining treatments (57%), and eliciting treatment preferences (51%). Almost half (45%) felt that too much time was spent on translation. A majority of clinicians perceived that lack of knowledge of the patient's model of disease and lack of knowledge of the patient's culture hindered their ability to provide quality medical care. However, only 18% felt they were unable to establish trust or rapport. CONCLUSION: Although most clinicians feel good about their encounters with patients in which they utilize an interpreter, many of them have received no training regarding that use, and their ability to elicit information, convey information, understand the patient in his/her cultural context, and empower the patient with regard to his/her own healthcare appears to be compromised. We conducted a controlled trial of a guideline-derived intervention, which included 3 components: 1) training of clinic nurses and medical assistants to use a modified vital signs stamp in identifying and counseling smokers at each visit, 2) feedback to clinic staff on performance of AHRQ guideline-recommended activities, and 3) proactive telephone counseling by a smoking cessation counselor (2 sessions) and free nicotine replacement therapy (NRT) for all pts who indicated willingness to make a quit attempt within 30 d of their clinic visit. After a period of baseline data collection (8/99 ± 1/00), the intervention was implemented at 1 pilot family practice (FP) clinic (2/00 ± 3/00); patterns of usual care were observed concurrently at 5 control FP clinics. We obtained exit interviews of consecutive adult smokers who presented for routine, non-emergency care. Abstinence (no cigarettes over prior 7 d) and quit attempts were determined by telephone interview during 6 mo follow-up. Odd ratios (OR) were computed for each outcome. RESULTS: There were no significant differences in demographic or smoking variables between baseline and intervention pts, 87 and 85% of whom completed 6 month follow-up. Concordance with guideline recommendations at the clinic visit and quit status are shown below ( * p < 0.05). For comparison, the 6 mo quit rate for pts at control clinics during baseline and intervention periods was 12 and 10%, resp. 37% of intervention group pts received telephone counseling plus NRT. CONCLUSION: Effective reduction of tobacco use requires redesigning health care systems to increase the identification of smokers and the delivery of smoking cessation advice in a timeefficient manner. The 9% absolute difference in 6 mo quit rates associated with this nursebased, primary care intervention is comparable to that observed in clinical trials of NRT. Cleveland between 1991 and 1997. Patient level data were obtained through the Cleveland Health Quality Choice (CHQC) program; mortality was obtained by linking CHQC data with MEDPAR files. Pneumonia was identified from secondary ICD-9-CM codes. Cox regression analysis was used to estimate the effect of pneumonia on mortality up to 30 days from admission after adjusting for severity of illness using a model of 30-day predicted mortality from admission data (c-statistic = 0.78). Patients dying or having a``Do Not Resuscitate'' order within 3 days of hospitalization were removed a priori from the regression analysis to focus on those for whom avoiding pneumonia was most pertinent. RESULTS: Pneumonia occurred in 6.9% (n = 985) of all patients hospitalized for acute stroke. There was a significantly higher incidence in patients: with hemorrhagic stroke (11.5% vs 6.3%,p < .001), men (9.0% vs 5.4%, p < 0.001), from nursing homes (11.4 vs 6.4%,p = 0.001), aged > 74 (7.2% vs 6.3%, p = 0.032), and with greater severity of illness on admission (predicted 30-day mortality 24.8% vs 13.2%, p < 0.001). Average length of stay for patients with pneumonia was 16.2 0.44 days compared to 7.5 0.05 days in patients without pneumonia (p < 0.001); fewer patients with pneumonia were discharged to home (12.0% vs 41.4%, p = 0.001). Crude 30-day mortality rates were 37.4% for patients with pneumonia and 13.0% for those without (p < 0.001). There was a steady increase in the adjusted hazard ratio for death among stroke patients with pneumonia throughout the 30-day period; adjusting for admission severity, the hazard ratio for death within 30 days was 4.31 (95% C.I. 3.55 ± 5.23). CONCLUSION: In this largest community-wide study of stroke complications, pneumonia conferred significantly higher severity-adjusted hazard for mortality within 30days of admission and was associated with dramatically longer lengths of hospital stay and reduced chances of discharge to home. Measures to reduce the incidence of pneumonia following stroke are warranted to reduce morbidity, mortality, and cost. , and personal experience with BRCA. The dependent variable, a sum score of attitudes towards BRCAS, was calculated such that a higher score indicated a more favorable attitude towards screening. Univariate and multivariate analyses with backwards ± stepwise regression assessed the relationship between the dependent and independent variables. RESULTS: The response rate for the survey was 82% (N = 140 responses); 120 physicians provided complete data for analysis. Of these physicians, 62% were male, 60% were under 30 years old, 12% worked in a private office, 42% worked in a health center, 46% worked in an outpatient setting, 38% had some personal experience with BRCA, and 68% had some professional experience with BRCA. In both univariate and (multivariate) models professional experience p = 0.006 (0.03) was associated with a more favorable attitude concerning BRCAS, but age p = 0.10 (0.54), gender p = 0.54 (0.59), practice type p = 0.23 (0.62), and personal experience 0.54 (0.37) were not. CONCLUSION: Prior professional experience of the physicians, but not demographic or personal variables, was significantly related to a favorable attitude towards BRCAS. Our data differs from previous studies, which found that BRCAS may be influenced by physician characteristics like age, gender, practice type, and personal experience. Increasing awareness through the education of physicians has been a focus of many efforts to increase the incidence of screening for BRCA. If professional experience is associated with a favorable attitude towards BRCAS, then medical trainees should be exposed to environments where BRCAS is a high priority in an effort to increase BRCAS in women. (4.4 ± 29.4, 95%CI) . Most commonly cited missing elements that were needed included current notes types that were not online (33%), notes predating the system (20%), EKGs (16%), and vital signs (12%). On the same Likert scale, 75% agreed that they could give up the traditional paper chart in favor of the mobile computer. CONCLUSION: Overall, internal medicine residents responded positively to the implementation of the mobile CPRS system. Based on surveys and computerized order logs, all residents voluntarily used the devices to enter nearly half of orders over available desktop computers. Reported difficulties with the technologies did not appear to significantly affect the mobile computer users ordering pattern, suggesting that the technical problems were limited and the technology was robust. Finally, feedback from this study was sufficiently positive to justify implementation to all internal medicine teams. After one year, we assessed their impact on patient length of stay as well as resident education and service from the viewpoint of both medical residents and community physicians. METHODS: Two clinician educators were hired to provide inpatient attending medical care and resident education, including 1:1 intern mentoring. Length of stay data was calculated for Medicaid and self-pay patients based on DRG groups where > 50% of patients were admitted to the clinician educator service and was compared to data on the same patient mix from the preceding year. Categorical medicine residents (N=36) were given an anonymous survey assessing the clinician educators' impact on resident education and service, including resource utilization and resident roles. Community internists (N=150 on staff, 100 who actively use hospital) also received an anonymous survey assessing their perceptions of hospitalist medicine and the clinician educators' impact on housestaff behavior. RESULTS: Length of stay: LOS was reduced from 5.3 to 4.4 days comparing the last 6 months of the clinician educators' first year with the last six months of the previous year. Reductions in LOS > 1 day were found with GI, pulmonary, infectious disease, endocrine and neurology admissions and 1/3 of a day for cardiology admissions. Resident survey: Return rate was > 90% with all residents noting improvement in the quality of attending rounds, bedside teaching and the overall inpatient experience. Increased use of evidence based medicine resources was noted by 90%. Residents' roles as teachers and team leaders were increased or unchanged for over two-thirds and none felt they had been reduced to unacceptable levels. A potential influence on these behaviors is the availability of pharmaceutical samples. A prospective blinded study was designed to evaluate this influence in an academic clinic. METHODS: The antibiotics in the drug closet of our teaching clinic were manipulated over 20 consecutive weeks. The following changes were made at 4 week intervals: 1) removal of all antibiotics, 2) removal of macrolides, 3) removal of quinolones, 4) removal of cephalosporins, 5) removal of amoxicillin/clavulanate and nitrofurantoin. Upon completion of the study, a chart review was conducted to identify acute infectious illnesses for which an antibiotic was likely to be prescribed. Datapoints collected include: clinical diagnosis, antibiotic prescribed, postgraduate year (if a resident), date of service, and patient's gender and age. Fishers Exact 2-sided tests were performed to determine whether the presence of antibiotics in the closet influenced their frequency of use. RESULTS: 465 encounters fulfilled our inclusion criteria. 77% of these encounters led to an antibiotic prescription. Of these, 73% had an antibiotic prescribed that could be found in the drug closet. Defining the relative risk as the risk of being prescribed a specific antibiotic if it was available in the closet versus if it were not, the relative risk ratios (RR) with their associated 95% confidence intervals (CI) for each class of antibiotics are listed in the following table. CONCLUSION: The prescribing practices of clinicians in our academic clinic do not appear to be directly influenced by the availability of antibiotic samples in a drug closet. Although a direct relationship between the drug closet and the prescribing practices of clinicians was not observed, it is notable that 73% of all prescriptions were for antibiotics that could be found in the drug closet. This still suggests that pharmaceutical marketing exerts an influence on clinician antibiotic prescribing practices. is important that primary care physicians be aware of the safety of drugs in pregnancy given to nonpregnant women, as well as the effect of common medical problems in pregnancy. For the same reasons, it is also important that counseling and prevention of risk factors known to affect pregnancy outcome occur prior to conception. The purpose of this study was to assess the knowledge and practice of preconception care by primary care attending physicians. METHODS: All primary care attending physicians in general internal medicine and family practice at our institution were given a written survey regarding their knowledge and practice of preconception care. Knowledge questions assessed were 1) safety of medication use in pregnancy 2) risk associated with diabetes in pregnancy, and 3) the rate of unplanned pregnancies and estimated gestational age at presentation to a pregnancy provider. Practice questions included counseling of the nonpregnant patient regarding 1) the hazards of smoking, alcohol and illicit drug use 2) folic acid supplementation, 3) rubella screening, and 4) the effect of chronic medical disorders were pregnancy to occur. Surveys were mailed. Responses were kept anonymous and a number was used to identify participants. RESULTS: Of 25 surveys mailed, 21 were returned. Analysis was done of the returned surveys. 80% of responding attending primary care physicians were aware that 50% of women present to their pregnancy provider after organogenesis and that similar rates of pregnancies are unplanned. 45% counseled women with substance abuse of potential effects on pregnancy, 40% recommended folic acid use, and 10% screened for rubella. 55% counseled women with chronic disease of deleterious effects on pregnancy. Safety of medications in pregnancy were correctly identified by 35% for pain relievers, 45% for antibiotics, 25% for asthma medications, and 10% for antihypertensives. Only 45% of providers were aware of the risk associated with diabetes in the first trimester. No statistical difference using Chi Square analysis was found when the results were computed by the sex of the provider or by primary care specialty, possibly due to the small sample size. CONCLUSION: Despite the knowledge that women often do not plan pregnancy and do not present to a pregnancy provider early enough to prevent the toxic effect of medications, chronic medical disorders, or personal behaviors, the majority of primary care providers were not knowledgeable regarding preconception care and did not incorporate it into the continuing care of women of childbearing age. PURPOSE: The quality of care provided to patients hospitalized for heart failure has been shown to vary by physician, hospital and region. Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. While hospitalists appear to reduce costs and length of stay, their impact on quality of care is less certain. We sought to compare the quality of care provided to patients with heart failure by hospitalists and nonhospitalist physicians. METHODS: We conducted a retrospective medical record review at a 550 bed communitybased teaching hospital in Massachusetts that is home to 3 hospitalist groups as well as numerous small group practices that provide care for their own hospitalized patients. We identified all patients cared for by hospitalists and by non-hospitalist general internists who were discharged with an ICD-9-CM principal diagnosis of heart failure between 4/1/99 and 3/30/00. We evaluated quality of care by measuring adherence to a set of process measures derived from the JCAHO's``Core Measures Set'' and HCFA's Health Care Quality Improvement Initiative. PURPOSE: There has been an increasing amount of research in the area of religion and spirituality and its effect on patient care and health outcomes, but how this should be incorporated into physicians' practice has been an area of debate. We evaluated the extent to which general internal medicine residents and faculty acknowledge a personal belief in spirituality and religion; and to what degree internists feel it is appropriate to incorporate religion and spirituality into health care. METHODS: A twelve-item survey of the general internal medicine residents and faculty at Wake Forest University. RESULTS: 87/112 physicians responded (response rate 77% of residents and 82% of faculty), and an impressive majority (90%) of respondents professed a belief in God or other higher power. 82% considered themselves to be religious or spiritual. An overwhelming 92% felt that patients' beliefs can influence their health. 71% agreed that it would be helpful to inquire about patients' religious/spiritual concerns relating to their health. However, less than half (47%) of respondents felt there is a role for direct physician involvement in meeting patients' religious or spiritual needs, and even less (43%) had actually been directly involved in patients' spiritual care. CONCLUSION: A vast majority of respondents profess their own personal religious and spiritual beliefs, and feel that religion and spirituality can have a positive effect on health outcomes. Yet only a minority feels that doctors should actively pursue any action in this area, and even fewer have actually done this. This is a striking disconcordance between physician attitude and action. Given the growing amount of evidence that suggests religion and spiritual factors can affect health outcomes, efforts should be made to determine what barriers lie between these attitudes and actions, and improve physician education on how to approach these important patient-centered issues. PURPOSE: HMOs' financial incentives to restrict medical care have generated public concern about the quality of care they provide. Public disclosure of quality of care data might improve public accountability, enhance informed consumer decision making and promote quality