CARDS. P.D. Faris 1 , W.A. Ghali 1 , R.F. Brant 1 ; University of Calgary, Calgary, Alberta PURPOSE: In health outcome report cards comparing providers for binary outcomes such as mortality, a commonly used method of profiling providers is to use risk factor data from patients treated by the providers to construct logistic regression models. Such models are then used to obtain the expected number (E) of outcomes for each provider and the ratio of observed (O) to expected outcomes (O/E ratio) is used as a risk-adjusted measure of provider performance. To account for chance variation and to determine``outlier status'', confidence intervals (CI's) derived from standard deviations are placed around the O/E ratios. Here we compare two methods for calculating standard devations (SD's) and CI's. The typically used method is compared with a more complex method based on the propagation of errors (PE). METHODS: Typically, when calculating the variances and SD's of O/E ratios, only O is treated as a random variable, and variability in E is ignored. A variance estimate treating both O and E as random variables was derived using the propagation of errors (PE) method. The resulting PE-SD estimates were compared with typical SD estimates using a data set (N = 50,357) previously employed to profile CABG providers in Canada. O/E ratios were used to profile three levels of hospital patient volume (low, medium, high), 8 provinces, and 23 hospitals. For each O/E ratio, the ratio of the typical SD to the PE-SD was used to evaluate the relative sizes of the SD estimates. In addition, computer simulations based on a hypothetical data set with three providers were used to evaluate the SD estimates. Measures of performance included empirical coverage and bias. RESULTS: For the CABG data profiles, the ratios of the typical SD's to the PE-SD's were 1.04, 1.65, and 1.23 for the low, medium and high volume hospitals, respectively. For 7 of 8 provinces, the ratios of the SD's were only marginally larger than 1. However, for the province treating the largest proportion of patients (52%) the ratio was 1.40. For the 23 hospitals, the largest SD ratio was 1.09. The computer simulations confirmed that the typical SD's were less accurate than the PE-SD estimates, and the coverage probabilities indicated that confidence intervals based on the typical SD's are too wide. CONCLUSION: The typically used SD estimates and CI's were always larger than the PE-SD estimates that accounted for variability in E. The bias in variance and SD was greatest when one or more providers treated a large proportion of the patients. When only a few providers are being compared, or when some providers treat a large proportion of the patients, the use of typical SD's may lead to incorrect conclusions regarding the outlier status of providers. PURPOSE: Language concordance between physicians and patients is associated with greater patient satisfaction. However, it is not known what level of physician Spanish language competence is important to Spanish speaking patients. We used four measures to test the association between physician Spanish ability and the probability of these physicians having Spanish speaking patients in their practice. METHODS: Primary care physicians for Spanish and English speaking diabetics from eleven public health clinics completed a questionnaire containing four questions about Spanish language competence: 1) self-rated fluency 2) use of interpreters 3) confidence in conducting an H&P 4) confidence in discussing complex topics. We used chi-squared to test the association between measures of physicians' Spanish competence and the proportion of Spanish speaking patients in their practice. RESULTS: 105 MDs caring for 365 Spanish and 1023 English speaking diabetics participated. 17 (16%) MDs rated their Spanish fluency as excellent and they cared for 144 (40%) of monolingual Spanish speaking patients. Conversely 27 (26%) of MDs rated their fluency as poor or none and they cared for 26 (7%) of Spanish speaking patients. MDs whose self-rated Spanish was excellent, good, or fair were much more likely to treat Spanish speaking patients than those whose Spanish was self-rated as poor or none (OR 3.5, CI 2.3 ± 5.3) . Similarly, MDs who never, rarely, or occasionally use an interpreter were more likely to treat Spanish speaking patients than those who usually, or always use an interpreter (OR 3.8, CI 2.6 ± 5.4) . The two additional questions assessing clinican confidence in conducting a Spanish patient history or carrying out a complex discussion were less predicitive of treating Spanish speaking patients. CONCLUSION: While factors other than patient preference may affect the distribution of patients, our study demonstrates that a brief physician questionnaire can discriminate degrees of language competence that appear meaningful to patients in selecting their physician. University of California, San Francisco, CA PURPOSE: Prior research has shown that old age and chronic conditions such as congestive heart failure are associated with multiple admissions of patients to the medical wards of community hospitals. Risk factors associated with multiple admissions to public hospital wards are unknown, though poor access to primary care is known to be associated with preventable hospitalizations. We studied the demographic, medical, and utilization patterns of high utilizing patients of an urban public hospital to determine risk factors for multiple admissions. METHODS: Using an administrative data set, we obtained data on patient demographics, inand out-patient utilization, and in-patient and out-patient billing diagnosis on all patients discharged from a public hospital medicine/cardiology service between 7/97 ± 6/98. Patients with 3 or more discharges in a one-year interval were defined as high utilizers (HU). We used chi square to test differences between high utilizers and non-high utilizers (NHU) in utilization of emergency room and primary care services in the year following the index discharge, in diagnosis and in demographic characteristics. RESULTS: 3562 patients had 5573 discharges in the study period. 465 patients (13%) were HU who accounted for 35% of discharges, and 36% of hospital bed-days. Compared to NHU, HU were slightly more likely to be male (71% vs. 66% p = 0.02) and more likely to be African American (46% vs.30% p = 0.001) They were no different in age. HU had more visits to primary care clinics (mean 5.72 vs.2.5 p = 0.01), to the emergency department (mean 4.38 vs.2.5 p = 0.01) and to any network clinical site (median 24 visits vs. 5 visits p = 0.001). HU had more congestive heart failure (21% vs.12% p = 0.01), AIDS (30% vs.14 p = 0.01) and COPD (21% vs. 13% p = 0.02). HU were much more likely to abuse alcohol (47% vs.25% p = 0.01) or drugs (58% vs 30% p = 0.01) or either alcohol or drugs (71% vs. 42% p = 0.01). CONCLUSION: High users of urban medical wards in a clinical system with good access to primary care have high rates of use of primary care services. Our data suggests that interventions to reduce multiple hospitalizations in urban public hospitals need to integrate substance abuse services to traditional disease management programs. Indicator  Benchmark  50th Percentile  10th Percentile  Influenza  64  50  29  Pneumococcal  55  43  30  Mammograms  80  68  51  Eye examinations  88  81  69  HgbA1c  96  88  61  Lipid profile  80  57 PURPOSE: Heart Failure (HF) is a leading cause of hospitalization and re-admission in most hospital systems. Multidisciplinary``Discharge Transition'' programs aimed specifically at the education and close follow-up of HF inpatients have been evaluated in a number of relatively small randomized controlled trials (RCTs). This is the first meta-analysis to evaluate the effectiveness of peri-discharge, multidisciplinary HF patient management programs. METHODS: Electronic database searches were conducted on MEDLINE, HealthSTAR and EMBASE. Reference lists of identified articles and experts' opinions were also reviewed. All potentially relevant articles were obtained. Study selection criteria were: (1) RCTs of adult inpatients hospitalized for HF enrolled at the peri-discharge transition period; (2) HF-specific patient education intervention coupled with a post-discharge follow up assesment; (3) Primary outcome of unplanned all-cause readmission secondary outcomes of mortality, compliance and quality of life. Study inclusion and quality assessment using a modified Jadad Scale were independently assessed by all four authors. Agreement was rated by a weighted Kappa and final decision agreed upon by consensus. RESULTS: A total of 529 citation titles were identified: 199 from MEDLINE; 148 from HealthSTAR; 162 from EMBASE and 20 from personal files, reference lists, or communication with experts. Of these, 94 were deemed potentially eligible for pre-test selection. Two research trials in progress were identified and interim data obtained from the principal investigators. The four reviewers selected 10 papers and two studies``in progress'' for inclusion in the overview. The Kappa agreement statistic for multiple reviewers was 0.73 (SE 0.09). One study was subsequently excluded because it represented an earlier publication of the same trial, and another study was excluded because of substantial heterogeneity in methods, patient population and results. PURPOSE: Depression typically presents in a medical rather than mental health setting. VA and non-VA settings may differ in physician characteristics, training opportunities, and organizational factors. We sought to assess VA and non-VA medical physicians' recognition and treatment of depression. METHODS: We selected a random sample of VA and non-VA primary care physicians and medical specialists practicing in the Northeastern United States. Physicians viewed a 5 minute, professionally produced video of a patient with somatic symptoms, who described 5 symptoms meeting clinical criteria for major depression. After viewing the video, physicians answered interviewer-administered questions about differential diagnosis and management recommendations. Because of the experimental design, every physician reviewed identical clinical data, permitting direct comparisons of physicians' diagnostic reasoning and management approaches. Physicians also viewed two``control'' scenarios (a patient with chest pain and a patient with polymyalgia rheumatica), further masking the key study purpose.