GAMING THE SYSTEM -PUBLIC PREFERENCES THAT DOCTORS PLAY? G. Alexander 1 , R. Werner 1 , A. Fagerlin 2 , P. Ubel 2 ; 1 University of Pennsylvania, Philadelphia, PA; 2 Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI PURPOSE: Efforts to contain rising costs have lead third party payers to restrict access to some healthcare services. Previous research suggests that the``hassle'' of the appeals process influences physicians' sanctioning of deception to obtain medically necessary services. However, little is known about whether the public supports such deception, and if so, whether this support is sensitive to the burden of the appeals process. METHODS: A clinical vignette was administered to 700 jurors and to a randomly selected national sample of 1617 physicians. Vignettes differed by condition severity (severe angina vs. moderate low-back pain), likelihood of successful appeal (95% vs. 50%), and length of appeals process (5-10 minutes vs. 1 hour). Participants were asked whether in response to a restriction on medically necessary healthcare the doctor in the vignette should (1) appeal the restriction, (2) accept the restriction, or (3) misrepresent the facts in order to obtain the desired service. RESULTS: Overall, the public was more likely than physicians to sanction deception (26% vs. 11% respectively, p < .001), and less likely to support accepting (4% vs. 12%, p < .001) or appealing (70% vs. 77%, p < .001) the restriction. Sanctioning of deception was greater among the public than physicians regardless of the vignette used. The public's support of misrepresenting (vs. appealing) was greater with a lower likelihood of successful appeal (Odds ratio [OR] 1.67, 95% confidence intervals [CI] 1.18, 2.37) but was not significantly related to the length of appeals process (OR 1.10, 95% CI .78, 1.55). Among physicians, the likelihood of sanctioning deception was significantly greater with both a lower likelihood of successful appeal and a longer length of the appeals process. CONCLUSION: Sanctioning of physician deception is even greater among the general public than among physicians, and unlike physicians, the public's support of deception is not sensitive to the length of the appeals process. Patients' preferences regarding deception of insurance companies may further pressure physicians who struggle to balance the tension between patient advocacy and honesty. There was no difference in the two groups in the percentage of patients discharged to Skilled Nursing facilities or to home with home health. However, for the patients needing SNF placement there was increased LOS for Friday admissions (mean LOS: Fri 4.7, Mon 3.7; p = 0.03). Similar trend was present for patients needing HH but did not reach statistical significance (mean LOS: Fri 4.4, Mon 4.0, p = 0.20) . There was no difference in mortality (% Expired: Fri 1.22%, Mon 1.88%; p = 0.45). Analysis of the yearly trend revealed decreasing cost and LOS through the four years, but the Mon-Fri difference was maintained. CONCLUSION: Patients admitted on Fridays have higher costs and LOS, despite similar case mix. They have more labs and diagnostic radiology testing done. They are admitted under`O bservation'' status less frequently and spend more time in observation. They wait longer for placement. Despite recent successes in decreasing cost and LOS, weekends continue to play a significant role in the cost of healthcare. Further reduction in cost will require attention to the factors we have identified including reduction in diagnostic testing and more efficient discharge planning over the weekend. this study was to determine the correlation between risk-adjusted hospital rates and rankings for postoperative mortality, postoperative pneumonia (POP), and respiratory failure (RF). METHODS: Cases were selected from those who underwent major noncardiac surgery at 44 VA hospitals participating in Phase I and II of the National VA Surgical Quality Improvement Program. Postoperative mortality was defined as death within 30 days postoperatively. POP was defined as a positive sputum culture with antibiotic treatment or an infiltrate on chest x-ray diagnosed as pneumonia or pneumonitis following surgery. RF was defined as mechanical ventilation greater than 48 hours postoperatively and/or reintubation and mechanical ventilation subsequent to postoperative extubation. Separate logistic regression models predicting mortality, POP, and RF were developed using Phase I cases (10/91 ± 12/93) and validated using Phase II cases (1/94 ± 8/95 PURPOSE: Due to a number of factors, many clinicians have experienced a decline in their income over the past few years. To compensate for this decline, some physicians have chosen to supplement their income through means not associated with their primary practice of medicine (e.g. drug trials, speaking engagements, malpractice case review, product sales). This is the first study to qualify and quantify the extent of participation in such supplemental income-generating activities (SIGAs). METHODS: We conducted a cross-sectional mailed survey of 1000 Maryland members of the American College of Physicians to determine the frequency of participation in various SIGAs. Members were sampled sequentially with a random start. The survey consisted of 24 items designed to collect information on demographics, practice patterns, income variables, and participation in nine different SIGAs. We used Chi-square analysis to determine whether relationships existed between personal and professional characteristics and involvement in SIGAs. RESULTS: After the first two mailings, our response rate was 40%. Sixty-three percent of those surveyed reported engaging in at least one SIGA. The three most common activities noted by these physicians are shown in the table below. Statistical analysis suggested a significant association between participation in SIGAs and male gender, married status, age between 41 and 50, having dependents, dissatisfaction with income, urban or suburban practice setting, and medical subspecialization. CONCLUSION: Physician participation in income-generating activities outside of their primary medical practices is widespread, perhaps reflecting an increase in financial pressures caused by decreasing reimbursements and managed care limitations. The impact of time diverted from the primary practice of medicine on continuity of care, as well as the ethical issues surrounding the enrollment of patients in clinical trials, the sale of medical and/or non-medical products from the office, and physician relationships with the pharmaceutical industry needs to be further examined. PURPOSE: Transthoracic echocardiograms (TTE) are frequently ordered by generalists to assess a heart murmur or screen for valvular heart disease. Little is known about interobserver agreement (IOA) in diagnosing aortic insufficiency (AI)or stenosis (AS)by TTE. The limited studies done have suffered from one or more of the following: 1) verification bias, 2) small sample size, 3) limited generalizability as observers were given a specific interpretation protocol and 4) possible Hawthorne effect. Despite these features fostering IOA, some studies have reported significant lack of IOA, particularly for AI. Our submission avoids the above deficiencies and appears to be the largest analysis of IOA in the diagnosis of AI and AS by TTE. METHODS: 143 patients undergoing TTE for any indication were prospectively enrolled in a blinded study assessing components of the physical exam for diagnosing AI. The TTE, incorporating color and continuous flow Doppler analysis, were performed by an experienced technician and officially read by one of three staff cardiologists. These studies were also interpreted by a blinded study cardiologist (SRB) for the presence of AI or AS. All observers were experienced in TTE interpretation and none (including SRB) were aware of each other's findings or the planned IOA analysis. No interpretation protocol was specified. SRB's findings were compared to the official readings. AI/AS was graded 0 (absent) to 3 (severe respectively. Data were not linked by respondent. The single item burnout measure used in this survey has previously been validated in this and other settings. RESULTS: Self-reported burnout increased in prevalence from 19% of the 439 respondents in 1991 to 41% of the 482 respondents in 1999 (p = .001). Between 1991 and 1999, the number of female and part time physicians increased as did the average age and organizational tenure. Burnout was higher in physicians in the middle range of tenure (6 ± 15 years) and in 1999 among physicians working part-time but was not associated with physician specialty, age, or gender. Burnout was associated with workload factors such as stress from long hours, inadequate time for patient visits, and the perception that the visit rate was too high to do a good job (p=.001).