Timothy F. Kirn

SEATTLE — Patients over the age of 80 years generally have good outcomes after routine major bowel operations, but those who have emergency surgery fare less well, Dr. Demetrios J. Louis reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Louis reviewed 138 patients over the age of 80 years who underwent major intestinal operations at Rush University Medical Center, Chicago, between 1995 and 2005. Overall, 53% of the 138 patients had surgical complications and the mortality rate was 8%.

Average rates of complications, morbidity, and mortality were much higher in those who had the emergent procedures than in those who had elective procedures: The length of hospital stay was 2.7 times longer (21 days versus 8 days), the major complication rate was more than twice as high (81% versus 35%), and the mortality rate was more than 16 times higher (32% versus 2%). The patients who underwent emergency procedures tended to have significantly worse American Society of Anesthesiologists (ASA) status.

The findings suggest that “absolute age is not a determinant in outcome” and that success in older patients is determined primarily by ASA status and the need for emergency surgery, said Dr. Louis, of the department of general surgery at Rush University.

Commenting on Dr. Louis' presentation, Dr. James Ogilvie, a Minneapolis surgeon, said, “These are not necessarily unique findings if you look at other retrospective series in cardiac, hepatobiliary, and endocrine surgery.”

SEATTLE — Patients over the age of 80 years generally have good outcomes after routine major bowel operations, but those who have emergency surgery fare less well, Dr. Demetrios J. Louis reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Louis reviewed 138 patients over the age of 80 years who underwent major intestinal operations at Rush University Medical Center, Chicago, between 1995 and 2005. Overall, 53% of the 138 patients had surgical complications and the mortality rate was 8%.

Average rates of complications, morbidity, and mortality were much higher in those who had the emergent procedures than in those who had elective procedures: The length of hospital stay was 2.7 times longer (21 days versus 8 days), the major complication rate was more than twice as high (81% versus 35%), and the mortality rate was more than 16 times higher (32% versus 2%). The patients who underwent emergency procedures tended to have significantly worse American Society of Anesthesiologists (ASA) status.

The findings suggest that “absolute age is not a determinant in outcome” and that success in older patients is determined primarily by ASA status and the need for emergency surgery, said Dr. Louis, of the department of general surgery at Rush University.

Commenting on Dr. Louis' presentation, Dr. James Ogilvie, a Minneapolis surgeon, said, “These are not necessarily unique findings if you look at other retrospective series in cardiac, hepatobiliary, and endocrine surgery.”

SEATTLE — Patients over the age of 80 years generally have good outcomes after routine major bowel operations, but those who have emergency surgery fare less well, Dr. Demetrios J. Louis reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Louis reviewed 138 patients over the age of 80 years who underwent major intestinal operations at Rush University Medical Center, Chicago, between 1995 and 2005. Overall, 53% of the 138 patients had surgical complications and the mortality rate was 8%.

Average rates of complications, morbidity, and mortality were much higher in those who had the emergent procedures than in those who had elective procedures: The length of hospital stay was 2.7 times longer (21 days versus 8 days), the major complication rate was more than twice as high (81% versus 35%), and the mortality rate was more than 16 times higher (32% versus 2%). The patients who underwent emergency procedures tended to have significantly worse American Society of Anesthesiologists (ASA) status.

The findings suggest that “absolute age is not a determinant in outcome” and that success in older patients is determined primarily by ASA status and the need for emergency surgery, said Dr. Louis, of the department of general surgery at Rush University.

Commenting on Dr. Louis' presentation, Dr. James Ogilvie, a Minneapolis surgeon, said, “These are not necessarily unique findings if you look at other retrospective series in cardiac, hepatobiliary, and endocrine surgery.”

SAN FRANCISCO — The use of fluoroquinolones, but not of proton pump inhibitors alone, was strongly associated with an outbreak of Clostridium difficile diarrhea in a hospital in the Netherlands, according to data presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

A second study that was conducted at the same hospital indicated that the outbreak was associated with C. difficile ribotype 027, a strain that appears to cause a more severe course of illness and to result in more deaths than do other strains of C. difficile.

The findings shed more light on suspicions that proton pump inhibitors and antibiotics, especially fluoroquinolones, are associated with nosocomial outbreaks of C. difficile diarrhea.

The data, which suggest that the risk of C. difficile diarrhea is not directly associated with proton pump inhibitors, also strongly implicate the use of fluoroquinolones.

Cephalosporins were used by more of the patients who developed C. difficile diarrhea during the outbreak than by those who did not develop such illness, said Dr. Norbert Vaessen of the Leiden University Medical Center, the Netherlands.

But in the statistical analysis of the case-control study of the outbreak, which occurred at St. Jansdal Hospital, Harderwijk, the fluoroquinolone association was found to be significantly stronger, Dr. Vaessen reported.

The odds ratio that someone taking a fluoroquinolone would develop C. difficile diarrhea was 15 times that of someone not on a fluoroquinolone. The odds ratio for cephalosporin use was 5.7.

The odds ratios of fluoroquinolone or cephalosporin use in controls who had diarrhea that was not caused by C. difficile were 2.2 and 0.9, respectively.

Intriguingly, in two instances, the cases no longer occurred when fluoroquinolone use was halted at the hospital, Dr. Vaessen said at the meeting, sponsored by the American Society for Microbiology.

The initial outbreak began in March 2005. Overall, the case rate at the hospital rose from 4–5 cases/10,000 admissions to 58 cases/10,000 admissions between April and September 2005.

The hospital had a total of 51 C. difficile cases between April and November. Three patients died from direct complications.

In June, the hospital instituted infection control measures and the number of cases began to fall. In July, the hospital stopped using fluoroquinolones, and almost no cases occurred in that month.

Case numbers rebounded in September when fluoroquinolone use was reinstituted, and that number fell dramatically again when fluoroquinolones were halted once more in October.

“Fluoroquinolones seemed very important, at least in this outbreak,” Dr. Vaessen said.

Proton pump inhibitors were used by a total of 47% of the case patients; however, these patients were not found to be associated with an increased odds ratio of risk in the analysis of this outbreak, Dr. Vaessen said.

The cases in Harderwijk were caused by the C. difficile ribotype 027 strain. Since about 2003, this strain has appeared with greater frequency in Canada, the United States, and Europe, according to Dr. Vaessen.

In the related presentation, Dr. Ed J. Kuijper, also of the Leiden University Medical Center, reported that confirmed cases of ribotype 027-associated diarrhea have occurred in 35 hospitals in the Netherlands. The strain also appears to have spread to Belgium and France, he said.

In Great Britain, the ribotype 027 strain has been observed in 24% of the isolates that have been tested, and it appears to have become the second-most-common strain found there.

The ribotype 027 strain has not yet been detected in cases in Spain, Turkey, or Greece, Dr. Kuijper added.

SAN FRANCISCO — The use of fluoroquinolones, but not of proton pump inhibitors alone, was strongly associated with an outbreak of Clostridium difficile diarrhea in a hospital in the Netherlands, according to data presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

A second study that was conducted at the same hospital indicated that the outbreak was associated with C. difficile ribotype 027, a strain that appears to cause a more severe course of illness and to result in more deaths than do other strains of C. difficile.

The findings shed more light on suspicions that proton pump inhibitors and antibiotics, especially fluoroquinolones, are associated with nosocomial outbreaks of C. difficile diarrhea.

The data, which suggest that the risk of C. difficile diarrhea is not directly associated with proton pump inhibitors, also strongly implicate the use of fluoroquinolones.

Cephalosporins were used by more of the patients who developed C. difficile diarrhea during the outbreak than by those who did not develop such illness, said Dr. Norbert Vaessen of the Leiden University Medical Center, the Netherlands.

But in the statistical analysis of the case-control study of the outbreak, which occurred at St. Jansdal Hospital, Harderwijk, the fluoroquinolone association was found to be significantly stronger, Dr. Vaessen reported.

The odds ratio that someone taking a fluoroquinolone would develop C. difficile diarrhea was 15 times that of someone not on a fluoroquinolone. The odds ratio for cephalosporin use was 5.7.

The odds ratios of fluoroquinolone or cephalosporin use in controls who had diarrhea that was not caused by C. difficile were 2.2 and 0.9, respectively.

Intriguingly, in two instances, the cases no longer occurred when fluoroquinolone use was halted at the hospital, Dr. Vaessen said at the meeting, sponsored by the American Society for Microbiology.

The initial outbreak began in March 2005. Overall, the case rate at the hospital rose from 4–5 cases/10,000 admissions to 58 cases/10,000 admissions between April and September 2005.

The hospital had a total of 51 C. difficile cases between April and November. Three patients died from direct complications.

In June, the hospital instituted infection control measures and the number of cases began to fall. In July, the hospital stopped using fluoroquinolones, and almost no cases occurred in that month.

Case numbers rebounded in September when fluoroquinolone use was reinstituted, and that number fell dramatically again when fluoroquinolones were halted once more in October.

“Fluoroquinolones seemed very important, at least in this outbreak,” Dr. Vaessen said.

Proton pump inhibitors were used by a total of 47% of the case patients; however, these patients were not found to be associated with an increased odds ratio of risk in the analysis of this outbreak, Dr. Vaessen said.

The cases in Harderwijk were caused by the C. difficile ribotype 027 strain. Since about 2003, this strain has appeared with greater frequency in Canada, the United States, and Europe, according to Dr. Vaessen.

In the related presentation, Dr. Ed J. Kuijper, also of the Leiden University Medical Center, reported that confirmed cases of ribotype 027-associated diarrhea have occurred in 35 hospitals in the Netherlands. The strain also appears to have spread to Belgium and France, he said.

In Great Britain, the ribotype 027 strain has been observed in 24% of the isolates that have been tested, and it appears to have become the second-most-common strain found there.

The ribotype 027 strain has not yet been detected in cases in Spain, Turkey, or Greece, Dr. Kuijper added.

SAN FRANCISCO — The use of fluoroquinolones, but not of proton pump inhibitors alone, was strongly associated with an outbreak of Clostridium difficile diarrhea in a hospital in the Netherlands, according to data presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

A second study that was conducted at the same hospital indicated that the outbreak was associated with C. difficile ribotype 027, a strain that appears to cause a more severe course of illness and to result in more deaths than do other strains of C. difficile.

The findings shed more light on suspicions that proton pump inhibitors and antibiotics, especially fluoroquinolones, are associated with nosocomial outbreaks of C. difficile diarrhea.

The data, which suggest that the risk of C. difficile diarrhea is not directly associated with proton pump inhibitors, also strongly implicate the use of fluoroquinolones.

Cephalosporins were used by more of the patients who developed C. difficile diarrhea during the outbreak than by those who did not develop such illness, said Dr. Norbert Vaessen of the Leiden University Medical Center, the Netherlands.

But in the statistical analysis of the case-control study of the outbreak, which occurred at St. Jansdal Hospital, Harderwijk, the fluoroquinolone association was found to be significantly stronger, Dr. Vaessen reported.

The odds ratio that someone taking a fluoroquinolone would develop C. difficile diarrhea was 15 times that of someone not on a fluoroquinolone. The odds ratio for cephalosporin use was 5.7.

The odds ratios of fluoroquinolone or cephalosporin use in controls who had diarrhea that was not caused by C. difficile were 2.2 and 0.9, respectively.

Intriguingly, in two instances, the cases no longer occurred when fluoroquinolone use was halted at the hospital, Dr. Vaessen said at the meeting, sponsored by the American Society for Microbiology.

The initial outbreak began in March 2005. Overall, the case rate at the hospital rose from 4–5 cases/10,000 admissions to 58 cases/10,000 admissions between April and September 2005.

The hospital had a total of 51 C. difficile cases between April and November. Three patients died from direct complications.

In June, the hospital instituted infection control measures and the number of cases began to fall. In July, the hospital stopped using fluoroquinolones, and almost no cases occurred in that month.

Case numbers rebounded in September when fluoroquinolone use was reinstituted, and that number fell dramatically again when fluoroquinolones were halted once more in October.

“Fluoroquinolones seemed very important, at least in this outbreak,” Dr. Vaessen said.

Proton pump inhibitors were used by a total of 47% of the case patients; however, these patients were not found to be associated with an increased odds ratio of risk in the analysis of this outbreak, Dr. Vaessen said.

The cases in Harderwijk were caused by the C. difficile ribotype 027 strain. Since about 2003, this strain has appeared with greater frequency in Canada, the United States, and Europe, according to Dr. Vaessen.

In the related presentation, Dr. Ed J. Kuijper, also of the Leiden University Medical Center, reported that confirmed cases of ribotype 027-associated diarrhea have occurred in 35 hospitals in the Netherlands. The strain also appears to have spread to Belgium and France, he said.

In Great Britain, the ribotype 027 strain has been observed in 24% of the isolates that have been tested, and it appears to have become the second-most-common strain found there.

The ribotype 027 strain has not yet been detected in cases in Spain, Turkey, or Greece, Dr. Kuijper added.

SAN FRANCISCO — At hospital admission, 5%–7% of patients are colonized with methicillin-resistant Staphylococcus aureus, according to investigators at Evanston Northwestern Healthcare, the first hospital group in the United States to screen patients routinely for nasal carriage of the resistant bacteria.

It was not surprising that older patients, sicker patients, and patients on dialysis had the highest likelihoods of MRSA colonization, according to a case-control analysis using the data, Dr. Ari Robicsek said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The prevalence of nasal carriage was 5% for patients in their 40s. Prevalence steadily increased with age to about 9% among patients in their 70s and peaked at 19% in patients 90 years or older, said Dr. Robicsek, the hospital epidemiologist for Evanston Northwestern Healthcare, which has three hospitals in the suburbs northwest of Chicago.

Over 24,000 patients have been screened by Dr. Robicsek's program, which began in August 2005.

The polymerase chain reaction (PCR) testing used to evaluate nasal carriage has been shown to have a sensitivity of 100% and a specificity of 98%, he said. The rates account for the variation in prevalence, considered to be 7% before and 5% after correcting for the specificity of the testing.

The association between nasal carriage of MRSA and being a sicker patient at admission was evident in the case-control analysis, which considered the number of ICD-9 codes a patient had on admission. The risk of being a MRSA carrier increased about 8% for each additional ICD-9 code.

Among adults who were admitted with a diagnosis of septicemia, the prevalence was 20%, Dr. Robicsek said.

Dr. Robicsek also found that MRSA carriage is difficult to eradicate. Fully 50% of the patients who had previously had a positive result on a nasal test or a clinical culture were carriers on readmission, compared with 4% of patients who had recently been tested or cultured and found to be negative.

Furthermore, patients who had had a prior history of a positive MRSAtest or infection, but had tested negative on their most recent test prior to admission, still had a 30% likelihood of being MRSA carriers on their readmission.

SAN FRANCISCO — At hospital admission, 5%–7% of patients are colonized with methicillin-resistant Staphylococcus aureus, according to investigators at Evanston Northwestern Healthcare, the first hospital group in the United States to screen patients routinely for nasal carriage of the resistant bacteria.

It was not surprising that older patients, sicker patients, and patients on dialysis had the highest likelihoods of MRSA colonization, according to a case-control analysis using the data, Dr. Ari Robicsek said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The prevalence of nasal carriage was 5% for patients in their 40s. Prevalence steadily increased with age to about 9% among patients in their 70s and peaked at 19% in patients 90 years or older, said Dr. Robicsek, the hospital epidemiologist for Evanston Northwestern Healthcare, which has three hospitals in the suburbs northwest of Chicago.

Over 24,000 patients have been screened by Dr. Robicsek's program, which began in August 2005.

The polymerase chain reaction (PCR) testing used to evaluate nasal carriage has been shown to have a sensitivity of 100% and a specificity of 98%, he said. The rates account for the variation in prevalence, considered to be 7% before and 5% after correcting for the specificity of the testing.

The association between nasal carriage of MRSA and being a sicker patient at admission was evident in the case-control analysis, which considered the number of ICD-9 codes a patient had on admission. The risk of being a MRSA carrier increased about 8% for each additional ICD-9 code.

Among adults who were admitted with a diagnosis of septicemia, the prevalence was 20%, Dr. Robicsek said.

Dr. Robicsek also found that MRSA carriage is difficult to eradicate. Fully 50% of the patients who had previously had a positive result on a nasal test or a clinical culture were carriers on readmission, compared with 4% of patients who had recently been tested or cultured and found to be negative.

Furthermore, patients who had had a prior history of a positive MRSAtest or infection, but had tested negative on their most recent test prior to admission, still had a 30% likelihood of being MRSA carriers on their readmission.

SAN FRANCISCO — At hospital admission, 5%–7% of patients are colonized with methicillin-resistant Staphylococcus aureus, according to investigators at Evanston Northwestern Healthcare, the first hospital group in the United States to screen patients routinely for nasal carriage of the resistant bacteria.

It was not surprising that older patients, sicker patients, and patients on dialysis had the highest likelihoods of MRSA colonization, according to a case-control analysis using the data, Dr. Ari Robicsek said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The prevalence of nasal carriage was 5% for patients in their 40s. Prevalence steadily increased with age to about 9% among patients in their 70s and peaked at 19% in patients 90 years or older, said Dr. Robicsek, the hospital epidemiologist for Evanston Northwestern Healthcare, which has three hospitals in the suburbs northwest of Chicago.

Over 24,000 patients have been screened by Dr. Robicsek's program, which began in August 2005.

The polymerase chain reaction (PCR) testing used to evaluate nasal carriage has been shown to have a sensitivity of 100% and a specificity of 98%, he said. The rates account for the variation in prevalence, considered to be 7% before and 5% after correcting for the specificity of the testing.

The association between nasal carriage of MRSA and being a sicker patient at admission was evident in the case-control analysis, which considered the number of ICD-9 codes a patient had on admission. The risk of being a MRSA carrier increased about 8% for each additional ICD-9 code.

Among adults who were admitted with a diagnosis of septicemia, the prevalence was 20%, Dr. Robicsek said.

Dr. Robicsek also found that MRSA carriage is difficult to eradicate. Fully 50% of the patients who had previously had a positive result on a nasal test or a clinical culture were carriers on readmission, compared with 4% of patients who had recently been tested or cultured and found to be negative.

Furthermore, patients who had had a prior history of a positive MRSAtest or infection, but had tested negative on their most recent test prior to admission, still had a 30% likelihood of being MRSA carriers on their readmission.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

"This is significantly lower than other reported rates have been," said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they had had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns. What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by an Ohio Medical Quality Foundation grant.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

"This is significantly lower than other reported rates have been," said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they had had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns. What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by an Ohio Medical Quality Foundation grant.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

"This is significantly lower than other reported rates have been," said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they had had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns. What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by an Ohio Medical Quality Foundation grant.

SEATTLE — The United States has a growing shortage of rural physicians, but interest in addressing the problem seems to be lagging behind that of some other countries, notably Australia.

At a recent conference on rural health sponsored by WONCA, the World Organization of Family Doctors, some participants were dismayed that there was not a greater U.S. presence at a meeting held in the United States.

“I honestly would have thought there would have been a large presence here from U.S. medical schools,” said Dr. James Rourke, dean of medicine at Memorial University, St. John's, Nfld., one of the meeting organizers. “If it is not an issue for them, it should be.”

Organizers said U.S. medical schools and departments of family medicine were invited. But Australia, which is seen as a world leader in efforts to improve rural physician supply, had the largest contingent of meeting participants. Presentations from Australia outnumbered those from the United States by almost three to one.

The population of Australia is 20 million, of which only about 2 million live in rural areas. The United States has 20 million people living in rural, federally designated primary-care-physician shortage areas.

Patricia Taylor, Ph.D., formerly director of research for the federal Office of Rural Health Policy, said she was disappointed by the U.S. showing but not especially surprised. In 1999, before retiring from the agency, Dr. Taylor organized a meeting of health educators on rural health issues. There has not been another such meeting since then, she said in an interview.

Good rural physicians need somewhat different training from that of urban general physicians, but medical schools and most residency programs are located in urban areas, where trainees have no exposure to rural practice, many speakers noted.

Moreover, they added, most schools tend to be more interested in burnishing their international reputation and in training specialists and academics than they are in addressing local and regional needs.

U.S. medical students who grew up near a medical school are less likely to become rural physicians, and those from a rural background are much more likely to end up practicing in a rural area, said Dr. Robert Bowman, director of rural health education and research in the department of family medicine at the University of Nebraska Medical Center, Omaha.

Currently, about 90% of U.S. medical students have urban roots, Dr. Bowman said. About 25% of medical students with rural backgrounds return to a rural area to practice, he added.

Although 20% of the U.S. population live in areas considered rural, only 9% of physicians practice there; most are family physicians and general surgeons.

In 1970, 17% of medical students had rural origins; in 2005, only 10% did, according to Dr. Bowman.

The issue of rural shortages has been overshadowed on the national level by concerns that there will likely be a shortage of physicians overall by 2020. Improvements in the supply of rural physicians are likely to come from state and local efforts, Dr. Taylor said in an interview.

There has not been a rural health issues meeting held in the U.S. since 1999. DR. TAYLOR

Schools on Both Sides of the Spectrum

Schools that produce the highest number of medical graduates who go into rural practice (between 21% and 36% of each graduating class):

University of Minnesota, Duluth

University of Mississippi, Jackson

University of South Dakota, Sioux Falls

Mercer University, Macon, Ga.

University of North Dakota, Grand Forks

East Carolina University, Greenville, N.C.

University of Kentucky, Lexington

University of Nebraska, Omaha

East Tennessee State University, Johnson City

University of Arkansas, Little Rock

Schools that produce the lowest number of medical graduates who go into rural practice (between 0% and 3% of each graduating class):

State University of New York, Brooklyn

Cornell University, New York

University of Chicago

Harvard Medical School, Boston

University of California, Los Angeles

Albert Einstein College of Medicine, New York

Yale University, New Haven, Conn.

New York University, New York

Stanford (Calif.) University

University of North Texas at Fort Worth

Source: Dr. Frederick Chen, WWAMI Rural Health Research Center, University of Washington, Seattle

SEATTLE — The United States has a growing shortage of rural physicians, but interest in addressing the problem seems to be lagging behind that of some other countries, notably Australia.

At a recent conference on rural health sponsored by WONCA, the World Organization of Family Doctors, some participants were dismayed that there was not a greater U.S. presence at a meeting held in the United States.

“I honestly would have thought there would have been a large presence here from U.S. medical schools,” said Dr. James Rourke, dean of medicine at Memorial University, St. John's, Nfld., one of the meeting organizers. “If it is not an issue for them, it should be.”

Organizers said U.S. medical schools and departments of family medicine were invited. But Australia, which is seen as a world leader in efforts to improve rural physician supply, had the largest contingent of meeting participants. Presentations from Australia outnumbered those from the United States by almost three to one.

The population of Australia is 20 million, of which only about 2 million live in rural areas. The United States has 20 million people living in rural, federally designated primary-care-physician shortage areas.

Patricia Taylor, Ph.D., formerly director of research for the federal Office of Rural Health Policy, said she was disappointed by the U.S. showing but not especially surprised. In 1999, before retiring from the agency, Dr. Taylor organized a meeting of health educators on rural health issues. There has not been another such meeting since then, she said in an interview.

Good rural physicians need somewhat different training from that of urban general physicians, but medical schools and most residency programs are located in urban areas, where trainees have no exposure to rural practice, many speakers noted.

Moreover, they added, most schools tend to be more interested in burnishing their international reputation and in training specialists and academics than they are in addressing local and regional needs.

U.S. medical students who grew up near a medical school are less likely to become rural physicians, and those from a rural background are much more likely to end up practicing in a rural area, said Dr. Robert Bowman, director of rural health education and research in the department of family medicine at the University of Nebraska Medical Center, Omaha.

Currently, about 90% of U.S. medical students have urban roots, Dr. Bowman said. About 25% of medical students with rural backgrounds return to a rural area to practice, he added.

Although 20% of the U.S. population live in areas considered rural, only 9% of physicians practice there; most are family physicians and general surgeons.

In 1970, 17% of medical students had rural origins; in 2005, only 10% did, according to Dr. Bowman.

The issue of rural shortages has been overshadowed on the national level by concerns that there will likely be a shortage of physicians overall by 2020. Improvements in the supply of rural physicians are likely to come from state and local efforts, Dr. Taylor said in an interview.

There has not been a rural health issues meeting held in the U.S. since 1999. DR. TAYLOR

Schools on Both Sides of the Spectrum

Schools that produce the highest number of medical graduates who go into rural practice (between 21% and 36% of each graduating class):

University of Minnesota, Duluth

University of Mississippi, Jackson

University of South Dakota, Sioux Falls

Mercer University, Macon, Ga.

University of North Dakota, Grand Forks

East Carolina University, Greenville, N.C.

University of Kentucky, Lexington

University of Nebraska, Omaha

East Tennessee State University, Johnson City

University of Arkansas, Little Rock

Schools that produce the lowest number of medical graduates who go into rural practice (between 0% and 3% of each graduating class):

State University of New York, Brooklyn

Cornell University, New York

University of Chicago

Harvard Medical School, Boston

University of California, Los Angeles

Albert Einstein College of Medicine, New York

Yale University, New Haven, Conn.

New York University, New York

Stanford (Calif.) University

University of North Texas at Fort Worth

Source: Dr. Frederick Chen, WWAMI Rural Health Research Center, University of Washington, Seattle

SEATTLE — The United States has a growing shortage of rural physicians, but interest in addressing the problem seems to be lagging behind that of some other countries, notably Australia.

At a recent conference on rural health sponsored by WONCA, the World Organization of Family Doctors, some participants were dismayed that there was not a greater U.S. presence at a meeting held in the United States.

“I honestly would have thought there would have been a large presence here from U.S. medical schools,” said Dr. James Rourke, dean of medicine at Memorial University, St. John's, Nfld., one of the meeting organizers. “If it is not an issue for them, it should be.”

Organizers said U.S. medical schools and departments of family medicine were invited. But Australia, which is seen as a world leader in efforts to improve rural physician supply, had the largest contingent of meeting participants. Presentations from Australia outnumbered those from the United States by almost three to one.

The population of Australia is 20 million, of which only about 2 million live in rural areas. The United States has 20 million people living in rural, federally designated primary-care-physician shortage areas.

Patricia Taylor, Ph.D., formerly director of research for the federal Office of Rural Health Policy, said she was disappointed by the U.S. showing but not especially surprised. In 1999, before retiring from the agency, Dr. Taylor organized a meeting of health educators on rural health issues. There has not been another such meeting since then, she said in an interview.

Good rural physicians need somewhat different training from that of urban general physicians, but medical schools and most residency programs are located in urban areas, where trainees have no exposure to rural practice, many speakers noted.

Moreover, they added, most schools tend to be more interested in burnishing their international reputation and in training specialists and academics than they are in addressing local and regional needs.

U.S. medical students who grew up near a medical school are less likely to become rural physicians, and those from a rural background are much more likely to end up practicing in a rural area, said Dr. Robert Bowman, director of rural health education and research in the department of family medicine at the University of Nebraska Medical Center, Omaha.

Currently, about 90% of U.S. medical students have urban roots, Dr. Bowman said. About 25% of medical students with rural backgrounds return to a rural area to practice, he added.

Although 20% of the U.S. population live in areas considered rural, only 9% of physicians practice there; most are family physicians and general surgeons.

In 1970, 17% of medical students had rural origins; in 2005, only 10% did, according to Dr. Bowman.

The issue of rural shortages has been overshadowed on the national level by concerns that there will likely be a shortage of physicians overall by 2020. Improvements in the supply of rural physicians are likely to come from state and local efforts, Dr. Taylor said in an interview.

There has not been a rural health issues meeting held in the U.S. since 1999. DR. TAYLOR

Schools on Both Sides of the Spectrum

Schools that produce the highest number of medical graduates who go into rural practice (between 21% and 36% of each graduating class):

University of Minnesota, Duluth

University of Mississippi, Jackson

University of South Dakota, Sioux Falls

Mercer University, Macon, Ga.

University of North Dakota, Grand Forks

East Carolina University, Greenville, N.C.

University of Kentucky, Lexington

University of Nebraska, Omaha

East Tennessee State University, Johnson City

University of Arkansas, Little Rock

Schools that produce the lowest number of medical graduates who go into rural practice (between 0% and 3% of each graduating class):

State University of New York, Brooklyn

Cornell University, New York

University of Chicago

Harvard Medical School, Boston

University of California, Los Angeles

Albert Einstein College of Medicine, New York

Yale University, New Haven, Conn.

New York University, New York

Stanford (Calif.) University

University of North Texas at Fort Worth

Source: Dr. Frederick Chen, WWAMI Rural Health Research Center, University of Washington, Seattle

ASPEN, COLO. — Although the conjugate heptavalent pneumococcal vaccine has decreased penicillin resistance rates in the vaccine's bacterial serotypes, there is some evidence replacement serotypes are emerging, according to a presentation at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

And with those replacement serotypes, penicillin resistance may again be on the increase, warned Dr. Sheldon Kaplan, chief of the infectious disease service at Texas Children's Hospital, Houston.

Serotypes 15 and 33 seem to be the more common serotypes in the vaccine decline, he said.

According to a pneumococci surveillance project of eight children's hospitals, there was a mean of five cases of invasive disease caused by serotype 15 in 1994–2000. In 2002, there were 14 cases.

For serotype 33, the mean number of cases was less than one during the 1994–2000 period. In 2002, there were nine cases, said Dr. Kaplan, whose hospital is part of the surveillance project (Pediatrics 2004;113:443–9).

Specific isolates of serotype 15 collected at the hospitals participating in the project have the same blot pattern on a pulse-field electrophoresis gel about 60% of the time. That suggests that different isolates taken from various children are the same clone of the bacteria.

About 80% of the serotype 33 isolates seem to be the same clone.

Serotype 19A also seems to be on the increase and seems specifically to be replacing 19F, a serotype in the vaccine. According to one report, the annual incidence of invasive disease in children less than 2 years of age caused by serotype 19A has increased from 1 case per 100,000 population in 2001 to more than 6 cases per 100,000 in 2004 (J. Infect. Dis. 2005;192:1988–95). There also has been a 2.5-fold increase in cases in children older than 5 years of age.

“We're not the only people who are seeing this,” Dr. Kaplan said. “The CDC is actually reporting increases in these serotypes as well.”

Data from a number of surveys have suggested there has been a decrease in antibiotic resistance since the introduction of the conjugate vaccine, but, said Dr. Kaplan, that may no longer be true.

The rate of penicillin nonsusceptible infections may actually be increasing again. Although the number of cases caused by serotypes in the vaccine has declined, the number of cases caused by serotypes not in the vaccine has increased, and it is those serotypes that seem to be acquiring more resistance.

The incidence of invasive disease caused by penicillin nonsusceptible pneumococci in children younger than 2 years has increased since 2002. And, considering only isolates that are not in the vaccine, it has increased from 51% in 1999 to 68% in 2004, Dr. Kaplan said.

“It looks like these nonvaccine serotypes are more likely to be penicillin nonsusceptible today than they were 5 years ago,” he said.

A group from Salt Lake City has seen an increase in pediatric cases of pneumococcal pneumonia complicated with empyema since the introduction of the vaccine. Moreover, the serotypes associated with these cases tend to be serotypes 1, 3, and 19A, which are not in the vaccine.

The Salt Lake City group reported that for the 4 years before the vaccine was introduced, the medical center saw an average of 38 cases of empyema, compared with an average of 72 cases in the first 4 years after its introduction.

Also, pneumococcal parapneumonic empyema represented only 17% of the cases of identified invasive pneumococcal disease seen at that center in the years before the vaccine was introduced, but 32% of the cases afterward (Pediatr. Infect. Dis. J. 2006;25:250–4). Serotype 1 was the most common serotype associated with the empyema both before (46%) and after (34%) the vaccine was introduced. Serotypes 3 and 19A became common after the vaccine (20% and 14%, respectively).

“I can't explain this, but they are seeing more cases with more nonvaccine types,” Dr. Kaplan said, noting that the vaccine may have to be updated with at least some of these emerging strains. “How we will address that down the road will have to be seen. It is an expensive vaccine.”

'We're not the only people who are seeing this. The CDC is reporting increases in these serotypes as well.' DR. KAPLAN

ASPEN, COLO. — Although the conjugate heptavalent pneumococcal vaccine has decreased penicillin resistance rates in the vaccine's bacterial serotypes, there is some evidence replacement serotypes are emerging, according to a presentation at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

And with those replacement serotypes, penicillin resistance may again be on the increase, warned Dr. Sheldon Kaplan, chief of the infectious disease service at Texas Children's Hospital, Houston.

Serotypes 15 and 33 seem to be the more common serotypes in the vaccine decline, he said.

According to a pneumococci surveillance project of eight children's hospitals, there was a mean of five cases of invasive disease caused by serotype 15 in 1994–2000. In 2002, there were 14 cases.

For serotype 33, the mean number of cases was less than one during the 1994–2000 period. In 2002, there were nine cases, said Dr. Kaplan, whose hospital is part of the surveillance project (Pediatrics 2004;113:443–9).

Specific isolates of serotype 15 collected at the hospitals participating in the project have the same blot pattern on a pulse-field electrophoresis gel about 60% of the time. That suggests that different isolates taken from various children are the same clone of the bacteria.

About 80% of the serotype 33 isolates seem to be the same clone.

Serotype 19A also seems to be on the increase and seems specifically to be replacing 19F, a serotype in the vaccine. According to one report, the annual incidence of invasive disease in children less than 2 years of age caused by serotype 19A has increased from 1 case per 100,000 population in 2001 to more than 6 cases per 100,000 in 2004 (J. Infect. Dis. 2005;192:1988–95). There also has been a 2.5-fold increase in cases in children older than 5 years of age.

“We're not the only people who are seeing this,” Dr. Kaplan said. “The CDC is actually reporting increases in these serotypes as well.”

Data from a number of surveys have suggested there has been a decrease in antibiotic resistance since the introduction of the conjugate vaccine, but, said Dr. Kaplan, that may no longer be true.

The rate of penicillin nonsusceptible infections may actually be increasing again. Although the number of cases caused by serotypes in the vaccine has declined, the number of cases caused by serotypes not in the vaccine has increased, and it is those serotypes that seem to be acquiring more resistance.

The incidence of invasive disease caused by penicillin nonsusceptible pneumococci in children younger than 2 years has increased since 2002. And, considering only isolates that are not in the vaccine, it has increased from 51% in 1999 to 68% in 2004, Dr. Kaplan said.

“It looks like these nonvaccine serotypes are more likely to be penicillin nonsusceptible today than they were 5 years ago,” he said.

A group from Salt Lake City has seen an increase in pediatric cases of pneumococcal pneumonia complicated with empyema since the introduction of the vaccine. Moreover, the serotypes associated with these cases tend to be serotypes 1, 3, and 19A, which are not in the vaccine.

The Salt Lake City group reported that for the 4 years before the vaccine was introduced, the medical center saw an average of 38 cases of empyema, compared with an average of 72 cases in the first 4 years after its introduction.

Also, pneumococcal parapneumonic empyema represented only 17% of the cases of identified invasive pneumococcal disease seen at that center in the years before the vaccine was introduced, but 32% of the cases afterward (Pediatr. Infect. Dis. J. 2006;25:250–4). Serotype 1 was the most common serotype associated with the empyema both before (46%) and after (34%) the vaccine was introduced. Serotypes 3 and 19A became common after the vaccine (20% and 14%, respectively).

“I can't explain this, but they are seeing more cases with more nonvaccine types,” Dr. Kaplan said, noting that the vaccine may have to be updated with at least some of these emerging strains. “How we will address that down the road will have to be seen. It is an expensive vaccine.”

'We're not the only people who are seeing this. The CDC is reporting increases in these serotypes as well.' DR. KAPLAN

ASPEN, COLO. — Although the conjugate heptavalent pneumococcal vaccine has decreased penicillin resistance rates in the vaccine's bacterial serotypes, there is some evidence replacement serotypes are emerging, according to a presentation at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

And with those replacement serotypes, penicillin resistance may again be on the increase, warned Dr. Sheldon Kaplan, chief of the infectious disease service at Texas Children's Hospital, Houston.

Serotypes 15 and 33 seem to be the more common serotypes in the vaccine decline, he said.

According to a pneumococci surveillance project of eight children's hospitals, there was a mean of five cases of invasive disease caused by serotype 15 in 1994–2000. In 2002, there were 14 cases.

For serotype 33, the mean number of cases was less than one during the 1994–2000 period. In 2002, there were nine cases, said Dr. Kaplan, whose hospital is part of the surveillance project (Pediatrics 2004;113:443–9).

Specific isolates of serotype 15 collected at the hospitals participating in the project have the same blot pattern on a pulse-field electrophoresis gel about 60% of the time. That suggests that different isolates taken from various children are the same clone of the bacteria.

About 80% of the serotype 33 isolates seem to be the same clone.

Serotype 19A also seems to be on the increase and seems specifically to be replacing 19F, a serotype in the vaccine. According to one report, the annual incidence of invasive disease in children less than 2 years of age caused by serotype 19A has increased from 1 case per 100,000 population in 2001 to more than 6 cases per 100,000 in 2004 (J. Infect. Dis. 2005;192:1988–95). There also has been a 2.5-fold increase in cases in children older than 5 years of age.

“We're not the only people who are seeing this,” Dr. Kaplan said. “The CDC is actually reporting increases in these serotypes as well.”

Data from a number of surveys have suggested there has been a decrease in antibiotic resistance since the introduction of the conjugate vaccine, but, said Dr. Kaplan, that may no longer be true.

The rate of penicillin nonsusceptible infections may actually be increasing again. Although the number of cases caused by serotypes in the vaccine has declined, the number of cases caused by serotypes not in the vaccine has increased, and it is those serotypes that seem to be acquiring more resistance.

The incidence of invasive disease caused by penicillin nonsusceptible pneumococci in children younger than 2 years has increased since 2002. And, considering only isolates that are not in the vaccine, it has increased from 51% in 1999 to 68% in 2004, Dr. Kaplan said.

“It looks like these nonvaccine serotypes are more likely to be penicillin nonsusceptible today than they were 5 years ago,” he said.

A group from Salt Lake City has seen an increase in pediatric cases of pneumococcal pneumonia complicated with empyema since the introduction of the vaccine. Moreover, the serotypes associated with these cases tend to be serotypes 1, 3, and 19A, which are not in the vaccine.

The Salt Lake City group reported that for the 4 years before the vaccine was introduced, the medical center saw an average of 38 cases of empyema, compared with an average of 72 cases in the first 4 years after its introduction.

Also, pneumococcal parapneumonic empyema represented only 17% of the cases of identified invasive pneumococcal disease seen at that center in the years before the vaccine was introduced, but 32% of the cases afterward (Pediatr. Infect. Dis. J. 2006;25:250–4). Serotype 1 was the most common serotype associated with the empyema both before (46%) and after (34%) the vaccine was introduced. Serotypes 3 and 19A became common after the vaccine (20% and 14%, respectively).

“I can't explain this, but they are seeing more cases with more nonvaccine types,” Dr. Kaplan said, noting that the vaccine may have to be updated with at least some of these emerging strains. “How we will address that down the road will have to be seen. It is an expensive vaccine.”

'We're not the only people who are seeing this. The CDC is reporting increases in these serotypes as well.' DR. KAPLAN

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., reported at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of Ohio University College of Osteopathic Medicine, Athens.

The study, sponsored by a grant from the Ohio Medical Quality Foundation, involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

“Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. If doctors did not take to the technology right away, they never did, she said.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., reported at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of Ohio University College of Osteopathic Medicine, Athens.

The study, sponsored by a grant from the Ohio Medical Quality Foundation, involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

“Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. If doctors did not take to the technology right away, they never did, she said.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., reported at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of Ohio University College of Osteopathic Medicine, Athens.

The study, sponsored by a grant from the Ohio Medical Quality Foundation, involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

“Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. If doctors did not take to the technology right away, they never did, she said.

SEATTLE — The United States has a growing shortage of rural physicians, but interest in addressing the problem seems to be lagging behind that of some other countries, notably Australia.

At a recent conference on rural health sponsored by WONCA, the World Organization of Family Doctors, some participants were dismayed that there was not a greater U.S. presence at a meeting held in the United States.

“I honestly would have thought there would have been a large presence here from U.S. medical schools,” said Dr. James Rourke, dean of medicine at Memorial University, St. John's, Nfld., one of the meeting organizers. “If it is not an issue for them, it should be.”

Organizers said U.S. medical schools and departments of family medicine were invited. But Australia, which is seen as a world leader in efforts to improve rural physician supply, had the largest contingent of meeting participants. Presentations from Australia outnumbered those from the United States by almost three to one.

The population of Australia is 20 million, of which only about 2 million live in rural areas. The United States has 20 million people living in rural, federally designated primary-care-physician shortage areas.

Patricia Taylor, Ph.D., formerly director of research for the federal Office of Rural Health Policy, said she was disappointed by the U.S. showing but not especially surprised. In 1999, before retiring from the agency, Dr. Taylor organized a meeting of health educators on rural health issues. There has not been another such meeting since then, she said in an interview.

Like Dr. Taylor's meeting, the WONCA meeting focused on the role of medical schools and residency programs in addressing rural shortages. Much of the discussion was about how medical schools often discourage rural practice.

Good rural physicians need somewhat different training from that of urban general physicians, but medical schools and most residency programs are located in urban areas, speakers said. Moreover, they added, most tend to be more interested in burnishing their international reputation and in training specialists and academics.

U.S. medical students who grew up near a medical school are less likely to become rural physicians, and those from a rural background are much more likely to end up practicing in a rural area, said Dr. Robert Bowman, director of rural health education and research in the department of family medicine at the University of Nebraska Medical Center, Omaha.

Currently, about 90% of U.S. medical students have urban roots, but 70% of rural physicians grew up in rural areas, Dr. Bowman said. About 25% of medical students with rural backgrounds return to a rural area to practice, he added.

Although 20% of the U.S. population lives in areas considered rural, only 9% of physicians practice there.

Current trends suggest the situation is getting worse rather than improving, Dr. Bowman said. Medical school students who come from rural areas tend to come from lower income homes. But the average household income of the families of medical students has been rising for about 20 years, so that in recent years, about 40% of medical school students come from families making $100,000 a year or more.

In 1970, 17% of medical students had rural origins; in 2005, only 10% did, he added. Also, the percentage of women in medical school classes is rising, but women tend not to go to rural areas.

This issue has been overshadowed on the national level by concerns that there will likely be a shortage of physicians overall by 2020. Improvements in the supply of rural physicians are likely to come from state and local efforts, Dr. Taylor said.

Improvements in the supply of rural physicians are likely to come from state and local efforts. DR. TAYLOR

Catering to Rural Practice Needs

Schools that produce the highest number of medical graduates who go into rural practice (between 21% and 36% of each graduating class):

University of Minnesota, Duluth

University of Mississippi, Jackson

University of South Dakota, Sioux Falls

Mercer University, Macon, Ga.

University of North Dakota, Grand Forks

East Carolina University, Greenville, N.C.

University of Kentucky, Lexington

University of Nebraska, Omaha

East Tennessee State University, Johnson City

University of Arkansas, Little Rock

Schools that produce the lowest number of medical graduates who go into rural practice (between 0% and 3% of each graduating class):

State University of New York, Brooklyn

Cornell University, New York

University of Chicago

Harvard Medical School, Boston

University of California, Los Angeles

Albert Einstein College of Medicine, New York

Yale University, New Haven, Conn.

New York University, New York

Stanford (Calif.) University

University of North Texas at Fort Worth

Source: Dr. Frederick Chen, Washington, Wyoming, Alaska, Montana, and Idaho Rural Health Research Center, University of Washington, Seattle

SEATTLE — The United States has a growing shortage of rural physicians, but interest in addressing the problem seems to be lagging behind that of some other countries, notably Australia.

At a recent conference on rural health sponsored by WONCA, the World Organization of Family Doctors, some participants were dismayed that there was not a greater U.S. presence at a meeting held in the United States.

“I honestly would have thought there would have been a large presence here from U.S. medical schools,” said Dr. James Rourke, dean of medicine at Memorial University, St. John's, Nfld., one of the meeting organizers. “If it is not an issue for them, it should be.”

Organizers said U.S. medical schools and departments of family medicine were invited. But Australia, which is seen as a world leader in efforts to improve rural physician supply, had the largest contingent of meeting participants. Presentations from Australia outnumbered those from the United States by almost three to one.

The population of Australia is 20 million, of which only about 2 million live in rural areas. The United States has 20 million people living in rural, federally designated primary-care-physician shortage areas.

Patricia Taylor, Ph.D., formerly director of research for the federal Office of Rural Health Policy, said she was disappointed by the U.S. showing but not especially surprised. In 1999, before retiring from the agency, Dr. Taylor organized a meeting of health educators on rural health issues. There has not been another such meeting since then, she said in an interview.

Like Dr. Taylor's meeting, the WONCA meeting focused on the role of medical schools and residency programs in addressing rural shortages. Much of the discussion was about how medical schools often discourage rural practice.

Good rural physicians need somewhat different training from that of urban general physicians, but medical schools and most residency programs are located in urban areas, speakers said. Moreover, they added, most tend to be more interested in burnishing their international reputation and in training specialists and academics.

U.S. medical students who grew up near a medical school are less likely to become rural physicians, and those from a rural background are much more likely to end up practicing in a rural area, said Dr. Robert Bowman, director of rural health education and research in the department of family medicine at the University of Nebraska Medical Center, Omaha.

Currently, about 90% of U.S. medical students have urban roots, but 70% of rural physicians grew up in rural areas, Dr. Bowman said. About 25% of medical students with rural backgrounds return to a rural area to practice, he added.

Although 20% of the U.S. population lives in areas considered rural, only 9% of physicians practice there.

Current trends suggest the situation is getting worse rather than improving, Dr. Bowman said. Medical school students who come from rural areas tend to come from lower income homes. But the average household income of the families of medical students has been rising for about 20 years, so that in recent years, about 40% of medical school students come from families making $100,000 a year or more.

In 1970, 17% of medical students had rural origins; in 2005, only 10% did, he added. Also, the percentage of women in medical school classes is rising, but women tend not to go to rural areas.

This issue has been overshadowed on the national level by concerns that there will likely be a shortage of physicians overall by 2020. Improvements in the supply of rural physicians are likely to come from state and local efforts, Dr. Taylor said.

Improvements in the supply of rural physicians are likely to come from state and local efforts. DR. TAYLOR

Catering to Rural Practice Needs

Schools that produce the highest number of medical graduates who go into rural practice (between 21% and 36% of each graduating class):

University of Minnesota, Duluth

University of Mississippi, Jackson

University of South Dakota, Sioux Falls

Mercer University, Macon, Ga.

University of North Dakota, Grand Forks

East Carolina University, Greenville, N.C.

University of Kentucky, Lexington

University of Nebraska, Omaha

East Tennessee State University, Johnson City

University of Arkansas, Little Rock

Schools that produce the lowest number of medical graduates who go into rural practice (between 0% and 3% of each graduating class):

State University of New York, Brooklyn

Cornell University, New York

University of Chicago

Harvard Medical School, Boston

University of California, Los Angeles

Albert Einstein College of Medicine, New York

Yale University, New Haven, Conn.

New York University, New York

Stanford (Calif.) University

University of North Texas at Fort Worth

Source: Dr. Frederick Chen, Washington, Wyoming, Alaska, Montana, and Idaho Rural Health Research Center, University of Washington, Seattle

SEATTLE — The United States has a growing shortage of rural physicians, but interest in addressing the problem seems to be lagging behind that of some other countries, notably Australia.

At a recent conference on rural health sponsored by WONCA, the World Organization of Family Doctors, some participants were dismayed that there was not a greater U.S. presence at a meeting held in the United States.

“I honestly would have thought there would have been a large presence here from U.S. medical schools,” said Dr. James Rourke, dean of medicine at Memorial University, St. John's, Nfld., one of the meeting organizers. “If it is not an issue for them, it should be.”

Organizers said U.S. medical schools and departments of family medicine were invited. But Australia, which is seen as a world leader in efforts to improve rural physician supply, had the largest contingent of meeting participants. Presentations from Australia outnumbered those from the United States by almost three to one.

The population of Australia is 20 million, of which only about 2 million live in rural areas. The United States has 20 million people living in rural, federally designated primary-care-physician shortage areas.

Patricia Taylor, Ph.D., formerly director of research for the federal Office of Rural Health Policy, said she was disappointed by the U.S. showing but not especially surprised. In 1999, before retiring from the agency, Dr. Taylor organized a meeting of health educators on rural health issues. There has not been another such meeting since then, she said in an interview.

Like Dr. Taylor's meeting, the WONCA meeting focused on the role of medical schools and residency programs in addressing rural shortages. Much of the discussion was about how medical schools often discourage rural practice.

Good rural physicians need somewhat different training from that of urban general physicians, but medical schools and most residency programs are located in urban areas, speakers said. Moreover, they added, most tend to be more interested in burnishing their international reputation and in training specialists and academics.

U.S. medical students who grew up near a medical school are less likely to become rural physicians, and those from a rural background are much more likely to end up practicing in a rural area, said Dr. Robert Bowman, director of rural health education and research in the department of family medicine at the University of Nebraska Medical Center, Omaha.

Currently, about 90% of U.S. medical students have urban roots, but 70% of rural physicians grew up in rural areas, Dr. Bowman said. About 25% of medical students with rural backgrounds return to a rural area to practice, he added.

Although 20% of the U.S. population lives in areas considered rural, only 9% of physicians practice there.

Current trends suggest the situation is getting worse rather than improving, Dr. Bowman said. Medical school students who come from rural areas tend to come from lower income homes. But the average household income of the families of medical students has been rising for about 20 years, so that in recent years, about 40% of medical school students come from families making $100,000 a year or more.

In 1970, 17% of medical students had rural origins; in 2005, only 10% did, he added. Also, the percentage of women in medical school classes is rising, but women tend not to go to rural areas.

This issue has been overshadowed on the national level by concerns that there will likely be a shortage of physicians overall by 2020. Improvements in the supply of rural physicians are likely to come from state and local efforts, Dr. Taylor said.

Improvements in the supply of rural physicians are likely to come from state and local efforts. DR. TAYLOR

Catering to Rural Practice Needs

Schools that produce the highest number of medical graduates who go into rural practice (between 21% and 36% of each graduating class):

University of Minnesota, Duluth

University of Mississippi, Jackson

University of South Dakota, Sioux Falls

Mercer University, Macon, Ga.

University of North Dakota, Grand Forks

East Carolina University, Greenville, N.C.

University of Kentucky, Lexington

University of Nebraska, Omaha

East Tennessee State University, Johnson City

University of Arkansas, Little Rock

Schools that produce the lowest number of medical graduates who go into rural practice (between 0% and 3% of each graduating class):

State University of New York, Brooklyn

Cornell University, New York

University of Chicago

Harvard Medical School, Boston

University of California, Los Angeles

Albert Einstein College of Medicine, New York

Yale University, New Haven, Conn.

New York University, New York

Stanford (Calif.) University

University of North Texas at Fort Worth

Source: Dr. Frederick Chen, Washington, Wyoming, Alaska, Montana, and Idaho Rural Health Research Center, University of Washington, Seattle

SEATTLE — Of the recommended measures taken in hospital treatment of pneumonia, only the administration of the proper, empiric antibiotic appears to make any difference in patient mortality. Culturing blood does not. And prompt antibiotic treatment does not, according to a study from the Mayo Clinic presented at the annual research meeting of Academy Health.

To explore the actual impact of the three principles of care that are thought to have the most influence in pneumonia treatment, the Mayo Clinic researchers analyzed data from a random selection of patients admitted with a diagnosis of pneumonia to the clinic's Rochester, Minn., facility between July 2004 and June 2005, a total of 395 patients. They excluded those who received comfort care only, those transferred from other institutions, and those who did not receive antibiotic treatment within 36 hours.

Since some patients were treated with adherence to all three of those principles—and some only one, two, or none—the patients could be compared for outcome, said Monica VanSuch, of the clinic's division of health care policy and research, in a poster presentation.

The study found that when patients were not treated with the type of antibiotic that guidelines suggest for empiric treatment, they were more likely to have a longer hospital stay (relative risk 1.71) and a decreased chance of survival (relative risk 3.26). They also tended to be less likely to be readmitted after discharge, though that finding was not statistically significant.

Whether the patient received an antibiotic within 4 hours, or within 8 hours, of admission did not make a difference in any of the outcomes. Neither did blood culturing.

The finding that the promptness of antibiotic treatment did not impact outcome is surprising, and might reflect a bias of the study instead of truth, Ms. VanSuch said in an interview. Only a small group of the patients did not receive the proper, empiric antibiotic (35 of the 395 patients), and the importance of that proper antibiotic might be so great that it overwhelmed the influence of prompt treatment in the analysis.

SEATTLE — Of the recommended measures taken in hospital treatment of pneumonia, only the administration of the proper, empiric antibiotic appears to make any difference in patient mortality. Culturing blood does not. And prompt antibiotic treatment does not, according to a study from the Mayo Clinic presented at the annual research meeting of Academy Health.

To explore the actual impact of the three principles of care that are thought to have the most influence in pneumonia treatment, the Mayo Clinic researchers analyzed data from a random selection of patients admitted with a diagnosis of pneumonia to the clinic's Rochester, Minn., facility between July 2004 and June 2005, a total of 395 patients. They excluded those who received comfort care only, those transferred from other institutions, and those who did not receive antibiotic treatment within 36 hours.

Since some patients were treated with adherence to all three of those principles—and some only one, two, or none—the patients could be compared for outcome, said Monica VanSuch, of the clinic's division of health care policy and research, in a poster presentation.

The study found that when patients were not treated with the type of antibiotic that guidelines suggest for empiric treatment, they were more likely to have a longer hospital stay (relative risk 1.71) and a decreased chance of survival (relative risk 3.26). They also tended to be less likely to be readmitted after discharge, though that finding was not statistically significant.

Whether the patient received an antibiotic within 4 hours, or within 8 hours, of admission did not make a difference in any of the outcomes. Neither did blood culturing.

The finding that the promptness of antibiotic treatment did not impact outcome is surprising, and might reflect a bias of the study instead of truth, Ms. VanSuch said in an interview. Only a small group of the patients did not receive the proper, empiric antibiotic (35 of the 395 patients), and the importance of that proper antibiotic might be so great that it overwhelmed the influence of prompt treatment in the analysis.

SEATTLE — Of the recommended measures taken in hospital treatment of pneumonia, only the administration of the proper, empiric antibiotic appears to make any difference in patient mortality. Culturing blood does not. And prompt antibiotic treatment does not, according to a study from the Mayo Clinic presented at the annual research meeting of Academy Health.

To explore the actual impact of the three principles of care that are thought to have the most influence in pneumonia treatment, the Mayo Clinic researchers analyzed data from a random selection of patients admitted with a diagnosis of pneumonia to the clinic's Rochester, Minn., facility between July 2004 and June 2005, a total of 395 patients. They excluded those who received comfort care only, those transferred from other institutions, and those who did not receive antibiotic treatment within 36 hours.

Since some patients were treated with adherence to all three of those principles—and some only one, two, or none—the patients could be compared for outcome, said Monica VanSuch, of the clinic's division of health care policy and research, in a poster presentation.

The study found that when patients were not treated with the type of antibiotic that guidelines suggest for empiric treatment, they were more likely to have a longer hospital stay (relative risk 1.71) and a decreased chance of survival (relative risk 3.26). They also tended to be less likely to be readmitted after discharge, though that finding was not statistically significant.

Whether the patient received an antibiotic within 4 hours, or within 8 hours, of admission did not make a difference in any of the outcomes. Neither did blood culturing.

The finding that the promptness of antibiotic treatment did not impact outcome is surprising, and might reflect a bias of the study instead of truth, Ms. VanSuch said in an interview. Only a small group of the patients did not receive the proper, empiric antibiotic (35 of the 395 patients), and the importance of that proper antibiotic might be so great that it overwhelmed the influence of prompt treatment in the analysis.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it.

He was the only one of the three to have a positive conclusion. The other two investigations, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said. Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets calls about the program, it is physicians trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater among individual doctors than they were among practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care. “Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston. He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL cholesterol testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P [pay for performance] has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Dr. Pearson suggested two possible explanations for why his study produced only slight evidence of an impact from pay for performance. First, a statewide trend toward quality improvement may have made it difficult to detect any effect of incentives. Alternatively, pay for performance may have been ineffective in Massachusetts, perhaps because the financial incentives were not large enough to motivate physicians.

Money indeed may turn out to be the pressing issue as pay for performance becomes more common. Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.”

Ignoring pay for performance won't make it go away, said Dr. Howard B. Beckman, medical director of the Rochester Individual Physician Association. Timothy F. Kirn/Elsevier Global Medical News

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it.

He was the only one of the three to have a positive conclusion. The other two investigations, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said. Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets calls about the program, it is physicians trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater among individual doctors than they were among practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care. “Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston. He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL cholesterol testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P [pay for performance] has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Dr. Pearson suggested two possible explanations for why his study produced only slight evidence of an impact from pay for performance. First, a statewide trend toward quality improvement may have made it difficult to detect any effect of incentives. Alternatively, pay for performance may have been ineffective in Massachusetts, perhaps because the financial incentives were not large enough to motivate physicians.

Money indeed may turn out to be the pressing issue as pay for performance becomes more common. Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.”

Ignoring pay for performance won't make it go away, said Dr. Howard B. Beckman, medical director of the Rochester Individual Physician Association. Timothy F. Kirn/Elsevier Global Medical News

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it.

He was the only one of the three to have a positive conclusion. The other two investigations, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said. Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets calls about the program, it is physicians trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater among individual doctors than they were among practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care. “Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston. He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL cholesterol testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P [pay for performance] has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Dr. Pearson suggested two possible explanations for why his study produced only slight evidence of an impact from pay for performance. First, a statewide trend toward quality improvement may have made it difficult to detect any effect of incentives. Alternatively, pay for performance may have been ineffective in Massachusetts, perhaps because the financial incentives were not large enough to motivate physicians.

Money indeed may turn out to be the pressing issue as pay for performance becomes more common. Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.”

Ignoring pay for performance won't make it go away, said Dr. Howard B. Beckman, medical director of the Rochester Individual Physician Association. Timothy F. Kirn/Elsevier Global Medical News