Utilization of Outpatient Diagnostic Imaging: Does the Physician’s Gender Play a Role?

OBJECTIVE: To examine physician and patient characteristics related to the ordering of imaging studies in a general medicine practice and to determine whether physician gender influences ordering patterns. DESIGN: Retrospective cohort study. SETTING: Hospital-based academic general medicine practice of 29 attending physicians. PATIENTS: All 8,203 visits by 5,011 patients during a 6-month period. METHODS: For each visit the following variables were abstracted from the electronic patient record: patient age, patient gender, visit urgency, visit type, and physician seen. All diagnostic imaging studies performed within 30 days of each outpatient visit were identified from the hospital’s Radiology Information System. Screening mammography was not included in the analysis. Physician variables included gender and years since medical school graduation. Logistic regression analysis was used to evaluate the effect of various patient, physician, and visit characteristics on the probability of a diagnostic imaging study being ordered. RESULTS: Patient age, urgent visits, visit frequency, and the gender of the physician were all significantly related to the ordering of an imaging study. Correcting for all other factors, the ordering of an imaging study during an outpatient medical visit was 40% more likely if the physician was female (odds ratio = 1.40; 95% confidence interval [CI] 1.01, 1.95). Female physicians were 62% more likely (95% CI 0.99, 2.64) than male physicians to order an imaging study for a male patient and 21% more likely (95% CI 0.87, 1.69) to order an imaging study for a female patient. CONCLUSIONS: Physician gender is a predictor of whether an outpatient medical visit generates an imaging study. Reasons for this observation are unclear, but may be the result of different practice styles of male and female physicians or unmeasured patient characteristics

Karma, reincarnation, and medicine: Hindu perspectives on biomedical research

Prior to the completion of the Human Genome Project, bioethicists and other academics debated the impact of this new genetic information on medicine, health care, group identification, and peoples’ lives. A major issue is the potential for unintended and intended adverse consequences to groups and individuals. When conducting research in, for instance, American Indian and Alaskan native (AI/AN) populations, political, cultural, religious and historical issues must be considered. Among African Americans, the Tuskegee Syphilis Experiment is a reminder of racism and discrimination in this country. The goal of the current study is to understand reasons for participating, or not, in genetic research such as the HapMap project and other genetic/medical research from the perspective of the Indian American community in Houston, Texas. In this article, we report on a topic central to this discussion among Indian Americans: karma and reincarnation. Both concepts are important beliefs when considering the body and what should happen to it. Karma and reincarnation are also important considerations in participation in medical and genetic research because, according to karma, what is done to the body can affect future existences and the health of future descendants. Such views of genetic and medical research are culturally mediated. Spiritual beliefs about the body, tissue, and fluids and what happens to them when separated from the body can influence ideas about the utility and acceptability of genetic research and thereby affect the recruitment process. Within this community it is understood that genetic and environmental factors contribute to complex diseases such as diabetes, hypertension, and cancer; and acknowledgment of the significance of environmental stressors in the production of disease. A commitment to service, i.e. “betterment of humanity,” karmic beliefs, and targeting environmental stressors could be prominent avenues for public health campaigns in this population. This study suggests that minority status does not automatically indicate unwillingness to participate in genetic or medical research. Indian Americans were not skeptical about the potential benefits of biomedical research in comparison to other ethnic minority communities in the United States

Adherence to Guidelines for Oral Anticoagulation after Venous Thrombosis and Pulmonary Embolism

OBJECTIVE: Guidelines for oral anticoagulation after deep venous thrombosis (DVT) or pulmonary embolism (PE) have recommended that patients be anticoagulated for at least 3 months after hospital discharge. We sought to determine whether this recommendation was being followed and what patient characteristics predict a shorter than recommended duration of therapy. DESIGN: Retrospective cohort study using linked health care claims data. SETTING: Routine clinical practice. PATIENTS: Five hundred seventy-three members of New Jersey's Medicaid or Pharmacy Assistance for the Aged and Disabled programs aged 65 years and older who were hospitalized for DVT or PE between January 1, 1991 and June 30, 1994. RESULTS: Of the 573 patients, 129 (23%) filled prescriptions covering less than 90 days of oral anticoagulant therapy. In multivariate models, African-American race was associated with an increased risk of a shorter than recommended duration of therapy (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.14 to 3.08), but age and gender were not. Patients who used anticoagulants in the year prior to admission were less likely to have a short duration of therapy (OR, 0.30; 95% CI, 0.12 to 0.78), than were patients with PE (OR, 0.58; 95% CI, 0.38 to 0.88). CONCLUSIONS: Nearly a quarter of those anticoagulated following DVT or PE received therapy for less than the recommended length of time after hospital discharge, with African Americans more likely to have a shorter than recommended course of treatment. Further research is needed to evaluate the causes of shorter than recommended duration of therapy and racial disparities in anticoagulant use

Using an Electronic Medical Record to Identify Opportunities to Improve Compliance with Cholesterol Guidelines

OBJECTIVE: To use an electronic medical record to measure rates of compliance with the National Cholesterol Education Program (NCEP) cholesterol guidelines for secondary prevention, to characterize the patterns of noncompliance, and to identify patient and physician-specific correlates of noncompliance. DESIGN: Cross-sectional descriptive analysis of data extracted from an electronic medical record. SETTING: Nineteen primary care clinics affiliated with a tertiary academic medical center. PATIENTS: All patients who visited their primary care physician in the preceding year who met criteria for secondary prevention of hypercholesterolemia. INTERVENTIONS: None. The main outcome was rate of compliance with NCEP cholesterol guidelines. MAIN RESULTS: Of 2,019 patients who qualified for secondary prevention, only 31% were in compliance with NCEP recommendations, although 44% were on lipid-lowering therapy. There was no low-density lipoprotein cholesterol (LDL-C) on record within the last three years for 771 (38%), and another 809 (40%) had a recent LDL-C that was above the recommended target of 100 mg/dL. Of the latter group, 374 (46%) were not on a statin, including 188 patients with an LDL-C >130 mg/dL. Compliance among secondary prevention patients with cerebrovascular or peripheral vascular disease, but not coronary disease, was even lower: 19% versus 36%, P < .0001. Most of the additional noncompliant patients never had an LDL-C checked. Patient-specific factors associated with compliance included having seen a cardiologist (45% vs 21%); having had a recent admission for myocardial infarction, unstable angina, or angina (41% vs 26%); being male (37% vs 24%); and being white (34% vs 26%). Patients over 79 and under 50 years old also were less likely to be compliant (22% vs 34% for 50–79 year olds). There were no significant differences in compliance rates based on physician-specific factors, such as level of training, gender, or panel size. CONCLUSION: We found poor compliance with nationally published and well-accepted guidelines on diagnosing and treating hypercholesterolemia in secondary prevention patients. Compliance was unrelated to physician or physician-specific characteristics, but it was especially low for women, African Americans, patients without a cardiologist, and patients with cerebrovascular and peripheral vascular disease

A Regional Evaluation of Variation in Low-Severity Hospital Admissions

OBJECTIVE: Determine patient and hospital-level variation in proportions of low-severity admissions. DESIGN: Retrospective cohort study. SETTING: Thirty hospitals in a large metropolitan region. PATIENTS: A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n = 25,213) or pneumonia (n = 17,996). MEASUREMENTS AND MAIN RESULTS: Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients’ medical records. Admissions were categorized as “low severity” if the predicted risk of death was less than 1%. Nearly 15% of patients (n = 6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p < .001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p < .001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p < .01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors. CONCLUSIONS: Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services

Ambulatory Hypercholesterolemia Management in Patients with Atherosclerosis: Gender and Race Differences in Processes and Outcomes

OBJECTIVE: To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control. DESIGN: Retrospective cohort study. SETTING: Primary care clinics affiliated with an academic medical center. PARTICIPANTS: Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl. MEASUREMENTS AND MAIN RESULTS: The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P =.01), and 37.3% of black and 31.7% of white patients' visits (P =.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P =.003), black than white patients (39% vs 58%; P =.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P =.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender. CONCLUSIONS: In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients

Do Race and Gender Influence the Use of Invasive Procedures?

OBJECTIVE: To assess the influence of race and gender influence on the use of invasive procedures in patients with acute myocardial infarction (AMI) in community hospitals. DESIGN: Prospective, observational. SETTING: Five mid-Michigan community hospitals. PATIENTS: All patients (838) identified with AMI between January 1994 and April 1995 in 1 of these hospitals. MEASUREMENTS AND MAIN RESULTS: After adjusting for age, hospital of admission, insurance type, severity of AMI, and comorbidity, using white men as the reference group, the rate of being offered cardiac catheterization (CC) was 0.88 (95% confidence interval [95% CI], 0.60 to 1.29) for white women; 0.79 (95% CI, 0.41 to 1.50) for black men; and 1.14 (95% CI, 0.53 to 2.45)for black women. Among patients who underwent CC, after also adjusting for coronary artery anatomy, the rate of being offered angioplasty, using white men as the reference group, was 1.22 (95% CI, 0.75 to 1.98) for white women; 0.61 (5% CI, 0.29 to 1.28, P = .192) for black men; and 0.40 (95% CI, 0.14 to 1.13) for black women The adjusted rate of being offered bypass surgery was 0.47 (95% CI, 0.24 to 0.89) for white women; 0.36 (95% CI, 0.12 to 1.06) for black men; and 0.37 (95% CI, 0.11 to 1.28)for black women. CONCLUSIONS: Our study shows that white women are less likely than white men to be offered bypass surgery after AMI. Although black men and women with AMI are less likely than white men to be offered percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in both unadjusted and adjusted analyses, these findings did not reach statistical significance. Our study is limited in power due to the small number of blacks in the sample

Racial/ethnic disparities among Asian Americans in inpatient acute myocardial infarction mortality in the United States

Abstract Background Acute myocardial infarction (AMI) is a common high-risk disease with inpatient mortality of 5% nationally. But little is known about this outcome among Asian Americans (Asians), a fast growing racial/ethnic minority in the country. The objectives of the study are to obtain near-national estimates of differences in AMI inpatient mortality between minorities (including Asians) and non-Hispanic Whites and identify comorbidities and sociodemographic characteristics associated with these differences. Method This is a retrospective analysis of 2010–2011 state inpatient discharge data from 10 states with the largest share of Asian population. We identified hospitalization with a primary diagnosis of AMI using the ICD-9 code and used self-reported race/ethnicity to identify White, Black, Hispanic, and Asian. We performed descriptive analysis of sociodemographic characteristics, medical comorbidities, type of AMI, and receipt of cardiac procedures. Next, we examined overall inpatient AMI mortality rate based on patients’ race/ethnicity. We also examined the types of AMI and a receipt of invasive cardiac procedures by race/ethnicity. Lastly, we used sequential multivariate logistic regression models to study inpatient mortality for each minority group compared to Whites, adjusting for covariates. Results Over 70% of the national Asian population resides in the 10 states. There were 496,472 hospitalizations with a primary diagnosis of AMI; 75% of all cases were Whites, 10% were Blacks, 12% were Hispanics, and 3% were Asians. Asians had a higher prevalence of cardiac comorbidities, including hypertension, diabetes, and kidney failure compared to Whites (p-value< 0.01). There were 158,623 STEMI (ST-elevation AMI), and the proportion of hospitalizations for STEMI was the highest for Asians (35.2% for Asians, 32.7% for Whites, 25.3% for Blacks, and 32.1% for Hispanics). Asians had the highest rates of inpatient AMI mortality: 7.2% for Asians, 6.3% for Whites, 5.4% for Blacks, and 5.9% for Hispanics (ANOVA p-value < 0.01). In adjusted analyses, Asians (OR = 1.11 [95% CI: 1.04–1.19]) and Hispanics (OR = 1.14 [1.09–1.19]) had a higher likelihood of inpatient mortality compared to Whites. Conclusions Asians had a higher risk-adjusted likelihood of inpatient AMI mortality compared to Whites. Further research is needed to identify the underlying reasons for this finding to improve AMI disparities for Asians