Is an online skin cancer toolkit an effective way to educate primary care physicians about skin cancer diagnosis and referral?

Background: Skin disorders account for over 20% of GP consultations. Half of dermatology referrals to secondary care are for skin lesions, but only 12% of urgent skin cancer referrals are deemed appropriate. Suitably designed online learning resources may positively impact GP confidence in the recognition of skin cancer and improve patient outcomes.

Attrition in the RAND Health Insurance Experiment: a response to Nyman.

In a prior article in this journal, John Nyman argues that the effect on health care use and spending found in the RAND Health Insurance Experiment is an artifact of greater voluntary attrition in the cost-sharing plans relative to the free care plan. Specifically, he speculates that those in the cost-sharing plans, when faced with a hospitalization, withdrew. His argument is implausible because (1) families facing a hospitalization would be worse off financially by withdrawing; (2) a large number of observational studies find a similar effect of cost sharing on use; (3) those who left did not differ in their utilization prior to leaving; (4) if there had been no attrition and cost sharing did not reduce hospitalization rates, each adult in each family that withdrew would have had to have been hospitalized once each year for the duration of time they would otherwise have been in the experiment, an implausibly high rate; (5) there are benign explanations for the higher attrition in the cost-sharing plans.

Effect of geotropism on instrument readings. Calibrating survey meters to account for geotropism is discussed.

Geotropism is an analog meter's response due to orientation in a gravitational field whether radiation is present or not. For a conventional analog meter, the geotropic response is reflected in the movement of the meter needle. Geotropism is not relevant for digital portable survey (e.

Differences in clinical decision making between internists and cardiologists.

Background: Whether cardiologists or internists use discretionary tests differently for noncritical cardiological presentation is unclear.

Objective: To explore differences in decision making for 3 common scenarios.

Methods: We asked 318 cardiologists and 598 internists to manage scenario patients presenting with (1) uncomplicated syncope, (2) nonanginal chest pain, and (3) nonspecific electrocardiographic changes.

Physicians' personal malpractice experiences are not related to defensive clinical practices.

Whether personal malpractice experience is part of a tort signal prompting physicians to practice defensively is unclear. To explore this issue further, we assessed how physicians' malpractice experiences affect clinical decision making. We surveyed 1,540 physicians from four specialty groups (cardiologists, surgeons, obstetrician-gynecologists, and internists) using specialty-specific clinical scenarios.

Empirical Bayes methods for estimating hospital-specific mortality rates.

We present alternative methods for estimating hospital-level mortality rates to those used by the Health Care Finance Administration for Medicare patients. We use an empirical Bayes model to represent the different sources of variation in observed hospital-specific mortality rates and we use a logistic regression model to adjust for severity differences (in patient mix) across hospitals. In addition to providing a principled derivation of a standard error for the commonly used estimator, our fully model-based formulation produces much more accurate estimates and resolves the severe problem of multiple comparisons that arises when extreme estimates are used to identify exceptional hospitals.

Amending the National Practitioner Data Bank reporting requirements: are small claims predictive of large claims?

This study addresses whether a physician incurring small malpractice claims is predictive of large claims. This is one consideration behind reevaluating whether all claims that result in an indemnity payment should continue to be reported to the National Practitioner Data Bank, or whether claims with payments below some "floor" should be excluded. Using a claims database from 3,098 physicians for 1977-1986, both cross-sectional and longitudinal analyses show that an individual having a small claim (under $30,000) is indicative of a propensity to incur large claims.

Malpractice claims data as a quality improvement tool. II. Is targeting effective?

Objective: --To evaluate the usefulness of malpractice claims data for identifying (1) physicians who are prone to negligent errors and (2) physician and hospital characteristics associated with particular kinds of errors.

Design: --Retrospective review of physician malpractice claim records.

Setting: --Large New Jersey physician malpractice insurer.

Malpractice claims data as a quality improvement tool. I. Epidemiology of error in four specialties.

Objective: --To identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology.

Design: --Retrospective review of physician malpractice claim records.

Setting: --Large New Jersey physician malpractice insurer.

The demand for episodes of treatment in the Health Insurance Experiment.

This paper analyzes claims data from the RAND Insurance Experiment, which were grouped into episodes of treatment. The insurance plans in the experiment have coinsurance and a cap on out-of-pocket spending. Using new statistical techniques to adjust for the increased sickliness of those who exceed the cap, the effects of coinsurance on cost per episode and number of episodes are estimated.

Use, costs, and quality of medical services: impact of the New Mexico peer review system. A 1971-1975 study.

To assess the effect of areawide peer review (such as that conducted by Professional Standards Review Organizations [PSROs]) on use, cost and quality of medical services, we evaluated 4 years of data on the efforts of the New Mexico Experimental Medical Care Review Organization in reviewing medical services for the Medicaid population. Utilization review had no demonstrable impact on hospital use; hospital days per 100 eligible persons rose 5.0% and 43.