0 I

Letters to the Editor are welcomed and will be published, iffound suitable, as space permits. Submission of a Letter to the Editor constitutes permission for its publication in the Journal. Letters should not duplicate similar material being submitted or published elsewhere. Letters refemng to a recent Journal article should be received within three months of the article's publication. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and should not exceed 400 words.

On Quality of Ambulatory Care The article on the quality of ambulatory care in Medicare HMOs by Retchin and Brown' may have an interpretation different from that of the authors. The authors did not describe the approach to recording of history and physical examinations in the HMOs and fee-for-services practices or how they differed. The administrative device of requiring use of standard preprinted forms results in recording of more negative history and physical findings than does the use of the blank page form common to physician office practice. The results reported in their Tables 2 and 3 may reflect practice organization and type of record as much as quality of physician performance. Table 3 reported the performance of urinalysis, hemoglobin, blood urea nitrogen or serum creatinine, and electrocardiograms. Apparently consultants had recommended that these tests should be performed as part of the routine evaluation of the geriatric population. These recommendations are in marked contrast to the recommendations from the Guide to Clinical Preventive Services2 reported by the US Preventive Services Task Force in 1989. In the Guide, urinalysis and hemoglobin are not recommended; the Guide is silent on blood urea nitrogen or serum creatinine; the resting electrocardiogram is specifically not recommended as a routine screening test for 1136

Letters to the Editor any group. The Guide recommends reserving these tests for specific indications presented by individual patients. Thus less than 100 percent achievement should be the expected and desirable result for asymptomatic patients by all physicians. In their Table 4, the authors report the odds ratio performance of various components of health examinations. The Guide does not recommend the use of the fecal occult blood test, and recommends mammography every one to two years after age 60, with no recommendation about the use of this examination after age 75. Using this standard performance is not adequately evaluated. The Guide recommends the performance of influenza immunization for individuals over age 65. For this proven preventive intervention the performance of the fee-for-service physicians exceeds that of IPA-HMO physicians. The data in Table 4 do not consistently document superior performance by physicians in either setting. Based on the data reported by Retchin and Brown, I am unable to determine which group of physicians most closely approximates the standard of ambulatory practice in this country. I cannot conclude that either fee-forservice or prepaid practice is practicing effective preventive medicine in ambulatory care. This research has not identified a standard of ambulatory practice or the technique to measure its achievement. REFERENCES 1. Retchin SM, Brown B: The quality of ambulatory care in Medicare health maintenance organizations. Am J Public Health 1990; 80:411-415. 2. Guide to Clinical Preventive Services. Report of the US Preventive Services Task Force, 1989; pp 3-6, 26-36, 106, 109, 246. John T. Ashley, MD Associate Vice President, University of Virginia, Health Sciences Center, Box 236, Charlottesville, VA 22908. © 1990 American Journal of Public Health

Response from Retchin and Brown Dr. Ashley raises interesting issues regarding the authenticity of medical

records as evidence on the quality of care. Different systems of care may indeed elect to use more organized formats for medical records that encourage physicians to be more diligent in recording items from medical history-taking and physical examination. However, for the complicated elderly patient often seen by multiple physicians, we believe the organization and legibility of the medical record is an important component of the quality of patient care. Medical practices that tolerate poorly organized records contribute to an already fragmented system of medical care, and may lead to unnecessary or harmful duplication of services. Others agree.' Dr. Ashley's remarks about components of the health examination that were more often performed for health maintenance organization (HMO) patients raise important issues concerning the design and purpose of our study. First, our sampling strategy was limited to new patient evaluations; we did not attempt to determine the appropriateness of physician-ordering for urinalyses, hemoglobins or electrocardiograms, according to the presence of signs or symptoms. The guidelines from the U.S. Preventive Services Task Force that Dr. Ashley cites address preventive measures for asymptomatic patients. To our knowledge, it was not the intent of the Task Force to comment on the appropriateness of ordering these tests for symptomatic patients. Dr. Ashley is correct in his conclusion that fee-for-service (FFS) patients were more likely than independent practice association (IPA) HMO patients to have influenza immunizations performed. However, the proportion of patients who had immunizations was low for both groups (FFS 21%, IPA HMO 12%); certainly below a reasonable standard of care. Second, the purpose of the National Medicare Competition Evaluation was to examine the medical care of beneficiaries who elected to enroll in prepaid plans. Because of concern that prepayment might lead to under-utilization of necessary items, we assessed a broad range of components representing both periAJPH September 1990, Vol. 80, No. 9

On quality of ambulatory care.

0 I Letters to the Editor are welcomed and will be published, iffound suitable, as space permits. Submission of a Letter to the Editor constitutes pe...
218KB Sizes 0 Downloads 0 Views