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A National Survey of Practice Patterns of Gastroenterologists With Comparison to the Past Two Decades

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A National Survey of Practice Patterns of Gastroenterologists With Comparison to the Past Two Decades
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  [Clinical Research] Journal of Clinical Gastroenterology Issue: Volume 29(4), December 1999, pp 339‐343Copyright: © 1999 Lippincott Williams & Wilkins, Inc.Publication Type: [Clinical Research]ISSN: 0192‐0790Accession: 00004836‐199912000‐00009Keywords: Gastroenterology, Survey, Irritable bowel syndrome A National Survey of Practice Patterns of Gastroenterologists With Comparison to the Past Two Decades Russo, Mark W. M.D., M.P.H.; Gaynes, Bradley N. M.D., M.P.H.; Drossman, Douglas A. M.D. Author Information From the Departments of Medicine (M.W.R., D.A.D.) and Psychiatry (B.N.G., D.A.D.), University of North Carolina, Chapel Hill, NC.Supported by the National Institutes of Health grant no. DK‐34987 (M.W.R.) and the Robert Wood Johnson Foundation while Dr. Gaynes was a Robert Wood JohnsonClinical Scholar.Address correspondence and reprint requests to Dr. Mark W. Russo, Cornell Medical Center‐New York Hospital, Division of Gastroenterology and Hepatology, 525 East68th Street, Room F231, New York, NY 10021. Abstract  Previous surveys on the practice of gastroenterology collected limited data on practice demographics.Gastroenterology practices may have changed over the past decade as a result of changes in health care delivery.The authors sought to describe the practice composition and demographics of today's gastroenterologist, and alsoto make comparisons to prior studies to determine whether changes have occurred. A nationwide cross‐sectionalsurvey was performed in 1997 of 900 American Gastroenterological Association (AGA) members selected randomlyfrom the AGA directory. A total of 767 AGA members were eligible for the study, and 376 responded (responserate, 49%). The mean age was 46 years old and the mean year training was completed was 1982. The majority of gastroenterologists were in solo or group practice (57%) and in an urban setting (55%). Respondents were fairlyequally represented from different regions of the country. The most common diagnosis seen was irritable bowelsyndrome ([IBS] 19%), followed by esophageal reflux (17%) and inflammatory bowel disease (14%). Functionaldisorders as a group (IBS, nonulcer dyspepsia, and other functional disorders) were, by far, the most commondisorders (35%), which is similar to findings in prior studies of gastrointestinal practices. Only 3% of gastroenterologists believed that managed care has made it easier to deliver quality health care to patients withIBS. Despite changes that have occurred in health care over the past decade, the types of diagnoses seen ingastroenterology practices has remained the same. Most gastroenterologists feel that managed care has not madeit easier to deliver quality health care. Since the study by Switz 1 in 1973 describing the practice of Virginian gastroenterologists, the practice of medicine has changed dramatically. At the time of Switz's study,1 solo practice was common, in contrast tocurrent times in which large group practices and managed care organizations are the norm. In the 1973 study of 22members of the Virginia state gastroenterologic society, the most common diagnoses seen by this group of physicians were functional disorders, duodenal ulcer, and hiatal hernia.1 Six years after Switz's study,1 Manning et al.2 surveyed the practice of a single gastroenterologist and identified abdominal pain of unknown cause (functional abdominal pain), esophageal reflux and its complications,peptic ulcer disease, and irritable bowel syndrome (IBS) as the most common diagnoses encountered. In 1984, asurvey of 500 American Gastroenterological Association (AGA) members was conducted on functionalgastrointestinal disorders and inflammatory bowel disease.3 Physicians reported that 28% of patients had IBS and13% had other functional disorders compared with 14% of patients who had Crohn's disease or ulcerative colitis. Each of these surveys describing the practice of the gastroenterologist has its limitations. The study by Switz 1was restricted to gastroenterologists from a single state, and the study by Manning et al.2 was limited to a singlepractice. The types of diagnoses seen may have changed since a prior survey of AGA members.3 Information wasnot reported on other important practice variables, such as number of patients seen or time spent with patients. Managed care organizations exert influence on clinicians and practices in an attempt to contain cost and atthe same time ensure high quality.4 Implications for gastroenterologists include limitation of patient access togastroenterologists and eliminating some endoscopic and consultative services.4 Because managed care influencesthe delivery of healthcare, there may have been substantial changes in referral patterns, and thus patientcomposition in gastrointestinal practices.4   The goals of our study were to collect information on practice demographics and types of diagnoses seen bygastroenterologists in 1997, to compare the data with previous surveys to determine whether changes haveoccurred, and to collect "baseline" data to determine if or how market forces may change future practice. Inaddition, we asked participants their opinion on how managed care has affected the delivery of health care, whichmay be helpful in gaining insight on how to improve quality of care.  METHODS  We developed a survey that asked gastroenterologists questions about their practice. The initial survey waspiloted by 20 North Carolina gastroenterologists to determine whether questions were interpreted clearly and toobtain feedback on content. After these surveys were returned, we made changes based on comments anddiscussions with the participants. The 20 gastroenterologists included in the pilot were excluded from the study.In March 1997 we mailed the finalized survey to 900 United States gastroenterologists sampled randomly from theAGA directory. Four weeks after the first mailing we mailed a second survey to those who did not respond. Twoweeks after the second mailing we mailed a third survey, and called physicians who did not return a survey. The survey collected data on demographics, such as age, practice type (health maintenance organization[HMO], solo/group, academic), practice setting (urban, suburban, rural), and proportion of practice covered bymanaged care. We also asked questions about types of principal diagnoses seen, time spent performing endoscopy,and time spent seeing patients. We included principal diagnoses that respondents from the pilot survey reportedseeing in at least 5% of patients. Geographic location was grouped according to the US Census Bureau, by West,Southeast, Midwest, and Northeast.5 Questions were either multiple choice, entailed the respondent to place anX on a scale (Likert scale), or required the respondent to fill in the blank. Only full‐time, academic, and private‐practice gastroenterologists in the United States were included in thestudy. Thus, surgeons, pediatric, part‐time or retired gastroenterologists, and hepatologists were excluded. Responses were entered into the Epi‐info and STATA statistical software package (STATA S, STATA Corp.,Collegetown, TX). Univariate analysis was performed, and means were compared using Student's t ‐test orWilcoxon's rank sum test when appropriate, and proportions were compared using chi‐square analysis. Responseswere stratified on variables we thought a priori to be important, including age, practice type and setting,proportion of practice covered by managed care, proportion of time spent performing endoscopy, and geographiclocation.  RESULTS   Demographic Features  Of 900 randomly selected AGA members, 767 were eligible for the study. Of these, 376 returned surveys(response rate, 49%). A total of 5% of respondents were hepatologists and were excluded from analyses; 92% of respondents were men. The mean age was 42 years old and the mean year training was completed was 1982. Mostgastroenterologists were in solo or group practice (57%) and in a urban or suburban setting (91%). Respondentswere fairly evenly distributed geographically. Characteristics of our study population were similar to those of theAGA (Table 1).   TABLE 1. Characteristics of the study population Diagnoses  Table 2 lists principal diagnoses seen in decreasing order of frequency. IBS was reported as the most commondisorder seen (19%), followed by esophageal reflux and esophagitis (17%). As a group, functional disorders (IBS,nonulcer dyspepsia, other functional disorders) were, by far, the most common group of disorders seen (35%).Biliary and pancreatic disorders were among the least common disorders seen. TABLE 2. Diagnoses seen in our survey and compared with prior surveys  We compared our results with prior surveys. Functional disorders as a group have remained the most commondisorders seen, and acid/peptic disorders seem to be decreasing in frequency. Our survey was most similar to thesurvey by Mitchell and Drossman 3 because we asked questions in the same manner as their survey and they alsosurveyed AGA members. Both studies found that 14% of patients had inflammatory bowel disease, and both foundthat IBS and functional disorders were the most common diagnoses made (see Table 2).  Practice Features  The mean number of outpatients seen in a typical month was 155 ± 103, and 30 of these patients (19%) hadIBS. Thirty‐nine percent of outpatients were covered by managed care or HMO, and respondents reportedspending 33% of their time performing endoscopy. Gastroenterologists reported spending 44 ± 15 minutes for newpatient consultations and 19 ± 7 minutes for follow‐up visits. Gastroenterologists reported similar results for thetime they believed they needed   to see new patient consultations and follow‐up visits: 48 ± 17 minutes and 21 ± 9minutes, respectively.  Comparative Data  After stratifying results by age, gender, practice setting, and geographic region, we did not find differences inthe frequency of diagnoses seen, time spent with patients, or time performing endoscopy. We did find differencesin managed care and number of outpatients by geographic region. The proportion of patient load covered bymanaged care was greatest in the West and least in the Midwest (50 ± 31% and 32 ± 185 respectively;  p  < 0.05).The mean number of outpatients seen in a typical month was greatest for the South and least for the Midwest(167 ± 106 and 137 ± 95 respectively;  p  < 0.01). The number of outpatients seen also varied by practice type.Solo/group and HMO physicians saw more outpatients in a month than academic physicians (184 ± 101 and 206 ± 114vs. 88 ± 62 respectively;  p  < 0.05) and academic physicians saw fewer IBS patients (12% compared with 22% and 20%for solo/group and HMO respectively;  p  < 0.05).  Responses About Managed Care  Table 3 shows results from responses to questions about managed care. Compared with 5 years ago, themajority of the respondents did not believe that primary care physicians follow more IBS patients. Forty‐eightpercent of gastroenterologists believed that managed care has limited their capacity to follow IBS patients. Mostgastroenterologists believed that managed care has not made it easier to deliver quality health care to their IBSpatients. TABLE 3. Responses to questions about managed careResponses about managed care varied when stratified by practice type. Sixty‐six percent and 61% of gastroenterologists in solo/group practice and academicians believed that managed care has made it more difficultto deliver quality health care to IBS patients respectively, whereas 23% of HMO physicians believed managed caremade it more difficult (  p  < 0.001 for solo/group vs. HMO; Fig. 1). Approximately half of those in solo/group practiceand academicians believed that managed care has limited their ability to follow IBS patients compared with 32% of   respondents in HMOs (  p  < 0.05 for solo/group vs. HMO). FIG. 1. Responses to the statement that managed care has made it easier to deliver quality health care topatients with irritable bowel syndrome, by practice type. HMO, health maintenance organization. DISCUSSION  There are approximately 60 million people enrolled in HMOs, and the percentage of workers in privatecompanies who are enrolled in some form of managed care has increased from 29% in 1988 to 70% in 1995.4,6Because the healthcare environment has changed substantially, we thought that changes might have occurred ingastroenterologic practices. Therefore, we surveyed AGA members to collect data on practice demographics andcomposition so that we could have current information on practices, make comparisons with a prior AGA survey todetermine whether changes have occurred, and ascertain gastroenterologists' attitudes on health care deliveryand quality of care. Our survey shows that IBS remains the most common disorder seen, and functional disorders as a group (IBS,nonulcer dyspepsia, other functional disorders) are by far the most common disorders encountered (35%),approximately twice as common as esophagitis and gastroesophageal reflux disease (17%). Our results are similar toresults published in 1987.3 Thus, although the health care environment has changed, this has not had an impacton referrals for functional gastrointestinal disorders. Our findings support the recommendation thatgastroenterology training programs include training for patients with functional gastrointestinal disorders.7 Diverticular disease, polyps, and cancer were noticeably absent from our list of diagnoses seen. Diverticulardisease was not reported in prior surveys,1‐3 possibly because it is rarely seen as a problem in the outpatientsetting. Colon cancer constituted 3% of diagnoses seen by Virginian gastroenterologists,1 and polyps constitutedonly 4.7% of diagnoses seen in the study by Manning et al.2 Colonic neoplasms remain an uncommon diagnosis forreferral in 1997. Responses from our pilot survey demonstrated that less than 5% of patients are referred forcolonic neoplasms. Thus, colonic neoplasm was not listed as a specific diagnosis in our survey. Patients with polypsor cancer are referred frequently for procedures rather than referred for diagnostic or management issues. 
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