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The Acute Community Care Program (ACCP) initiative sends specially trained paramedics to evaluate and treat patients with urgent care problems in their residences during evening hours. ACCP safety depends on making appropriate triage decisions from patients’ reports during phone calls about whether paramedics could care for patients’ urgent needs or whether they require emergency department (ED) services. Furthermore, after ACCP paramedics are on scene, patients may nonetheless need ED care if their urgent health problems are not adequately treated by the paramedic’s interventions. To train clinical staff participating in all aspects of ACCP, including these triage decisions, ACCP clinical leaders developed brief vignettes: 27 represented initial ACCP triage decisions and 10 the subsequent decision to send patients to EDs. This report describes findings from an online survey completed by 24 clinical staff involved with ACCP triage. Clinical vignettes could be useful for staff training and quality control in such paramedic initiatives.

Objectives The objective of this study is to describe the maternal characteristics, pregnancy complications, and birth outcomes among a representative sample of Rhode Island women with disabilities who recently gave birth. Methods Data from the 2002-2011 Rhode Island Pregnancy Risk Assessment Monitoring System survey were analyzed. Results Approximately 7% of women in Rhode Island reported a disability. Women with disabilities reported significant disparities in their health care utilization, health behaviors, and health status before and during pregnancy and during the postpartum period. Compared with nondisabled women, they were significantly more likely to report stressful life events and medical complications during their most recent pregnancy, were less likely to receive prenatal care in the first trimester, and more likely to have preterm births (13.4%; 95% CI, 11.6-15.6 compared with 8.9%; 95% CI, 8.5-9.3 for women without disabilities) and low-birth-weight babies (10.3%; 95% CI, 9.4-11.2 compared with 6.8%; 95% CI, 6.8-6.9). There was no difference in the rates of cesarean section between women with and without disabilities. Conclusions These findings support the need for clinicians providing care to pregnant women with disabilities to be aware of the increased risk for medical problems during pregnancy and factors that increase the risk for poor infant outcomes.

Background The number of US women of childbearing age who have chronic physical disabilities (CPD) is increasing. However, little is known about their reproductive experiences. Historically, women with physical disabilities have confronted stigmatized attitudes about becoming pregnant. Objectives To explore the national prevalence of current pregnancy among women with and without CPD; examine differences in current pregnancy prevalence between these 2 groups of women. Research design Bivariable and multivariable analyses of cross-sectional, nationally representative National Health Interview Survey data from 2006 to 2011. Subjects Forty-seven thousand six hundred twenty-nine civilian, noninstitutionalized women aged 18-49 years. Measures National Health Interview Survey asks women ages 18-49 if they are currently pregnant; it also asks about various movement difficulties. We used responses from 8 movement difficulty and other questions to identify women with CPD. Results Six thousand forty-three (12.7%) sampled women report CPD. Compared with other women, women with CPD are significantly: older; more likely to be black and less likely to be Asian or Hispanic; more likely to be divorced or separated; more likely to have less than a high school education; less likely to be employed; and have much lower incomes. Across all women, 3.5% report being currently pregnant: 3.8% of women without CPD and 2.0% with CPD. Controlling for sociodemographic factors, the adjusted odds ratio (95% confidence interval) of current pregnancy is 0.83 (95% confidence interval, 0.65-1.05; P=0.12) for women with CPD compared with nondisabled women. Conclusions Women with CPD do become pregnant, and their numbers will likely grow. Obstetrical practitioners therefore require training about the special needs of these women.

This narrative is related in the alternating voices of the two authors. One author, a 55-year-old man, quadriplegic from primary progressive multiple sclerosis, describes the 10 weeks he spent in four facilities for treatment of a stage IV ischial pressure ulcer. The other author, his friend and health care proxy, describes the advocacy and personal assistance she gave him in the face of often inadequate care that at times threatened his safety, comfort, and emotional well-being. The authors describe their differing perspectives on this care, which involved a transfer onto his open wound, frequently missed meals, and poor bowel management and personal hygiene. They believe that inadequate staffing and insufficient training and supervision of nursing assistants, among other factors, underlay these problems.

Hospital-wide mortality rates are used as a measure of overall hospital quality. However, their parsimony and apparent simplicity belie significant conceptual and methodological concerns. For many diagnoses included in hospital-wide mortality, the association between short-term mortality and quality of care is not well established. Furthermore, compared with condition-specific or procedure-specific mortality, hospital-wide mortality rates pose greater methodological challenges (ie, eligibility and exclusion criteria, risk adjustment, statistical techniques for aggregating across diagnoses, usability). Many of these result from substantial interprovider heterogeneity in diagnosis frequency, sample sizes, and patient severity. Hospital-wide mortality is problematic as a quality metric for public reporting, although hospitals may elect to use such measures for other purposes. Potential alternative approaches include multidimensional composite metrics or mortality measurement limited to selected conditions and procedures for which the link between hospital mortality and quality is clear, legitimate exclusions are uncommon, and sample sizes, end points, and risk adjustment are adequate.

Although critics often raise concerns about Medicare's acute care focus, 1, 2 the program also covers substantial services beyond acute care, including rehabilitation therapy in inpatient rehabilitation hospitals, skilled nursing facilities, hospital outpatient departments, private therapists’ offices, and patients’ homes. Lumped broadly under the phrase “post-acute care,” Medicare costs for such services grew rapidly, especially after adoption of prospective payment for acute care hospitalizations. 3-7 To slow and contain these rising Medicare costs, the 1997 Balanced Budget Act (BBA) introduced prospective payment for post-acute care, phasing in these systems in different settings across several years. 4, 7-11 Since then, governmental agencies (e.g., the Medicare Payment Advisory Commission or MedPAC) and researchers have examined how BBA's payment policy changes have affected post-acute care service use and expenditures. 3, 5, 9, 11-19 Early draconian drops in home health care prompted Congress to pass the 1999 Balance Budget Refinement Act (BBRA), which eased certain BBA payment provisions. Congress worried that some persons who needed post-acute care no longer had access to these services. Studies of recent trends in rehabilitation therapy use by Medicare beneficiaries have generally relied on information with limited clinical content, notably reimbursement claims. 11, 20 Claims-based analyses provide excellent information about the volume and costs of covered services. However, claims analyses offer little insight into whether service patterns have changed for persons with strong clinical indications for rehabilitation services. In other words, has service intensity changed over time for patients who likely need these services? This study explored use of physical and occupational therapy (PT and OT) between 1994 and 2001 using data from the Medicare Current Beneficiary Survey (MCBS). MCBS data include respondents’ self reports of various diagnoses, functional impairments, and activities of daily living (ADL) limitations; MCBS files also include the amount of services used with and without Medicare reimbursement. We examined therapy patterns within five conditions that often could benefit from PT and/or OT: new (incident) stroke; new (incident) acute myocardial infarction (AMI); chronic obstructive pulmonary disease (COPD); arthritis or degenerative joint disease (DJD); and lower extremity mobility problems, regardless of cause. These five conditions represent three broad clinical indications for PT and/or OT: acute events with potentially chronic, debilitating consequences (stroke and AMI); chronic, progressive conditions with potentially acute exacerbations (arthritis/DJD and COPD); and a functional impairment representing a “final common pathway” for many debilitating diseases, regardless of etiology (lower extremity mobility problems). This research was part of a larger study looking at outcomes of PT and OT provided in community settings. Given its policy and practical importance, we took advantage of our longitudinal data set to examine trends of service use immediately before and after passage of the BBA. An earlier publication used cross-sectional analyses of MCBS data from 1995, 1999, and 2001 to explore patterns of PT and OT use in different settings of care (inpatient rehabilitation facility, skilled nursing facility, home health agency, and outpatient settings).7 The analyses presented here use the complete longitudinal data file (1994-2001) and sophisticated mathematical modeling methods to explore three primary research questions: (1) What proportion of persons with these clinical indications for PT and/or OT received services from 1994 through 2001? (2) How did their service intensity (i.e., units of services used) vary from 1994 through 2001? (3) Did service intensity vary by patients’ demographic characteristics (e.g., were there disparities in care by gender or race/ethnicity)? We hypothesized that the proportion of persons receiving these services – and the intensity of service use – would decline in the years following the BBA passage as new prospective payment systems were implemented. We also hypothesized that certain subsets of patients, such as those with low incomes, less education, and racial and ethnic minorities, would be less likely to receive PT and/or OT services.

Background: Efforts to enhance patient-physician communication may improve management of underdiagnosed chronic conditions. Patient internet portals offer an efficient venue for coaching patients to discuss chronic conditions with their primary care physicians (PCP). Objectives: We sought to test the effectiveness of an internet portal-based coaching intervention to promote patient-PCP discussion about chronic conditions. Research Design: We conducted a randomized trial of a nurse coach intervention conducted entirely through a patient internet portal. Subjects: Two hundred forty-one patients who were registered portal users with scheduled PCP appointments were screened through the portal for 3 target conditions, depression, chronic pain, mobility difficulty, and randomized to intervention and control groups. Measures: One-week and 3-month patient surveys assessed visit experiences, target conditions, and quality of life; chart abstractions assessed diagnosis and management during PCP visit. Results: Similar high percentages of intervention (85%) and control (80%) participants reported discussing their screened condition during their PCP visit. More intervention than control patients reported their PCP gave them specific advice about their health (94% vs. 84%; P = 0.03) and referred them to a specialist (51% vs. 28%; P + 0.002). Intervention participants reported somewhat higher satisfaction than controls (P = 0.07). Results showed no differences in detection or management of screened conditions, symptom ratings, and quality of life between groups. Conclusions: Internet portal-based coaching produced some possible benefits in care for chronic conditions but without significantly changing patient outcomes. Limited sample sizes may have contributed to insignificant findings. Further research should explore ways internet portals may improve patient outcomes in primary care.

Persons who are blind or have low vision face special challenges in obtaining care that is safe, effective, timely, and patient centered. To explore perceptions of care and recommendations for improvements, we conducted 8 interviews with experts and 2 focus groups with 19 persons, all of whom are blind or have low vision. Interviewees perceived that they confront special barriers to care because of being blind or having low vision. Barriers fell into 4 broad categories: basic respect, including concerns about physicians thinking they cannot participate fully in their own care; communication barriers, including difficulties interacting with physicians and office staff; physical access barriers, including difficulties getting to and around physicians' offices; and information barriers, including receiving written materials in inaccessible formats (eg, not in Braille, large print, or audiotape). Using common courtesy and individualized communication techniques, physicians and office staff could improve health care experiences of blind and low-vision patients.

The Americans With Disabilities Act defines disability on the basis of physical or mental impairments or external perceptions of impairment.The objective of this study was to examine perceptions of disability among people with lower-extremity mobility difficulties.This study used a cross-sectional, nationally representative survey, the 1994 to 1995 National Health Interview Survey-Disability (NHIS-D) supplement. Using SAS-callable SUDAAN for all analyses, we produced national population estimates.This study included 142,572 noninstitutionalized, civilian residents of the United States who wereor =18 years of age, with 80,423 self-respondents and 49,883 proxy respondents.We created a 4-level mobility variable using NHIS-D questions about the ability to walk, climb stairs, stand and the use of mobility aids. We examined associations between mobility and answers to 2 questions about self- and external perceptions of disability.The results showed that 3.1% (estimated 5.82 million persons) reported major mobility difficulties, including 3.7% of self-respondents and 2.7% of those with proxy respondents. Among persons with major mobility problems, 70.8% perceived themselves as disabled, whereas 64.8% thought other people see them as disabled. Also, 80.5% of manual wheelchair users saw themselves as disabled. Proxies were somewhat more likely to perceive disability than self-respondents, although differences were not generally statistically significant. In multivariable regressions, mobility level was the strongest predictor of self-perceived disability, followed by general health status.Mobility problems increase the likelihood that people will see themselves as disabled, but these perceptions are not universal. Although the schematic of wheelchair users has become an international symbol of disability, many people with serious mobility problems do not view themselves as disabled.

This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital.We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California.Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record. For 13% of the surgical cases and 58% of the medical cases, the condition represented by the code was judged to be present on admission rather than occurring in-hospital. The positive predictive value of the claim was greater than 80% for the surgical risk pool, suggesting the value of the CSP as a screening tool.The CSP has validity as a screen for most surgical complications but only for 1 medical complication. The CSP does not have validity as a "stand-alone" tool to identify more than a few in-hospital surgery-related events. The addition of an indicator to the Medicare claim to capture the timing of secondary diagnoses would improve the validity of the CSP for identifying both surgical and medical in-hospital events.

We aim to develop and validate a questionnaire that examines quality of care from the patient's perspective for limited-English-proficient Asian Americans (AA) of Chinese and Vietnamese descent. We will conduct focus groups of patients to identify issues important to them, with an emphasis on communication and access to care. We will then draft a questionnaire and test its validity using standard survey research methods and direct observation of patient-provider encounters. Subsequent field testing will involve face-to-face patient interviews 1 month after an outpatient visit. We will evaluate alternate modes of administration to test feasibility and to maximize response. The result of our study will be a validated, culturally sensitive, patient-centered instrument that measures health care quality for limited-English-proficient AA patients. Our research will provide a template for developing future quality measures for other vulnerable populations.

Being hospitalized is traumatic enough. No one wants anything more to go wrong certainly least of all patients. Clinicians, other hospital staff, and management also share powerful incentives to strive for the best possible outcomes of care. For health care professionals, many of whom likely entered their fields motivated by humanistic goals of reducing suffering and doing good, moral imperatives add to very practical inducements: happy patients return, recommend them to family and friends, and do not file lawsuits. Hospital managers, also wary of legal actions and regulatory investigations, wish to avoid embarrassing headlines in local newspapers and to fulfill their mission of community service. Nonetheless, these compelling and multifaceted motivations have not yet sufficed to eliminate or significantly reduce iatrogenic inpatient complications. Despite landmark studies that raised public consciousness about unacceptable levels of adverse events in the United States,1 hospital patients continue to confront threats from poor quality services. Maybe financial forces could finally induce hospitals to address this persistent risk by conducting aggressive quality improvement programs to reduce complications of inpatient care. As described in this issue of Medical Care, the underlying premise of the proposals of McNair et al involves aligning incentives structuring an inpatient hospital prospective payment system (PPS) that will financially reward hospitals and physicians for reducing in-hospital complications, thereby improving patient outcomes. Using administrative data files from the State of Victoria in Australia, McNair et al have deftly manipulated their analytic database containing more than 1 .2 million hospital discharges to produce a new scheme for assigning per case payment weights. Victoria currently sets hospital PPS payment levels using Australian-refined diagnosis related groups (AR-DRGs). After stripping off all diagnoses flagged as occurring after hospital admission and thus considered complications of care along with other diagnoses viewed as prima facie indicators of in-hospital complications (including prolonged ventilator use without a tetraplegia diagnosis), the researchers reran the AR-DRG grouper algorithm. With the newly assigned groupings, now unaffected by putative inpatient complications, they recomputed PPS payment weights using total cost figures from the 132 Victoria public acute care hospitals. These budget neutral cost weights, they assert, could support a PPS that would still compensate the total Victoria public hospital system for the costs of inpatient complications but would financially benefit individual hospitals that manage (such as through quality improvement interventions) to reduce their complication rates. Despite the theoretical attractions of this approach and the clever manipulations of the administrative database, something about the proposal leaves me uneasy. Yes, I know I have slipped into the first person, singular pronoun not the omniscient voice of the all-knowing, all-wise editorial writer. But as a serial manipulator of administrative data myself, I recognize others who indulge in this pursuit. Although McNair et al offer intriguing ideas and hopeful speculation, they provide no evidence that their approach will achieve its ultimate aim of reducing inpatient complications. Retaining the first person conceit, I therefore respond in kind, offering primarily my opinion organized around 6 brief arguments to explain my unease.

Background. Decreasing hospital lengths of stay (LOS) hamper efforts to detect and to definitively treat complications of care. Patients leave before some complications are identified. Objectives. To develop a computerized method to screen for hospital complications using readily available administrative data from outpatient and nonacute care within 90 days of discharge. Design. We developed the Complications Screening Program for Outpatient data (CSP-O) by using diagnosis and procedure codes from Medicare Part A and B claims to define 50 complication screens. Seventeen apply to specific procedural cases, and 33 apply to all adult, acute, medical, or surgical hospitalizations. The CSP-O algorithm examined outpatient, physician office, home health agency, and hospice claims within 90 days following discharge. Subjects. Seven hundred thirty nine thousand, two hundred and forty eight discharges of Medicare beneficiaries (age range, ≥ 65 years) were admitted to 515 hospitals nationwide in 1994. Results. Complete 90-day, post-discharge windows were present for 62.8% of all and 68.5% of procedural cases. The 33 general screens flagged 13.6% of all cases; only 1.8% of procedural cases were flagged by the 17 procedural screens. When we allowed the CSP-O algorithm to scan information from acute hospital readmissions, flag rates rose to 32.8% for general and 8.7% for procedural complications. Controlling for patient and hospital characteristics, flag rates were considerably higher among the very old and at small and for-profit institutions. Conclusions. Whereas several CSP-O findings have construct validity, limitations of claims raise concerns. Regardless of the CSP-O's ultimate utility, examining post-discharge experiences to identify inpatient complications remains important as LOSs fall.

Objectives.Severity-adjusted death rates for coronary artery bypass graft (CABG) surgery by provider are published throughout the country. Whether five severity measures rated severity differently for identical patients was examined in this study.Methods.Two severity measures rate patients using cli

Using data from the American Hospital Association and the Medicare program, the authors analyzed the effects of financial pressure and market competition on changes in several measures of performance of 1,435 acute care hospitals between 1987 and 1989. Over the observation period, the least profitable hospitals constrained their growth in total expenses to half that for the most profitable hospitals (13.3% versus 27.6%) by limiting the growth of their staffs and their total assets. These changes were associated with a reduction in inefficiency of 1.8% (11.2%) compared with a very slight increase in inefficiency for the highest profit group. Similarly, hospitals in highly competitive markets controlled expenses relative to those in the least competitive areas. However, they also experienced slower revenue growth than did less competitive hospitals so that, in relative terms, their profit rates fell. The authors found no evidence to suggest that financial pressures created by either low profits or market competition resulted in hospitals engaging in cost-shifting. The authors conclude that health care reforms or market forces that put financial pressures on hospitals can result in cost-containment and improved efficiency without significant cost-shifting.

Timely use of necessary follow-up services is an important dimension of ambulatory care quality. Using a hospital-based walk-in center, this study identified patients who were referred for follow-up care and examined factors related to compliance with these referrals. The participants were 696 adults seen in a hospital-based walk-in unit between June 1, 1992, and December 1, 1992. Patients completed a self-administered questionnaire including questions about sociodemographic characteristics, prior use of health services, and the Medical Outcomes Study (MOS) 36-Item Health Survey. Medical findings, follow-up recommendations, insurance status, and compliance with follow-up referrals were ascertained using chart review, the hospital's computing system, and clinic records. Fifty percent of the patients were referred for follow-up medical care; 55% of these complied with follow-up referrals. Factors associated with referral for follow-up care included older age, inability to afford a physician, longer duration of chief complaint, the patient's belief that follow-up care would be needed, and worse MOS pain score. The most important factor associated with compliance with follow-up referral was scheduling appointments while patients were still in the walk-in unit. Patients with such scheduled appointments were almost 10 times more likely than others to receive follow-up (adjusted odds ratio = 9.6, 95% confidence interval = 4.4-21.2). The most important step a provider can take to improve compliance with follow-up referral is to schedule appointments before patients are sent home. This should presumably improve quality of ambulatory care.

We examined computerized hospital discharge abstract data from 372,680 major surgery patients admitted to 404 California acute care hospitals in 1988 to identify potential complications of care. At least one potential in-hospital complication occurred for 10.8% of patients. Patients with complications were older and more likely to die in-hospital (9.4% compared to 1.0%, P < 0.0001). On average, patients with complications had longer stays (13.5 versus 5.4 days, p < 0.0001) and higher total charges ($30,896 versus $9,239, p < 0.0001). After adjusting for demographic, clinical, and hospital factors, patients with potential complications averaged $16,023 higher total hospital charges than uncomplicated patients. Complications were associated with 96.6% (95% confidence interval = 95.2%, 98.0%) higher hospital charges after adjusting for these factors. Across all patients, complications were related to over $647 million in additional total hospital charges for these major surgery patients.

When comparing outcomes of medical care, it is essential to adjust for patient risk, including severity of illness. A variety of severity measures exist, but perceptions of outcomes may differ depending on how severity is defined. We used two severity-adjustment approaches to demonstrate that comparisons of outcomes across subgroups of patients can vary dramatically depending on how severity is assessed. We studied two approaches: model 1 was the admission MedisGroups score; model 2 was computed from age and 12 chronic conditions defined by diagnosis codes. Although common summary measures of model performance (R-squared and C) both suggested that model 1 is a better predictor of in-hospital death than model 2, the weaker model consistently produced more accurate expectations by payer class and age group. Using model 1 for severity adjustment suggested that Medicare patients did substantially worse than expected and Medicaid patients substantially better. In contrast, use of model 2 found Medicare patients doing as expected, but Medicaid patients faring poorly.

This research investigates the degree that estimates of the magnitude of small area variations in hospitalization rates depend on both the estimation method and the number of years of data used. Hospital discharge abstracts for patients 65 and older from acute care hospitals in Massachusetts from 1982 to 1987 were analyzed. The SCV statistic, the approach used in many current small area variation studies, and empirical Bayes (EB), an approach that adjusts more fully for the effect of random variation, were compared. EB estimates based on 3 years of data were best able to predict future area-specific hospitalization rates. Compared to EB estimates using 3 years of data, the SCV statistic with 1 year of data overestimated the median amount of systematic variation by over 70% for the 68 conditions studied; with 3 years of data, the SCV overestimated the median by 55%. Regardless of method, the same conditions were identified as relatively more variable and the same geographic areas were found to have higher than expected hospitalization rates. The magnitude of differences in hospitalization rates depends on how the data are analyzed and how many years of data are used. Hospitalization rates across small geographic areas may vary substantially less than reported previously.

Since the adoption of Medicare's Prospective Payment System (PPS), critics have raised concerns about the degree of variation in cost per case due to variability in severity of illness within DRGs. Using hospital (Part A) costs for all Medicare beneficiaries hospitalized in Michigan during 1982, this paper applies multivariate techniques to test the ability of two state-of-the-art case-mix measures to either replace or act as a severity modifier to DRGs. When compared with DRGs, neither Patient Management Categories (PMCs) nor Disease Staging explains any more of the variation in costs. Results show that DRGs explain 33%, while PMCs and Disease Staging explain 26% and 17%, respectively. The use of either alternative in tandem with DRGs explains only 1-2% more of the observed variation; however, both PMCs and Disease Staging identify subgroups of patients with significantly different costs. These findings suggest that the alternatives may prove modestly useful as DRG modifiers by identifying classes of patients that do not belong. More importantly, they offer a measure of "unrelated comorbidity" that may improve the performance of DRGs.

Concerns about the insensitivity of Medicare's diagnosis-related groups (DRGs) to illness severity heightened interest in the potential of alternative patient classification systems to improve the fairness of hospital reimbursement. This article examines the ability of admission MedisGroups score to explain the costs of hospital stays. The database contained 54,112 patients 65 years or older discharged in 28 high-frequency DRGs from 1984 to the middle of 1986 from 24 hospitals across the country. Admission MedisGroups score alone explained 3% of costs using trimmed data. Addition of admission MedisGroups score to DRGs modestly improved ability to predict differences in cost: for trimmed data, DRGs alone explained 52% of the variation in costs, compared with 55% when admission MedisGroups score was added. Within individual DRGs, the explanatory power of admission MedisGroups score ranged from 0% to 21%. The level of explanatory power was not related to the spread of cases across admission MedisGroups scores within DRG. No consistent clinical pattern explained these differences across DRGs.

Under current law, Medicare's Prospective Payment System (PPS) recognizes a 25% differential in standardized average costs per admission between rural and urban areas. Using Medicare Part A and B claims data from four states across the country, this paper employs descriptive and multivariate techniques to explain the underlying sources of cost variation. DRG mix and within-DRG severity differences were found to contribute only 10-15% to the overall urban-rural variation compared to about one third for wage differences. Differences in procedure intensity for basically similar patients explained another 25-50% of the urban-rural difference depending on illness. Evidence was also found for systematic cost and procedure differences between core city versus suburban hospitals. If the urban-rural rate differential were eliminated, the impact on urban hospitals could have major effects on the intensive way in which physicians treat patients. Whether this would have demonstrable outcome effects is unknown, but initial severity differences alone do not justify the observed procedural differences.