Episodes of care for abdominal pain in a primary care practice
M. S. Klinkman
Department of Family Practice, University of Michigan, Ann Arbor, USA.
OBJECTIVES: To explore the usefulness of episodes of care in describing the
clinical epidemiology of abdominal pain in the primary care setting and to
develop methods to analyze clinician decision-making strategies during
abdominal pain episodes. DESIGN: Complete episodes of care for nonpregnant
adults with nonspecific abdominal pain from an established episode-based
clinical information system were supplemented and validated by medical
record review. Utilization decisions during episodes were quantified by
summing the costs of all visits, services, tests, and referrals ordered or
performed by the clinician. A decision model was used to analyze
significant influences on utilization decisions. SETTING: An established
faculty practice site of a Midwestern academic family practice department.
SUBJECTS: Two hundred ten nonpregnant adults who had nonspecific abdominal
pain. MAIN OUTCOME MEASURES: Utilization and costs generated during the
episode of care. RESULTS: The average abdominal pain episode required 1.32
visits and cost $123.36. In more than half of all episodes (51%), a
specific diagnosis was not reached. The most common specific diagnoses were
gastritis and gastroesophageal reflux disease (5% each). Bivariate analyses
showed that two variables, clinician uncertainty about diagnosis and a
nonspecific diagnosis, were significantly associated with episode cost.
Patient age, gender, comorbidity, and the presence or absence of specific
clinical findings were not associated with episode cost. Stepwise
regression modeling resulted in a two-factor model. Clinician uncertainty
and complexity explained only 9% of the variance in episode cost.
CONCLUSIONS: Episodes of abdominal pain most often remained undiagnosed.
The decision model did not predict episode cost. Utilization decisions did
not seem to be driven by commonly cited clinical risk factors, but by
diagnostic uncertainty or individualized decision rules.
