Footnote: what's new in the literature: July 30.

* The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients, says an article in the August 5 issue of the New England Journal of Medicine (Vol 351 Issue 6).

The study examined the premise that in the United States most black patients are treated by physicians whose qualifications or resources are inferior to those physicians who treat white patients. The researchers performed a cross-sectional analysis of 150,391 visits by black and white Medicare beneficiaries age 65 or older The patients were seen for medical "evaluation and management" by 4,355 primary care physicians who had participated in a biannual telephone survey, the 2000-2001 Community "Tracking Study Physician Survey. Most of the black patients visited a small group of physicians (80% of visits were accounted for by 22% of physicians) who provided care to only a small percentage of white patients.

In comparing the visits by white patients and black patients, researchers found that the physicians whom the black patients visited were less likely in be board certified (77.4 %) than were the physicians visited by the white patients (86.1%, P=0.02) and were more likely to report that they could not provide high-quality care to all their patients (27.8% vs 19.3%, P=0.005). The physicians treating black patients also reported having greater difficulty obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital.

The researchers concluded that additional studies are needed in determine the extent in which racial differences may be responsible for disparities in health care.

* Patients with chronic shoulder pain, with or without accompanying stiffness, can expect significant decreases in shoulder pain and improvements in shoulder function in the long term after conservative treatment, says a study in the August issue of Archives of Physical Medicine arm Rehabilitation (Vol 85 No 8).

Eighty-two subjects participated in a randomized controlled trial that compared the short-term effectiveness of conservative treatment for chronic, unilateral shoulder pain of mechanical origin with and without accompanying stiffness, and who were available for longer-term follow-up 6 months after the cessation of formal treatment. Conservative treatment consisting of various combinations of exercise therapy, passive joint mobilization, electrophysical modalities, and corticosteroid injections were administered. Main outcome measures were pain intensity, functional limitation, perceived change in symptoms, active range of motion, muscle force, and clinical and demographic variables.

According in the results, patients showed significant improvement in all outcome measurements in the long-term whether or not their shoulder pain was accompanied by stiffness. Long-term outcome was nor predicted by hand dominance, clinical history of the shoulder condition, severity of the shoulder problem, or shoulder mechanics.

* A study in the July issue of the Journal of the American Geriatrics Society (Vol 52 Issue 7) finds that physical therapy immediately after hip fracture surgery is beneficial and also calls for well-designed randomized, controlled trials to evaluate the effect of varying schedules and amounts of therapy on functional status after hip fracture.

Researchers evaluated 443 hospitalized older patients discharged after surgery for hip fracture in 1997-98 by patient demographics, fracture type, comorbidities, dementia, number of new impairments at discharge, amount of physical therapy between day of surgery and postoperative day (POD) 3, amount of therapy between POD4 and 8 weeks later, and prefracture, 2-, and 6-month mobility measured using the Functional Independence Measure.

According to the results, more physical therapy immediately after hip fracture surgery was associated with significantly better locomotion 2 months later. Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points (P=.032) on the 14-point locomotion scale, but the positive relationship between early physical therapy and mobility was attenuated by 6 months postfracture. There was no association between later therapy and 2- or 6-month mobility.

* Among for-profit plans, group/network models provided better processes of care for diabetes than independent practice association (IPA) models. Although reasons are uncertain, researchers believe this may be due to the clinical infrastructure available in group models that is not available in IPA models.

The goal of the study, published in the July 2004 issue of Diabetes Care (Vol 27, No 7), was to examine the association between the organizational model and diabetes processes of care. The study ream used data from Translating Research into Action for Diabetes (TRIAD), a multicenter study of diabetes care in managed care that included 8,354 patients with diabetes. Researchers identified five model types: for-profit group/network, for-profit IPA, nonprofit group/network, nonprofit IPA, and nonprofit group/staff.

The process measures included retinal, renal, foot, lipid, and HbA1c testing; aspirin recommendations; influenza vaccination; and a sum of these seven processes of care over 1 year. Hierarchical regression models were constructed for each process measure and accounted for clustering at the health plan and provider-group levels and adjusted for participant age, sex, race, ethnicity, diabetes treatment and duration, education, income, health status, and survey language.

Participant membership in the model types ranged from 9% in nonprofit IPA models to 38% in nonprofit group/staff models. More than 75% of participants received most of the processes of care, regardless of model type. However, among for-profit plans, group/network models provided on average more processes of care than IPA models (5.5 vs. 4.7, P < 0.0001), and group/network models generally increased the probability of receiving a process by 10 percentage points or more. Among nonprofit plans, no effect of model type was found. The study was sponsored in part by the Division of Research, Kaiser Permanente, Oakland, California, and Pacific Health Research Institute, Honolulu, Hawaii.