Showing papers by "RAND Corporation published in 1987"

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures.

Abstract: We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significant levels of inappropriate use:17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures. (JAMA1987;258:2533-2537)

A short-form measure of loneliness.

Abstract: The revised UCLA Loneliness Scale (ULS-20) and a four-item short form (ULS-4) are widely used in personality research (Russell, Peplau, & Cutrona, 1980). In an exploratory factor analysis of the ULS-20, we identified eight items that loaded substantially on the first factor. These items were combined to form an alternative short-form measure, the ULS-8. The results of this study indicate that the ULS-8 is reliable, valid, and a better substitute for the ULS-20 than is the ULS-4. Consistent with the previous research, the loneliness measures (ULS-20, ULS-8, ULS-4) were strongly related to socially undesirable personality characteristics, but loneliness was uncorrelated with the six different health-related behaviors (exercise, meal regularity, alcohol use, hard drug use, smoking, and hours of sleep) assessed in this study.

Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles.

Abstract: La prevalence (au cours de l'existence) de trois entites morbides psychiatriques definies par le DSMIII a ete etudiee comme fonction du niveau d'acculturation et du lieu de naissance (Mexique ou USA) dans un vaste echantillon d'adultes americano-mexicains vivant a Los Angeles. On a trouve qu'un degre eleve d'acculturation etait associe a des taux plus hauts de phobie, d'alcoolisme et d'abus de drogues (dans l'anamnese)...

Six-month prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles.

Abstract: • The lifetime prevalence of specificDSM-III—defined psychiatric disorders among 1243 Mexican-American and 1309 non-Hispanic white residents of two Los Angeles communities is reported from the Los Angeles site of the Epidemiologic Catchment Area (ECA) research study. Results from household interviews in response to the National Institute of Mental Health Diagnostic Interview Schedule revealed overall rates of disorders for the total Los Angeles sample and ethnic subsamples that were similar to rates reported from the initial three ECA sites. Non-Hispanic whites reported far more drug abuse/ dependence and more major depressive episodes than Mexican Americans. Young non-Hispanic white women reported high rates of major depressive episodes and drug abuse/ dependence. Alcohol abuse/dependence is highly prevalent among Mexican-American and non-Hispanic white men of any age. Mexican-American women infrequently abuse or become dependent on drugs or alcohol at any age. Dysthymia, panic disorder, and phobia are somewhat more prevalent among Mexican-American women over 40 years of age compared with both non-Hispanic white women over and Mexican-American women under 40 years of age. Antisocial personality is predominantly a disorder of young men of both ethnic groups.

The prevalence of adult sexual assault the los angeles epidemiologic catchment area project

Abstract: Data were collected as a supplement to the Los Angeles Epidemiologic Catchment Area project, one of five field sites of a National Institute of Mental Health-initiated program. The authors used a two-stage probability sampling technique to interview 3,132 Los Angeles residents of two mental health catchment areas during the period January 1983-August 1984. Hispanics and non-Hispanic whites were about equally represented in the sample, as were males and females. Respondents were asked, "In your lifetime has anyone ever tried to pressure or force you to have sexual contact? By sexual contact I mean their touching your sexual parts, your touching their sexual parts, or sexual intercourse?" Persons who reported an assault were asked additional questions, including information about the most recent assault. Lifetime prevalence of sexual assault during adulthood (at or after age 16 years) was estimated at 10.5% for the entire sample. Women, non-Hispanic whites, and young people (less than age 40 years) reported higher rates of sexual assault than men, Hispanics, and older people. Highest rates were reported by young non-Hispanic white women with some college education (26.3%). In the most recent sexual assault, three-fourths of respondents knew their assailant, over half experienced harm or the threat of harm, and half experienced sexual contact including but not limited to intercourse.

Hospital Inpatient Mortality: Is It a Predictor of Quality?

Abstract: Various potential measures of quality of care are being used to differentiate hospitals. Last year, on the basis of diagnostic and demographic data, the Health Care Financing Administration identified hospitals in which the actual death rate differed from the predicted rate. We have developed a similar model. To understand why there are high-outlier hospitals (in which the actual death rate is above the predicted one) and low-outlier hospitals (in which the actual death rate is below the predicted one), we reviewed 378 medical records from 12 outlier hospitals treating patients with one of three conditions: cerebrovascular accident, myocardial infarction, and pneumonia. After adjustment for the severity of illness, the death rate in the high outliers exceeded that predicted from the severity of illness alone by 3 to 10 percent, and in the low outliers, the actual death rate fell short of the severity-adjusted predictions by 10 to 15 percent (P less than 0.01). Reviews of the process of care using 125 criteria revealed no differences between the high and low outliers. However, detailed reviews by physicians of the records of patients who died during hospitalization revealed a higher rate of preventable deaths in the high outliers than in the low outliers. For the three conditions studied, we project that 5.7 percent of a standard cohort of patients admitted to the high-outlier hospitals would have preventable deaths, as compared with 3.2 percent of patients admitted to the low-outlier hospitals (P less than 0.05). A meaningful comparison of hospital death rates requires adjustment for severity of illness. Our findings indicate that high-outlier hospitals care for sicker patients. However, these same hospitals or their medical staffs may also provide poorer care. Our results need confirmation before death-rate models can be used to screen hospitals.

Measurement of Acculturation in a Community Population of Mexican Americans

Abstract: A 26-item acculturation measure was administered to a probability sample of 1245 adult Mexican Americans residing in Los Angeles. This measure demonstrated high internal reliability for the total sample and for specific sex, educational, and language groups. Construct validity was supported by showing acculturation scores predicted length of exposure to U.S. culture. Data suggested that, among first generation Mexican Americans, those who were younger and male acculturated more rapidly than those who were older and female. This sex difference, but not the age difference, could be explained by educational and employment experiences. Among later generation Mexican Americans, those who were younger again had higher acculturation levels, possibly due to age differences in education and employment, or to historical factors differentially effecting age cohorts.

The prevalence of childhood sexual assault. The Los Angeles Epidemiologic Catchment Area Project.

Abstract: This study reports childhood sexual assault data collected as part of a community-based population study on mental health. A household sample, stratified by catchment area, was selected using a two-stage probability technique. A total of 3,132 adults (18 years or older) were interviewed between January 1983 and August 1984. The sample was 46% Hispanic and 42% non-Hispanic white, 47% male and 53% female. Childhood sexual assault was defined as incidents before age 16 years which involved pressure or force for sexual contact. The prevalence (weighted for sampling design and nonresponse) of childhood sexual assault for the total sample was 5.3%. Rates were higher for non-Hispanic whites (8.7%) compared with Hispanics (3.0%), women (6.8%) compared with men (3.8%), and younger persons at the time of interview (6.5%) compared with older persons (3.9%). Most assaults were by an acquaintance and occurred for the first time around age 10 years. Data from a subsample of assaulted respondents show that childhood sexual assaults are not usually accomplished through physical aggression, but rather through persuasion, and through the psychological threat of the assailant being bigger or stronger. Research is needed on the natural history and sequelae of childhood sexual assault.

Fairness and Participation in Evaluation Procedures: Effects on Task Attitudes and Performance

Abstract: A laboratory study was conducted to examine the role of two components of participatory work evaluation procedures on fairness attitudes and work performance. “Opportunity for influential opinion expression” and “knowledge of evaluation criteria” were manipulated in a business simulation exercise. Thirty-eight male and 49 female undergraduates worked under a task evaluation procedure that either did or did not allow them to express their opinions to the evaluator. In addition, subjects either were or were not provided with specific information about the criteria to be used in making the performance evaluation, and they received either a favorable or an unfavorable outcome. Questionnaire responses indicated that influential opinion expression enhanced perceptions of procedural and distributive fairness independently of the outcome of the evaluation. Both knowledge of evaluation criteria and perceptions of evaluation fairness correlated with subsequent task performance. The implications of these findings are discussed with respect to understanding the influence of procedural justice on attitudes and task behavior in organizational settings.

Uncertainty, Policy Analysis and Statistics

Abstract: Statistical activity can be divided for descriptive and analytical purposes into (a) discovery/imposition of structure, (b) assessment of var- iation conditional on structure and (c) execution of techniques. Each of these three areas of activity has an associated type of uncertainty, respec- tively, structural uncertainty, risk and technical uncertainty. In any statis- tical analysis, an analyst has limited supplies of time, money, knowhow and computational power and must use these resources to diminish and to characterize better the three main types of uncertainty and the many subtypes that comprise them. No existing school of statistical thinking provides a comprehensive framework for considering the various types of uncertainty and the tradeoffs among them that analysts must make. One result of this is the absence of a system that properly accounts for all of the types of uncertainty. This paper describes the types of uncertainty, cata- logues and evaluates current methods as tools for characterizing and dimin- ishing them, considers the types of tradeoffs that analysts must make in applying statistical methods in problems and examines the bias introduced into deliberations by the absence of a proper system of accounting for uncertainty. This paper is an attempt to begin the construction of such a proper system and thus to reduce or eliminate that bias.

How coronary angiography is used: clinical determinants of appropriateness

Abstract: Using ratings of appropriateness derived from an expert physician panel, we measured how appropriately physicians in 1981 performed coronary angiography in a randomly selected, community-based sample of cases in the Medicare population. We studied large geographic areas (three sites) in three states, representing regions of high and low use. The high-use site had fewer procedures classified as appropriate (72%) than either low-use site (77% and 81%, respectively). Over all sites, 17% of procedures were classified as inappropriate. Patients in the high-use site were older, had less severe angina, and were less intensively medically treated than patients in either of the low-use sites. Patients without angina who had not undergone exercise testing constituted the most common subgroup of inappropriate cases. Although overall differences in appropriateness were not large, practice differences do exist. This analysis of practice differences among study sites provides the clinical basis for understanding the small, but significant, differences in the appropriateness of use of coronary angiography. The finding of 17% inappropriate use may be cause for concern.

The Wealth and Poverty of Widows: Assets Before and After the Husband's Death

Abstract: We verify that widows are much more likely than couples to be poor and that they make up a large proportion of the poor elderly; 80 percent are widows or other single individuals Then we seek to explain why the single elderly are poor, with emphasis on widows We do this by tracing back over time their financial status, using the Longitudinal Retirement History Survey The death of the husband very often induces the poverty of the surviving spouse, even though the married couple was not poor While only about 9 percent of prior couples are poor, approximately 35 percent of the subsequent widows are A large proportion of the wealth of the couple is lost when the husband dies In addition we find that: (1) the prior households of poor widows earned and saved less than the prior households of non-poor widows, (2) more of the smaller accumulated wealth was lost at the death of the husband, (3) the absence of survivorship benefits or life insurance insured that the loss in wealth would leave the widow poor thereafter

Physician Response to a Mailed Survey: An Experiment in Timing of Payment

Abstract: This article reports the results of an experiment in obtaining physician response to a mailed questionnaire. Each physician was eligible for a payment of $20. A randomly selected half received the payment with their initial questionnaire and cover letter; half were told they would receive their payment after they completed and returned the questionnaire. The same mail and telephone followup procedures were used for both groups. Overall, prepayment had significant positive effects on response rates. This paper examines these effects in terms of response rates for various specialties, field efficiencies, cost, and representativeness of the sample. The ability to make unbiased inferences about populations based on sample survey data depends on having complete information about all selected sample units or establishing that the nonrespondents do not differ from respondents in any important way (Fowler, 1984). Since it is difficult to rule out biased nonresponse, it is desirable to obtain high response rates. This can be especially challenging with some populations. Physicians, for example, are widely believed to be a difficult population from which to collect survey data (Sudman, 1985). Physicians are frequently SANDRA H. BERRY is Director of the Survey Research Group and DAVID E. KANOUSE iS Senior Behavioral Scientist at the Rand Corporation. This research was supported by the National Institutes of Health, Office of Medical Applications of Research, under Contract N01-OD-2-2128. The authors are grateful to Don Dillman, Gus Haggstrom, and two anonymous reviewers for helpful comments on the paper, and to Ellyn Bloomfield, Susan Goulet, and Joyce Simmons for assistance with the research. An earlier draft of this paper was presented at the 1985 Annual Conference of the American Association for Public Opinion Research. Public Opinion Quarterly Volume 51:102-114 ? by the American Association for Public Opinion Research Published by The University of Chicago Press / 0033-362X/87/0051-01/$2.50 This content downloaded from 157.55.39.203 on Thu, 20 Oct 2016 04:13:53 UTC All use subject to http://about.jstor.org/terms Timing of Payment in a Mailed Survey 103 approached for surveys, the demands on their time are great, and their office staffs are vigilant in protecting them. As key decisionmakers in the health system, however, physicians are of considerable research interest, and a good deal of effort has been devoted to improving methods of obtaining information from them. Much of this effort has focused on providing physicians with financial incentives to participate in research. In this paper, we report the results of an experiment that tested the timing of payment in a mailed survey of physicians. The results are not only of practical interest, they also raise important questions about how payment "works" in eliciting high response rates.

Object verification apparatus and method

Abstract: Apparatus and methods of verifying objects utilize an inherent randomly varying and detectable characteristic of a recordable magnetic region affixed to the object. Detectability of the randomly varying magnetic characteristic can be enhanced by recording a selected electrical signal thereon. Digital and analog signals may be used. Both saturation and nonsaturation forms of recording can be used. A verification apparatus senses the enhanced randomly varying magnetic characteristic and compares it to a prestored representative profile previously created. Correspondence between the prestored profile and the currently read characteristic indicates an authentic object. Other objects can be rejected.

Is periodontal disease the primary cause of tooth extraction in adults

Abstract: Preventing caries and reducing out-of-pocket costs for dental services are two strategies proposed by the authors to lower the rate of tooth extractions. Efforts also must be made to change public values about the importance of restoring rather than extracting carious teeth.

Market and Non-Market Failures: Comparison and Assessment

Abstract: This paper aims to redress the asymmetry in the standard economic treatment of the shortcomings of markets and governments by developing and applying a theory of ‘nonmarket’ failure– that is, of government failure – so that the comparison between markets and governments can be made more systematically, and choices between them arrived at more intelligently. Several conclusions are drawn. First, the choice between markets and governments is not a pure one, actual systems inevitably involve combinations between markets and governments. Second, with respect to both static and dynamic efficiency criteria, markets generally do better than governments. Third, there are various ways in which government can contribute to improving the functioning of markets. Fourth, market forces can play a useful role in improving the functioning of government and reducing the incidence of nonmarket failures.

Structural-equation models of current drug use: are appropriate models so simple(x)?

Abstract: The simplex and common-factor models of drug use were compared using maximum-likelihood estimation of latent variable structural models in two samples: a sample of 226 high school students, using ratio-scale measures of current drug use, and a sample of 310 industrial workers and 811 college students, using ordinal-scale measures of current drug use. Latent variables of alcohol, marijuana, enhancer hard drugs, and dampener hard drugs were specified in a series of structural models. Contrary to previous findings with cumulative drug-use data, the common-factor model provided a more acceptable representation of the observed current-use data than did the simplex model in both samples. In addition, the similarity of results across both of these samples supports recent contentions by Huba and Bentler (1982) that quantitatively measured variables are not necessarily superior to qualitative, ordinal indicators in latent variable models of drug use.

Expert systems for legal decision making

Abstract: AI technology is being used to develop expert systems that solve complex problems in the legal area. Most of these systems employ rules to describe the strategies and procedures used by litigators to analyze legal issues. The tasks performed by these systems include interpreting the law, anticipating the legal consequences of proposed actions, predicting the effects of changes in legislation, as well as analyzing and managing cases. The special characteristics of the legal domain cause certain problems for expert system builders. We discuss some of these problems and describe LDS and SAL, two expert systems we have developed for case evaluation and settlement in the product liability area. SAL (System for Asbestos Litigation) evolved from the earlier and more general expert system, LDS (Legal Decisionmaking System). We also describe XPL, an explanation facility we developed for use by SAL and other expert system applications.

Future emission scenarios for chemicals that may deplete stratospheric ozone

Abstract: Scenarios are developed for long-term future emissions of seven of the most important manmade chemicals that may deplete ozone and the corresponding effect on stratospheric ozone concentrations is calculated using a one-dimensional atmospheric model. The scenarios are based on detailed analysis of the markets for products that use these chemicals and span a central 90% probability interval for the chemicals' joint effect on calculated ozone abundance, assuming no additional regulations.

Monitoring quality of care in the Medicare program. Two proposed systems.

Abstract: TWENTY years ago, when much of the methods work in quality assessment began, 1 an age of optimism about the provision of health services in the nation appeared to have dawned. Resources seemed unlimited, and legislation to increase access to services for the underserved was at last being enacted. Measures of quality and health status were seen as crucial aids in knowing where to put additional funds to make Americans as healthy as possible, and it was believed that more resources would be available to develop the best possible methods for assessing quality and health status. As we now know, events did not unfold as had been so expansively expected. Even as access to care improved, costs of health care escalated beyond all imagined levels. In this environment, the field of quality assessment did not flourish as its proponents had hoped. Apparently unlimited resources and rapid technologic changes were, perhaps,

Changing living arrangements: A hazard model of transitions among household types

Abstract: This paper analyzes movements among household types. Persons in one household may join another type. Correspondingly, a household’s structure may change when someone joins it. Data are from the Panel Survey of Income Dynamics, spanning 1968–1980. The individuals followed in the survey generated spells analyzed with a multivariate competing risk hazard model. We develop a map of the flow among household types and of the economic and demographic profiles of individuals making the transitions. We find wide variability in the stability of household types and marked racial differences in the relative stability and pattern of destination choices.

Obtaining Clinical Data on the Appropriateness of Medical Care in Community Practice

Abstract: We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample Only three of 230 hospitals did not participate We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the develop ment of carefully designed medical record abstraction systems We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive ( JAMA 1987;258:2538-2542)