Showing papers in "Medical Care in 1975"

Sociobehavioral determinants of compliance with health and medical care recommendations.

Abstract: Over the past two decades, hundreds of articles, editorials, and commentaries have been published describing the considerable disruptive effects on quality of care of individuals noncompliance with health and medical advice While much research has been directed at determining factors responsible for poor compliance, past studies have tended to focus upon easily measured characteristics of the patients, regimen, or illness which, unfortunately, are usually neither predictive nor alterable This paper systematically reviews the literature on patient acceptance of recommended health behaviors, attempting to find social-psychological and related variables which have proven to be consistent predictors of compliance The review suggests that certain health beliefs (especailly personal estimates of vulnerability to, and seriousness of, the disease, and faith in the efficacy of care), health-related motivations, perceptions of psychological and other costs of the recommended action, various aspects of the doctor-patient relationship, and social influence are the most productive dimensions for present intervention and further exploration Building upon an earlier formulation, an hypothesized model is presented which combines these elements for explaining and predicting compliance behavior Further research should, with standardized questionnaires and analysis techniques, employ prospective, experimental designs for a variety of population groups, settings, and regimens, to evaluate the ability of practical attempts to modify the model variables and thus enhance compliance

Dimensions of patient attitudes regarding doctors and medical care services.

Abstract: The factor analytic development and validation of numerous index scores to measure patient attitudes regarding characteristics of doctors and medical care services is described. Index scores meeting factor analytic criteria and found to be reliable were used to study the nature and number of attitudinal dimensions underlying patient satisfaction. The use of index scores which have met logical and empirical criteria is in contrast to the common practice of using individual questionnaire items as the unit of analysis. Four major dimensions of patient attitudes were identified and described, including attitudes toward doctor conduct (humanness and quality) and such enabling components as availability of services, continuity/convenience of care and access mechanisms (cost, payment mechanisms, and ease of emergency care). Measures of attitudes toward caring (humanness) and curing (quality/competence) aspects of doctor conduct appear to reflect the same underlying attitudinal dimension. Findings are discussed in relation to concepts and measures mentioned in the published literature and suggestions are offered for future research.

Correlates of Satisfaction and Dissatisfaction with Medical Care: A Community Perspective

Abstract: The attitude of the public toward physicians and medical services is an issue of current concern and debate. To address this problem, an instrument was developed using Thurstone scaling methods in conjunction with a Likert format and a modified scoring technique. Following pretesting of the instrume

An emergency room's patients: their characteristics and utilization of hospital services.

Abstract: specified period and the magnitude of the relationship between these patients and the utilization of other hospital services, and 3) to introduce the patient's "frequency-of-visit" as an important variable in the analysis of emergency room utilization. Some specific findings are: 1) the vast majority of patients who used the emergency room did so very infrequently; 46,527 visits were made in one year by an estimated 34,286 different patients; 2) an estimated 2,586 patients made three or more visits during the year; a disproportionately large number of these "high-frequency" users were black, low-income, and from inner-city areas; a relatively small percentage of their visits were for accidental injury, 3) approximately 53 per cent of the hospital's inpatient admissions and 68 per cent of the inpatient days were generated by patients who also made at least one emergency room visit during the year studied.

The Organization of Medical Practice and Practice Orientations Among Physicians in Prepaid and Nonprepaid Primary Care Settings

Abstract: Data are presented on office-based general practitioners and pediatricians working in varying practice settings. Fee-for-service physicians spend more time in direct patient care activities than those in prepaid practice, and devote more time to each patient. The data suggest that the patient load characteristic of general practice in prepaid groups encourages a more assembly line practice which is less responsive to patients than the pattern characteristic of fee-for-service practice. Prepaid physicians work during scheduled hours and may deal with increased load by processing patients more rapidly. Fee-for-service physicians tend to respond to increased demand by working longer hours. The responsiveness of primary care physicians to patient problems seems to reflect primarily their social orientations to medical practice and the time pressures they face. Varying practice settings result in different techniques of coping with the pressures of practice. Data are also presented on sociodemographic and professional characteristics of primary care physicians in varying settings, workload, use of diagnostic and laboratory procedures, social orientations to medical practice, satisfactions and dissatisfactions, and attitudes toward sociopolitical aspects of medical care. Suggestions are offered for improving the responsiveness of prepaid practice.

Copayments for ambulatory care: penny-wise and pound-foolish.

Abstract: The California “copayment experiment” imposed a charge of $1 on certain Medicaid beneficiaries for the first two visits to a doctor and 50 cents for the first two drug prescriptions each month, effective January 1, 1972. Data on utilization rates were gathered for six months before this date and for

Economic and noneconomic barriers to the use of needed medical services.

Abstract: This paper introduces an index of access to medical care that describes the use of services relative to the actual need for care. Findings on this particular measure suggest that, contrary to the implications of much of the existing literature, the poor continue to use fewer services-relative to the disability they experience-than do the nonpoor. Further, despite the advent of publicly financed economic solutions to these access differentials-Medicaid and Medicare, in particular-organizational barriers to entry, such as the long queues to obtain service and long travel times to care in some areas, still exist. The implications of these findings for the evaluation of existing and proposed national health policy efforts are discussed.

Making sense out of utilization data.

Abstract: demonstrate why such ambiguities exist, provide empirical tests of different models, and suggest an appropriate analytical framework. A household survey of a rural California community was used to collect both family and individual data on utilization, "need," accessibility, attitudes, and demographics. A number of possible utilization models are presented, each containing alternative sets of dependent and independent variables. Multiple regression analysis is applied to each model, providing considerable insight into the roles of specific independent variables in explaining alternative utilization measures. The omission of certain variables, such as health status (or "need"), can result in an incorrect interpretation of the results. A GROWING CONCERN for the equitable distribution of health services in the U.S. has

The Health Maintenance Organization Act of 1973 (P.L. 93-222) and prepaid group practice plans.

Abstract: The 1972 Social Security amendments contained the landmark Professional Standards Review Organization (PSRO) provisions as well as several sections upgrading existing utilization review (UR) requirements under Medicare and Medicaid. With issuance of the PSRO Program Manual and the recent publication of the new UR regulations, HEW for the first time has brought Medicare and Medicaid hospital review requirements into conformity and made them compatible with and supportive of the PSRO program. This article defines the PSRO hospital review system, describes how the three major components-concurrent review, medical care evaluation studies, and profile analysis-interrelate and provides examples of each of these components. Under utilization review requirements or PSRO, hospitals will be required to implement an integrated system of review designed to assure appropriate utilization practices and improve the quality of care. These aims are to be accomplished through the application of concepts of peer review, the use of norms, criteria, and standards, the identification of deficiencies in the quality, administration, or appropriateness of health care services, and their correction through linkage with programs of continuing medical education. Although PSROs are initially responsible for review in hospitals, they will likely provide the locus for a community-wide system of peer review for all services provided under National Health Insurance.

Factors related to the preference for a female gynecologist.

Abstract: Four hundred and nine female patients of both male and female physicians completed a self-administered questionnaire exploring their attitudes and practices regarding gynecologists and gynecological examinations. Responses to the question "Would you prefer a woman gynecologist?" divided the sample into three groups: those responding "yes" (33.9 percent); those responding "no" (19.3 percent); and those responding "no difference" (36.2 percent). Results revealed that patients who preferred female gynecologists were most likely to find gynecological examinations difficult and to be critical of gynecololgists' understanding of women's psychological and sexual problems. A subsample of patients in psychotherapy was especially apt to prefer female gynecologists. The "no difference" group had the most positive attitudes towards gynecological examinations and gynecologists. Demographic differences were insignificant. The importance of judging a gynecologist's competence without sexual bias, of re-evaluating stereotypes of women physicians, and of increasing the proportion of women in gynecology is stressed.

A study of consumer attitudes about health care: the role of the emergency room.

Abstract: Contrary to the traditional role of the emergency room (ER) as a care source for the treatment of urgent medical needs, it is evident that substantial numbers of people now use the ER for the treatment of nonurgent problems In this paper, we report on public opinion about the role of the ER, the perceived urgency of the problems that people bring to the ER, the accessibility of medical care, and factors that prompt the use of the ER rather than other sources of care The data result from a community survey of households (N = 521) in the area of Rochester, New York, representative of a population of about 580,000 people The findings, which relate ER utilization to source of payment, use of other sources of care, demographic variables, and consumer attitudes illustrate the rationality of the patient's use of ER facilities and reflect the patient's view of the ER as a place to obtain medical treatment when other sources are not available

Quality of patient care-a measurement of change: the staging concept.

Abstract: A method that can be used to classify the severity of health problems and measure change in health status is described. The "staging" concept provides a system which classifies patients with similar medical conditions into clusters useful for patient care evaluation. The method defines different levels of severity: Stage I-disease with no complications or problem of minimal severity; Stage II-disease with local complications or problem of moderate severity; and Stage III-disease with systemic complications or a problem of a serious nature. Examples of the method are given and the value of the approach is described for the evaluation of the hospitalized and ambulatory patient.

Practice characteristics and quality of primary medical care: the doctor-patient relationship.

Abstract: Physician and practice characteristics were reviewed in relation to the quality of the doctor-patient relationship in primary medical care. This relationship was defined in terms of communication between physicians and patients, patient satisfaction with care, and physician awareness of patient concerns. The study subjects were mothers of infants and pregnant women, identified from the offices of a random sample of primary care physicians in a single community. The patients of 49 physicians, 363 pregnant women and the mothers of 523 infants were the subjects of the study. When controlled for patient characteristics, communication was better for pediatricians with mothers of infants and for obstetricians with pregnant women as compared with other physicians. Mothers of infants were more highly satisfied with care provided by residency-trained physicians; pregnant women were more satisfied with non-Board certified physicians. Physician awareness of patient concerns presented a mixed pattern of associations with several physician and practice characteristics. These findings suggest that physician credentials are not consistently associated with the three identified dimensions of the doctor-patient relationship.

Evaluation of a cardiopulmonary resuscitation course for secondary schools.

Abstract: The objective of this study was to test the feasibility of teaching secondary school students to perform cardiopulmonary resuscitation (CPR) according to National Research Council (NRC)--American Heart Association (AHA) standards Criterion levels specified by AHA call for cardiac compression at a rate of 60 times a minute with two ventilations interposed after 15 cardiac compressions Translated into numerical performance per minute, this standard equates to 36 compressions and six ventilations per minute Students were instructed by their usual teachers who received a special educational program in preparation Both immediate learning and retention of the students after three months were evaluated using a practical and a written test Teacher performance was evaluated by means of a practical test and a behavior rating CPR is a motor task involving both continuous and discrete processes Results of the study corresponded to analogous studies in the psychomotor literature: practice group students' retention of continuous skills (breaths and compressions) was good (little loss of skill), while retention of discrete motor skills (open the airway, check vital signs) was poor Fifty-five per cent of the practice group in the initial test and 31 per cent in the retention study were able to perform the skills Retention figures compare favorably with studies in the area of psychomotor learning The study suggests that it is possible to train secondary school students to perform the ABC's of CPR if they have an opportunity to practice these skills The study also suggests that the teacher training is an important factor

Physicians view national health insurance: a national study.

Abstract: Nationally representative samples of senior physicians, interns and residents, and medical students were interviewed during the spring of 1973. The main focus of the present analysis is senior physicians' responses to national health insurance issues. The level of support among physicians is underestimated by physicians themselves. Despite the fact that 56 per cent of the doctors were in favor of "some form of national health insurance," almost three-fourths of the respondents believed that most doctors they knew personally were opposed. More than four-fifths of the physicians believed that NHI was inevitable, and those who saw NHI as inevitable were more likely to favor it. Doctors' views about NHI were closely related to their general political views. In general, attitudes of AMA members and grassroots state and local medical society leaders were not greatly divergent. In terms of responses to specific components differentiating NHI alternatives, physicians preferred conservative options on how a program was to be financed and administered as well as whether the development of prepaid groups should be encouraged. Support for the liberal alternative was strongest on the question of peer reviews, with 75 per cent in favor of such reviews under a NHI program. Differentiation in the profession is considerable. Main activity, work setting, specialty, percentage of income in salary, geographical location, and career stage all contribute to differing reactions to NHI among physicians.

The effect of preceptorship and rural training programs on physicians' practice location decisions.

Abstract: This study analyzes the relationship between medical student participation in rural training programs, including preceptorships, and the decision to locate medical practice in rural areas. Data consist primarily of responses to questionnaires mailed in 1972 to all graduates of United States medical schools in 1965. Study findings indicate that the overall impact of such programs on practice location decisions is relatively slight, but is most pronounced with respect to urban-reared physicians in nonprimary care specialties. It was also found that a large proportion of urban-located physicians had seriously considered rural practice and that the reluctance of many physicians to locate in rural areas is linked to fear of professional isolation. The findings suggest that an increased orientation toward urban-reared students and dissemination of information on nonsolo practice opportunities in rural areas are means of increasing the effectiveness of preceptorships and other rural training programs in attracting young physicians to underserviced areas.

A review of the research on general health status indexes.

Abstract: During the mid-1960's, recognition of the spiraling cost of health care motivated Congress to enact several major pieces of legislation designed to underwrite efforts to improve the delivery of health services. The increased level of federal fiscal participation in the health service system has forced greater consciousness of the need for better accountability of the effectiveness and efficiency of the allocation of the dollar. Demands were articulated for precision tools which could evaluate the imput to output linkage between need and response; however, the tools were nascent and had limited applicability. Cost-effectiveness and cost-benefit analysis are two procedures that have since been applied with varying levels of success. A third tool, also developed as an outgrowth of the desire for a more accurate characterization of the planning concerns of an efficient/effective health service system, is the general health status index. The purpose of this article is to provide the reader with a comprehensive review of the literature on general health status indexes. Common objectives and constraints are presented, as well as a discussion of the expanding role of general health status indexes.

Risk vulnerability and enrollment in a prepaid group practice.

Abstract: An hypothesis that specifies conditions under which risk vulnerability factors are associated with enrollment in prepaid practices is presented and tested. We assert that such factors as illness histories and previous use of medical services are linearly and positively associated with enrollment when the prepaid option offers significantly lower marginal out-of-pocket costs. The hypothesis is supported by observations from a prostpective study of a lowincome population.

A study of consumer attitudes about health care: the delivery of ambulatory services.

Abstract: This paper examines the patient's decision to select a source of care, offers a theoretical construct of this choice process, and reports on the results of a survey that tested the model among the population of Rochester, New York. Respondent reasons for selecting a source of ambulatory care are collapsed into categories that relate to individual perceptions of the utility of cost, time, convenience, sociopsychological factors, and the technical quality of care. The relative importance of these criteria and other findings relating to sociodemographic characteristics and individual patterns of utilization are reported. The data are derived from a survey (N = 521) of households representative of the area of Rochester, New York.

Verbal communications of community pharmacists.

Abstract: Community pharmacists, by virtue of their location, are thought to be among the most accessible health care workers in the delivery system. To estimate the importance of this assertion it is necessary to understand the communication habits of pharmacists, especially their interactions with patients. Since verbal communication is the most frequent form of patient interaction, this study attempts to specify the type and amount of all pharmacist communication with emphasis on the pharmacist-patient process. Using a modified work sampling technique, communication data were collected on community pharmacists practicing in chain pharmacies. Data are presented in the context of a causal model. The strongest pathway in the model is found to be the inverse relationship of prescription department staffing to the percentage of time pharmacists devote to communication with patients. Prescription volume is seen to have a moderately positive effect on the level of communication. However, further analysis reveals staffing to be the limiting factor. The findings suggest that changes in the environment of the community pharmacists studied would do much to increase pharmacist-patient contact. An educational effort also is indicated to assure that patients receive quality communication.

Impact of integration of mental health service and comprehensive medical care.

Abstract: Effect of the introduction of mental health services into a comprehensive prepaid medical care facility was studied. The subjects were two independent subsamples of all individuals seen in the mental health service for the first time in 1967, and two comparison groups not seen in the mental health s

An Assessment of Institutional Review Committees in Human Experimentation

Abstract: A study of the functioning of an institutional review committee, when combined with the Barber et al. survey data on 300 institutions, allows for a useful provisional assessment of the strengths and weaknesses of existing procedures for protecting human research subjects. The evidence shows that there is an important role for such committees; however, most committees are relatively permissive. While on committees' performance showed that such committees can have an impact on proposed research, the absence of effective monitoring procedures and lack of feedback from research subjects limits the impact of the review procedure on the actual conduct of research. The question is also raised whether the review procedure, because of its legitimizing functions, may have some regressive consequences for the protection of human subjects.

Clinical styles and motivation: a study of laboratory test use.

Abstract: The study reported in this paper examines clinical reasoning styles with a focus on laboratory utilization. A stratified sample of 80 physicians participated in the solution of a simulated patient management problem. The analysis focuses on variation in the portfolio of laboratory tests ordered as a function of practice setting (e,g., physicians in practice versus physicians in training). The study also examines the response of physicians to the imposition of constraints on ordering, as well as behavior, when unlimited ordering capacity is provided. Overall, the data profiles emerging from the analysis indicate the variety inherent in physician decision-making strategies, and point to the necessity of employing a cautious and flexible approach toward any general scheme of constraints upon medical diagnostic procedures;

Medicine's great schism: prevention vs. cure: an historical interpretation.

Abstract: All societies, primitive and advanced, demand therapeutic services, but a society must develop sophisticated prerequisites before it can support preventive services. This discordance in the origins of curative medicine and of public health does not explain why a schism between them still persists. T

Use of traditional Indian medicine among urban native Americans.

Abstract: The purpose of this paper is to provide a systematic explanation of the use of traditional medicine among the native American population living in the San Francisco Bay area. Several hypotheses concerning the factors associated with this behavior are tested. These include tribal grouping, socioeconomic and sociocultural factors, as well as the relationship between traditional medicine and modem Anglo medicine. The analysis is based on a probability sample of 277 native American families, systematically drawn from a specially prepared list of 5,000 in three Bay area counties with the largest native American population (Alameda, San Francisco, and Santa Clara). Traditional medicine was used by almost one out of three families in the sample and it is shown that use of traditional medicine, although related to sociocultural factors, did not detract from the use of modem Anglo medicine.

The use of item importance weights in assessing physician performance with predetermined criteria indices.

Abstract: Conditions for using single measures or combinations of measures of physician performance are discussed. Studies reporting combination indices of proficiency are reviewed for their use of equally or differentially weighted components and for the use of these with many or with single diagnoses, Comparisons of diagnostic-specific measures are made using differential and equal item weights. Under the general conditions of this research, few psychometric differences existed. The use and acceptability of differential item weights in this research are also discussed.

The role of prescriptions in therapy.

Abstract: The aim of the present study was that of discovering whether the prescription of drugs displaces other forms of therapy. The method adopted was that of behavior simulation. Doctors were requested to provide therapeutic proposals regarding a standard set of patient cases described in questionnaires sent to them. These cases were formulated in such a way that in the author's opinion they could easily, and perhaps best, be treated without drugs. Nevertheless, most of the cases were treated with drugs, thereby indicating the important role of drug therapy as a means of treatment. In particular, psychic disturbances were often treated by drugs. Frequently, drugs represented the only treatment offered, and no alternative form of treatment was suggested.

Emergency hospitalization of young children: some neglected psychological considerations.

Abstract: In spite of the fact that emergency admission is the most common form of hospitalization for young children, as well as containing the greatest potential for trauma, almost no reference has been made to it in the psychological literature on pediatric hospitalization. To explore the theoretical and practical feasibility of research in this area, a pilot study was designed to investigate the reactions of a sample of children, parents, and staff to the first six hours of emergency hospitalization, compared with those of a similar sample to elective admission. Sixteen children (eight in each group) aged 11 to 48 months were selected on a time-sample basis from the patient population of a large, metropolitan, pediatric hospital and were followed by trained observors using a specially designed observation schedule. The results indicated that, as expected, emergency does constitute an even greater stress for children, parents, and staff than the already stressful situation of elective admission. In both conditions, however, the results were more complex and more disturbing than anticipated. The implications of these findings, as well as suggestions for further research, are discussed. ANYONE CONCERNED with the psychological trauma that can result from the hospitalization of a young child should, theoretically, be particularly sensitive to the hazards of emergency hospitalization. For the emergency admission of a young child presumably contains not only the usual stresses (separation, unfamiliar surroundings, restricted mobility, etc.) in an intensified fashion, but might also be expected to engender a host of other factors known to be

Antibiotic use and abuse among physicians in private practice in Shiraz, Iran.

Abstract: From 120 practicing physicians in Shiraz, Iran, 40 were selected to identify their attitude toward the use of antibiotics A young, healthy man who complained of mild fever and cold symptoms was referred to them and 37 of them prescribed inappropriate doses of antibiotics It is assumed that the behavior of the physicians is based on pressure by the patient to receive more medicine, particularly antibiotics

Primary care in a penal institution. A study of health care problems encountered.

Abstract: The kinds of health care problems encountered in a 600-man panel institution were studied. Five hundred twenty-eight problems were identified in 333 inmates seen on sick call. The large number of psychosocial problems (194 out of 528) and the wide diversity of problems (125 in 333 inmates) were documented. The questionable suitability of the medical model for health care in this type of setting is discussed. The implications for primary health care delivery and education are considered.