Showing papers in "Medical Care in 1981"

The Sickness Impact Profile: development and final revision of a health status measure.

Abstract: The final development of the Sickness Impact Profile (SIP), a behaviorally based measure of health status, is presented. A large field trial on a random sample of prepaid group practice enrollees and smaller trials on samples of patients with hyperthyroidism, rheumatoid arthritis and hip replacements were undertaken to assess reliability and validity of the SIP and provide data for category and item analyses. Test-retest reliability (r = 0.92) and internal consistency (r - 0.94) were high. Convergent and discriminant validity was evaluated using the multitrait--multimethod technique. Clinical validity was assessed by determining the relationship between clinical measures of disease and the SIP scores. The relationship between the SIP and criterion measures were moderate to high and in the direction hypothesized. A technique for describing and assessing similarities and differences among groups was developed using profile and pattern analysis. The final SIP contains 136 items in 12 categories. Overall, category, and dimension scores may be calculated.

The concept of access: definition and relationship to consumer satisfaction.

Abstract: Access is an important concept in health policy and health services research, yet it is one which has not been defined or employed precisely. To some authors "access" refers to entry into or use of the health care system, while to others it characterizes factors influencing entry or use. The purpose of this article is to propose a taxonomic definition of "access." Access is presented here as a general concept that summarizes a set of more specific dimensions describing the fit between the patient and the health care system. The specific dimensions are availability, accessibility, accommodation, affordability and acceptability. Using interview data on patient satisfaction, the discriminant validity of these dimensions is investigated. Results provide strong support for the view that differentiation does exist among the five areas and that the measures do relate to the phenomena with which they are identified.

Equity of access to medical care: a conceptual and empirical overview

Abstract: This paper summarizes the major ethical considerations in the conceptualization and measurement of the equity of access concept, presents national and community data on the most current profile of access in the United States, and discusses the implications of these conceptual and empirical issues. Changes in health care policy and the future of the "equity of access" objective in the U.S. are also discussed. THE ETHICAL considerations in the conceptualization and measurement of equity of access to medical care, the current empirical profile of equity in the United States, and the implications of these conceptual and empirical issues for future health policy dealing with the "equity of access" objective are the focus points of this report. Implicit in this objective of equity are three assumptions that serve as a starting point for examining the ethics of equity: 1) Health care is a right; 2) The resources for allocating health care are finite; 3) Health policy should be concerned with the design of "just" mechanisms for allocating

The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care.

Abstract: A major national health policy objective is to improve the efficiency of hospital utilization. To evaluate programmatic interventions with this objective, such as the Professional Standards Review Organization program, measures of appropriate use are a fundamental need. This report represents the results of two developmental trials of a new technique, labeled the Appropriateness Evaluation Protocol (AEP), for assessing potentially unnecessary hospital days of care. Twenty-seven objective criteria items related to medical services, nursing/life support services and patient condition factors were incorporated in the protocol. If any one of the criteria was met, the day was deemed "appropriate," and if none was met, the day was deemed "inappropriate" at an acute hospital level of care. A reviewer could override the objective criteria in either direction in reaching a final judgment. Three reviewers, two nurses and one physician each reviewed 200 charts at a teaching hospital. After correcting for a small number of abstracting errors, overall agreement rates between pairs of reviewers ranged from 92 to 94 per cent, levels significant p less than 0.0001. Of all cases judged inappropriate by at least one of the reviewers, specific agreement rates for the reviewer pairs on which days were inappropriate ranged from 73 to 79 per cent. These overall agreement rates and specific agreement rates on days of care judged as inappropriate are higher than those of any previously reported assessment methods. A parallel study of the appropriateness of admissions in these same cases, using purely subjective reviewer judgments, found overall agreement rates averaging 90 per cent, but rates of specific agreement on inappropriate admissions were less than 40 per cent between pairs of reviewers. Along with comparisons to other, more subjective, assessment techniques, this finding suggests that objective criteria are a vital element in developing methodologically sound techniques for assessing appropriate hospital use.

Advances in the measurement of functional status: construction of aggregate indexes.

Abstract: This article summarizes tests of the appropriateness of aggregating specific categories of physical capacities and limitations into aggregate functional status indexes. Self-administered questionnaires were used to gather data from 4,603 people between 14 and 66 years of age. Cumulative indexes defi

The Duke-UNC Health Profile: an adult health status instrument for primary care.

Abstract: The Duke--UNC Health Profile (DUHP) was developed as a brief 63-item instrument designed to measure adult health status in the primary care setting along four dimensions: symptom status, physical function, emotional function and social function. Reliability and validity were tested on a group of 395 ambulatory patients in a family medicine center. Temporal stability Spearman correlations ranged from 0.52 to 0.82 for the four dimensions. Cronbach's alpha for internal consistency was 0.85 for emotional function. Guttman's reproducibility coefficients were 0.98 for physical function and 0.93 for social function, and the scalability coefficients were 0.89 for physical and 0.71 for social. Observed relationships between DUHP scores and demographic characteristics of the respondents correlated well with those predicted by the investigators (overall Spearman correlation 0.79). Convergent and discriminant validity was supported by strong associations between components of DUHP and those on the Sickness Impact Profile (SIP), the Tennessee Self-Concept Scale (Tennessee), and the Zung Self-Rating Depression Scale (Zung). DUHP with SIP monocomponent-heteromethod Spearman correlations ranged from 0.34 to 0.45, and those for DUHP with Tennessee ranged from 0.68 to 0.81. DUHP with Zung monoitem--heteromethod correlations ranged from 0.54 to 0.57. It is concluded that this evidence supports the reliability and validity of the DUHP as an instrument suitable for studying the impact of primary health care on the health outcomes of patients.

Disclosure of information to patients in medical care.

Abstract: It is generally agreed that patients have a right to be adequately informed. However, little is known about the extent to which doctors and patients agree about information that should be disclosed. We studied what patients want to know, as contrasted with what physicians report actually disclosing, in a population of physicians who treat seizures and patients or parents of patients who have this disorder. In general, it was found that patients or parents of patients who have this disorder. In general, it was found that patients prefer far more detailed disclosures than physicians routinely offer and that the two groups have widely different beliefs about the consequences of detailed disclosures. Patients and parents preferred extensive disclosures, particularly regarding risks and alternative therapy. Physicians were likely to disclose only risks with a relatively high probability of occurrence and they provided little information about alternative therapies. Patients and parents were also much more likely than physicians to believe that the final decision concerning therapy should rest with the patient. The data suggest that a better empirical understanding of the consequences of detailed disclosures may help resolve differences of opinion regarding how much information should be provided to patients.

The validity of the medical record

Abstract: The medical record is the source of information for many purposes, including evaluation of the quality of care provided. Despite this reliance on the record, there have been few attempts to validate the recorded content against the verbal content of the interaction between patient and physician. In this study, we compared the record with verbatim transcripts of outpatient visits. Overall, 59 per cent of units of information present in either source were found in the record. Recording was more complete for the chief complaint (92 per cent) and information related to the patient's present illness (71 per cent) than for other medical history (29 per cent). Incomplete recording of elicited information may partially explain the often low levels of performance of recommended care items found in quality-of-care studies. We suggest that more attention be paid to improving communication about tests and therapies to patients.

Structural and Social Psychological Factors in the Decision to Seek Medical Care for Symptoms

Abstract: Panel data are presented from the Los Angeles Health Survey, in which 1 year of symptom experience is analyzed. Of the 1,210 individuals originally in the panel, 769 reported at least one symptom in reinterviews conducted every 6 weeks during the study year. The dependent variable in the analysis is whether or not the individual decided to seek medical attention for his symptoms. Hierarchical multiple regression was used to organize the independent variables into five groups: 1) need; 2) social structure; 3) organization of care; 4) general social network patterns and health orientations; and 5) social network influences and personal beliefs specific to the symptoms. Of the 57 per cent of the variance explained by the entire set of independent variables, need factors accounted for 12 per cent and network influences and personal beliefs specific to the symptom accounted for 42 per cent. In spite of the amount of variance explained in this analysis, the allocation of the explained variance among the predictor variables raises some disturbing questions regarding our ability to understand the decision to use health services.

Refinements in the Measurement of Health-Specific Locus-of-Control Beliefs

Abstract: A health-specific locus-of-control (HLC) questionnaire was constructed to measure beliefs about Self-Control Over Health, Provider Control Over Health, Chance Health Outcomes and General Health Threat. A factor analysis of items confirmed these dimensions, and corresponding scales were shown to be reliable. A factor analysis of HLC scales and other measures was used to evaluate construct validity. Persons believing in provider control over health outcomes tended to have strong favorable attitudes toward the quality of medical care. Chance Health Outcomes was associated with more general chance and controllability measures. General Health Threat seemed to tap susceptibility to disease and beliefs that doctors are unable to diagnose those diseases. People who believe in Self-Control Over Health tended to reject the role of chance and health threat in determining health outcomes and to believe in the efficacy of doctors, although they view them as inaccessible. Results are compared with those of previous studies, and some applications of the questionnaire are discussed.

Physicians' Attitudes Toward Female Patients

Abstract: The relative impact of a patient's sex and expressivity (expression of a personal problem) on attitudes of physicians toward patients was assessed using case simulations and questionnaires. Eight simulated cases were used that varied by presenting complaint, patient sex, and inclusion or exclusion of a personal problem. Two non-identical cases were read by each of 253 primary-care physicians, yielding 506 questionnaires for analysis. Of the physicians, 25 per cent believed women were likely to make excessive demands on physician time, although only 14 per cent believed this likely of men (p less than 0.01); women's complaints were judged more likely to be influenced by emotional factors (65 per cent versus 51 per cent in men, p less than 0.01), and were identified as psychosomatic more frequently than were men's (21 per cent versus 9 per cent, p less than 0.01). No sex differences were observed for tranquilizer prescriptions. Sex differences persisted when complaint and expressiveness were controlled; however, physicians' reactions to expressivity were strong enough to equalize male-female differences in some items. Although non-expressive women were more likely to receive a psychosomatic diagnosis than non-expressive men (14 per cent versus 2 per cent, p less than 0.01), expressive men and women were almost equally likely to receive psychosomatic diagnoses. Thus, differences in labeling occurred as a function of the patient's sex and expressivity. The effects of these differences on quality of care remain to be determined.

The Manitoba longitudinal study on aging: preliminary findings on health care utilization by the elderly.

Abstract: This research links survey data from a large probability sample of the elderly population of one Canadian province with provincial insurance data documenting all their health care use during the years before and after the interview. The data show that “the elderly” are not high users of the health c

Hospital Medical Staff Organization and Quality of Care: Results for Myocardial Infarction and Appendectomy

Abstract: This article examines the relationships among hospital structural characteristics, individual physician characteristics, medical staff organization characteristics and quality of care for two conditions: acute myocardial infarction and appendicitis. Using data obtained from the Commission on Professional and Hospital Activities (CPHA), approximately 50,000 acute myocardial infarction cases and 8,183 appendectomy cases collected from 96 hospitals in the East North Central Region of the country (Illinois, Indiana, Michigan, Ohio and Wisconsin) were examined. These data were merged with medical staff organization and related data on hospital characteristics obtained from the American Hospital Association. The results indicate that such medical staff organization factors as involvement of the medical staff president with the hospital governing board, overall physician participation in hospital decision making, frequency of medical staff committee meetings and percentage of active staff physicians on contract are positively associated with higher quality-of-care outcomes, independent of the effects of hospital and physician characteristics. Further, the medical staff organization factors appear to be somewhat more strongly associated with higher quality-of-care outcomes than the hospital and physician characteristics. For acute myocardial infarction, higher volume of patients treated per family practitioner and internist and presence of a coronary care unit were also associated with better outcomes. Given the restricted number of conditions studied, the geographically limited sample and the fact that specific variables were not consistently related to quality of care for both conditions, the results area viewed as preliminary. However, they are consistent with and extend other developing findings in this area. They also suggest that more attention needs to be given to the organization of the hospital medical staff and its articulation with the overall hospital decision-making structure and process in attempts to improve outcomes of hospitalization.

Physician treatment of men and women patients: sex bias or appropriate care?

Abstract: This paper considers medical care given by physicians to men and women in the United States. It asks how often significant sex differences in care occur, and if these differences are attributable to medically relevant factors or not. Sex differences in diagnostic services, therapeutic services, and dispositions for follow-up are studied for All Visits, 15 major groups of complaints, and 5 specific complaints (fatigue, headache, vertigo/dizziness, chest pain, and back pain). Data are from the 1975 National Ambulatory Medical Care Survey (NAMCS). The analysis reveals that medical care is often similar for men and women, but a sizable number of significant sex differences occur (about 30 to 40 per cent of the services and dispositions studied), and they tend to show more medical care for women. Most of the differences persist even after controlling for medically relevant factors (patient age, seriousness of problem, diagnosis, prior visit status, and reasons for visit). Notably, women still receive more total and extensive services, and more laboratory tests, blood pressure checks, drug prescriptions, and return appointments for many complaint groups. They receive more services for back pain and headaches and more follow-up plans for vertigo/dizziness and back pain. Remaining sex differences may be due to missing medical factors, patient requests for care, patient distress and needs for nurturance, and physician sex bias. In contrast to a recent San Diego study,1 national data show few significant sex differences in the extent and content of diagnostic services given for five common complaints.

Use of ambulatory medical care by the poor: another look at equity.

Abstract: Access to health services by the poor and other disadvantaged groups has improved considerably over the past 15 years. These circumstances have led some to question whether the poor now have equal access to health care. This article presents recent evidence from the 1976-78 National Health Interview Surveys (NHIS) comparing utilization among age, race, and income groups. Without adjustment for health status, the poor have more physician visits than those with higher incomes. After adjusting for age and health status, however, these differences are reversed. Depending on which measure is used, the poor have between 7 per cent and 44 per cent fewer visits than those with income above twice the poverty level. Furthermore, the age- and health-adjusted data show blacks have significantly fewer visits than their white counterparts. In addition, there are large differences among race and income groups in the characteristics of the ambulatory care obtained. Blacks and the poor are much more likely to use hospital clinics and less likely to use private physician offices or telephone consultations. The poor also receive less preventive care. It would appear from the present evidence that still further progress is required to achieve the goal of equity in the distribution of medical care services.

Short- and long-term residents of nursing homes.

Abstract: This article analyzes reported data on length of stay of discharged patients from the 1977 National Nursing Home Survey. Assuming that patients admitted to nursing homes are one of two types, short-stayers and long-stayers, the statistically best-fitting proportions and expected lengths of stay for the two types are derived. The results are applied to statistics on characteristics of resident and discharged patients to find admission characteristics that differentiate the two groups. Because long-stayers and short-stayers have quite different characteristics, nursing home statistics will be very different if one bases them on discharges or a cross-section of residents. For example, we estimate that short-stay patients represent 61 per cent of discharges but only 9 per cent of residents. A further application shows that, including deaths in hospitals, almost half of discharged patients die, rather than the usually cited figure of 25 per cent.

Determinants of hospital staff nurse turnover.

Abstract: Organizational and nonorganizational determinants of staff nurse turnover are investigated in a panel study of 1,259 nurses employed in two university-affiliated hospitals. Findings are consistent with a causal chain in which perceived autonomy, job satisfaction, intent to leave the hospital and turnover are a sequence of outcomes reflecting the successive stages of a nurse's decision to resign. Both personal characteristics and job-related attributes are predictive at various stages of the process, although family status variables have no significant effects. Implications for hospital management of turnover are discussed.

Screening for noncompliance among patients with hypertension: is self-report the best available measure?

Abstract: The substantial prevalence of noncompliance with drugs in populations of patients with treated hypertension suggests that a reliable, clinically applicable screening test for this behavior is needed Among employed white males, patient response to a nonjudgmental clinician inquiry has been reported to be highly predictive of noncompliance when positive but relatively insensitive (40 per cent) We assessed the performance of patient self-report in a demographically different population and confirmed the generalizability of prior observations A compound decision rule combining blood pressure and verbal inquiry observations, however, had higher sensitivity (83 per cent) for noncompliance in our population than self-report alone (55 per cent) and could be considered for use when the prevalence of noncompliance among uncontrolled hypertensives is sufficiently high Because 40 per cent of well-controlled hypertensives in our test population were noncompliant by pill-count, a question is raised regarding the need for "stepping down" drug therapy in some individuals under treatment for high blood pressure

The Use of Functional Assessment in Understanding Home Care Needs

Abstract: This study explored the use of functional assessment as a means for understanding individuals' needs for long-term care in the home setting. A primary focus of the study was to test the usefulness of a modified Barthel Index as the functional assessment instrument that measured personal care need. Data were derived from 89 chronically ill and/or disabled people who were receiving home health care from the Visiting Nurse Association of metropolitan Providence, Rhode Island (VNA). In addition to personal care need, the study explored psychological, socioeconomic and demographic characteristics of these individuals, as well as the specific services delivered by the VNA. Results indicate that the modified Barthel Index may be used to obtain detailed information regarding ability to perform activities of daily living in the home. The data also suggest that psychological functioning must be carefully assessed when personal care need is found to exist, particularly in elderly persons. The findings of the study indicate that individual need for long-term care might be measured by functional assessment in order to most effectively direct services into the home.

Use of Diagnostic Services by Physicians in Community Practice

Abstract: This study analyzes the use of diagnostic studies by community physicians. Data from billing claims for outpatient visits by Medicaid recipients in three northeastern Pennsylvania counties during a 38-month period were studied, including 55,420 visits to 336 physicians. The use of outpatient laboratory tests and roentgenograms was correlated with the personal characteristics of the prescribing physicians. When case mix was controlled, analysis by specialty showed that internists ordered approximately the same number of procedures as family physicians, and both groups ordered more procedures than general practitioners. The number of years since medical school graduation showed a statistically significant inverse relationship with laboratory and radiology use. Public school graduates ordered more laboratory tests than private school graduates, and foreign medical graduates ordered more roentgenograms than domestic graduates. Other variables, including size and location of practice, and osteopathic or medical training, were not significantly related to patterns of use.

Improving hospital discharge data: lessons from the National Hospital Discharge Survey.

Abstract: The most recent study by the Institute of Medicine of the reliability of hospital discharge data abstracted from patients' medical records documents the continuing presence of a substantial level of imprecision and error, affirming the findings of earlier studies. The most obvious factors leading to unreliability stem from inadequacies in the face sheets of medical records. Significant improvements could be attained if the discharge summary were routinely used to abstract information on patient disposition and principal diagnosis and if the operative report were routinely used to abstract information on principal procedure. Additional recommendations are offered for developmental activities intended to improve the designation of diagnosis, diagnostic classification schemes and hospital medical records systems.

Improving hypertension control: impact of computer feedback and physician education.

Abstract: Two interventions designed to help physicians manage hypertensive patients were evaluated in a controlled trial: 1) computer-generated feedback to facilitate identification of poorly controlled patients; and 2) a physician education program on clinical management strategies, emphasizing patient compliance. Four physician practice teams received either computer feedback, the education program, both, or neither. Feedback team physicians received seven monthly listings of the latest visits and blood pressures of their hypertensive patients. The self-administered learning program included written clinical simulations and associated didactic material. Experimental and control physicians were similar in baseline knowledge, patient mix and level of training. All feedback team physicians requested appointments for listed patients, and their patients made twice as many visits as control patients during the intervention period (p 0.20). The probability of missing a 10 mm interteam difference in outcome diastolic pressure was 1 per cent (power of 0.99). Strategies for further improvement in outpatient hypertension management may need to come from outside the traditional medical model.

Sources of assessment of physician performance: a study of comparative reliability and patterns of intercorrelation.

Abstract: The technical and the interpersonal skills of resident physicians in four separate samples were examined with subjective performance evaluations from four different sources: attending physicians, peers, patients and the residents themselves. Residents were from programs in internal medicine, family practice and general surgery. The reliabilities of measures from all four sources were found to be substantial, suggesting the potential usefulness of these sources of physician evaluation. Ratings of technical and interpersonal skill were found to be highly intercorrelated within each source. Reasons for this high degree of overlap are discussed. Finally, the ratings from the four sources were found to be fairly independent, indicating that they provide relatively separate measures of physician performance. The implications of these findings for medical care, education and research are considered.

The Usefulness of Patients' Individual Characteristics in Predicting No-Shows in Outpatient Clinics

Abstract: Patients' characteristics and no-show patterns are analyzed in order to determine the number of patients to schedule in outpatient clinics. This predictive model is evaluated on a second sample of data and compared with another scheduling technique that is based on the average no-show rate for each clinic. Our survey suggests that it is possible to predict accurately the number of no-shows with a small set of variables, and that patient scheduling can be improved by paying attention to the characteristics of individual patients. The most important single predictor is the patient's previous appointment-keeping pattern.

Life satisfaction and chronic disease: exploration of theoretical model.

Abstract: This research was undertaken to demonstrate the usefulness of a theoretical model for explaining differences in the life satisfaction of persons with different chronic diseases Through stepwise multiple regression, an assessment was made of the effects of social activity, perceived health, health locus-of control and degree of disability on the life satisfaction of 51 persons with coronary artery disease (CAD) and 32 persons with chronic obstructive pulmonary disease (COPD) Findings were as follows: (1) COPD patients were significantly less satisfied, less socially active and more disabled, and they perceived their health as poorer than did the CAD patients; (2) social activity emerged as the single best predictor of life satisfaction for both groups; (3) the second best predictor was perceived health for the CAD patients and degree of disability for the COPD patients; (4) the four variables accounted for 48 per cent of the variance in life satisfaction for the COPD patients, 124 per cent of the CAD patients It was concluded that predictors of life satisfaction vary with the particular disease, as does the manner in which these factors interact to mitigate or compound the impact of the particular disease Suggestions are made regarding modification of the theoretical model

Seeing the same doctor: determinants of satisfaction with specialty care for disabled children.

Abstract: The effect of continuity of physician on satisfaction with medical care was examined in a sample of 370 families of disabled children receiving care from four specialty clinics of teaching hospitals. Families of children with myelodysplasia, cystic fibrosis (CF), cerebral palsy and multiple physical handicaps were included. A comparison of scores on the eight scales of the Patient Satisfaction Questionnaire across the four clinics revealed marked and consistent differences: patients of cystic fibrosis clinic scored significantly higher than patients of other clinics on most scales. Multiple regression analysis in which source of care (CF clinic versus other clinics), continuity of care, waiting time and patient and family characteristics (income, race, education, level of disability) were used as predictors indicated that continuity of care accounted for a large part of the association between source of care and satisfaction. Further, when continuity of physician and waiting time in the clinic were held constant, patients of the CF clinic were indistinguishable from patients of other clinics in their satisfaction with doctors and with medical care. Further analysis revealed that continuity of care contributed to patient satisfaction not only in a clinic that constitutes a patient's principal source of care, but also in a clinic in which only specialized care is given, excluding care for intercurrent illnesses or immunizations.

Price and Membership in a Prepaid Group Medical Practice

Abstract: Federal interest in prepaid group practices as a means to control rising health care costs in reviving. This article is an empirical study of price and membership at a prepaid group practice among employees of Yale University. This article is the first to estimate the effect of price on the decision for membership in a prepaid group. The probability of joining the prepaid group is estimated to be a function of the relative price of the prepaid group and a conventional third-party insurance plan, the distance of residence to the prepaid group, the perceived quality of services at the prepaid group and the demand for medical services. Our most important finding is that employees' choice is quite sensitive to the relative price of the two plans. This has important implications for federal policy toward prepaid group practices.

On the Perceived Meaning of Symptoms

Abstract: The importance of understanding the manner in which symptoms are interpreted is generally recognized, but has received relatively little direct research attention. In an attempt to obtain some evidence on the meaning attached to each of a set of 45 symptoms, subjects were asked to rate the symptoms on eight semantic properties. The symptom ratings on the various properties were then correlated and the correlation matrix subjected to a principal components factor analysis. Three factors of perceived meaning emerged. The first factor is defined by the extent to which symptoms are perceived as threatening, disruptive and painful. The second factor consists of the familiarity of symptoms and the perceived personal responsibility for their occurrence. The third factor reflects how embarrassing the symptoms are. This structure of preceived meaning of symptoms is discussed with reference to the literature on delay in seeking medical care.