Showing papers in "Medical Care in 1992"

The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.

Abstract: A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.

Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue.

Abstract: We asked if the factors that predict overall mortality following two common surgical procedures are different from those that predict adverse occurrences (complications) during the hospitalization or death after an adverse occurrence, which we refer to as "failure to rescue." We examined 5,972 Medicare patients undergoing elective cholecystectomy or transurethral prostatectomy using three outcome measures: 1) the death rate (number of deaths/number of patients); 2) the adverse occurrence rate (number of patients who developed an adverse occurrence/number of patients); and 3) the failure rate (number of deaths in patients who developed an adverse occurrence/number of patients with an adverse occurrence). The death rate was associated with both hospital and patient characteristics. The adverse occurrence rate was associated primarily with patient characteristics. In contrast, failure to rescue was associated more with hospital characteristics, and was less influenced by patient admission severity of illness as measured by the MedisGroups score. We concluded that factors associated with hospital failure to rescue are different from factors associated with adverse occurrences or death. Understanding the reasons behind variation in mortality rates across hospitals should improve our ability to use mortality statistics to help hospitals upgrade the quality of care.

The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts. Results from the Medical Outcomes Study.

Abstract: This study estimated the validity and relative precision (RP) of four methods (MOS long- and short-form scales, global items, and COOP Poster Charts) in measuring six general health concepts. The authors also tested whether and how precisely each method discriminated relatively well adult patients (N = 638) from those with only severe chronic medical (N = 168) and only psychiatric conditions (N = 163), as clinically defined. For comparisons between the well group and both medical and psychiatric groups, RP estimates favored long-form over short-form, multi-item scales, and favored multi-item scales over single-item global measures and poster charts. In relation to long forms, short-form multi-item scales achieved a median RP of .93; RP estimates for global items and poster charts were .81 and .67, respectively. Variations in RP across methods and concepts were linked to differences in the coarseness of measurement scales, reliability, and content (including the effects of chart illustrations). These variations in RP have implications for the interpretation of scores, the statistical power of comparisons between clinical groups, and the size of confidence intervals around individual patient scores.

Adequacy and duration of antidepressant treatment in primary care

Abstract: Among a sample of 119 distressed high-utilizers of primary care, 45% of patients evaluated by a psychiatrist as needing antidepressant treatment had been treated in the year before the examination. However, only 11% of the patients needing antidepressants had received adequate dosage and duration of pharmacotherapy. In the year following the intervention, study patients whose physicians were advised regarding treatment during a psychiatric consultation were more likely to receive antidepressant medications (52.7%) relative to a randomized control group (36.1%). However, the intervention did not significantly increase the provision of adequate antidepressant therapy (37.1% vs 27.9%). Among study patients using antidepressants, patient characteristics did not differentiate patients who received adequate dosage and duration of antidepressant medications from those who did not. Analysis of data on the duration of antidepressant therapy for all health maintenance organization enrollees initiating use of antidepressants showed that only 20% of patients who had been given prescriptions for first-generation antidepressants (amitriptyline, imipramine, or doxepin) filled four or more prescriptions in the following six months, compared to 34% of patients who had prescriptions for newer antidepressants (nortriptyline, desipramine, trazodone and fluoxetine). Experimental research evaluating whether these newer medications (with more favorable side effect profiles) improve adherence, and thereby patient outcome, is needed.

Development of the 'Activities of Daily Vision Scale'. A measure of visual functional status

Abstract: To develop a method for the evaluation of visual function in subjects with cataracts, the authors identified 20 visual activities and categorized them into five subscales (distance vision, near vision, glare disability, night driving, and daytime driving) that comprised the Activities of Daily Vision Scale (ADVS). Each subscale in the ADVS was scored between 100 (no visual difficulty) and 0 (inability to perform the activity because of visual difficulty). In 334 subjects scheduled for cataract extraction (mean age 75 +/- 9 years, 67% women), ADVS scores (mean +/- standard deviation) for each subscale ranged from 44 +/- 31 for night driving to 72 +/- 24 for near vision activities. When administered by telephone, inter-rater reliability coefficients (r) were 0.82 to 0.97 (P < 0.001) for each of the subscales, and test-retest reliability was 0.87 for the scale overall. Cronbach's coefficient alpha was very high for both the in-person (alpha = 0.94) and telephone (alpha = 0.91) formats. Criterion validity, the correlation between visual loss and ADVS score, was -0.37 (P < 0.001) when the ADVS was administered in person and -0.39 (P < 0.001) when it was administered by telephone. Content validity as assessed with factor analysis showed that 88% of the variance of the principal components weighted on one factor. The authors conclude that substantial visual disability is not captured by routine visual testing and that the ADVS is a reliable and valid measure of patient's perception of visual functional impairment.

Comparative measurement sensitivity of short and longer health status instruments.

Abstract: Short measures of health status are used increasingly in health services research, yet their sensitivities to clinical change have not been compared with longer, established instruments. In this study, 5 health status measures were administered preoperatively and 3 months postoperatively to 54 patients undergoing total hip arthroplasty. These instruments included the Sickness Impact Profile (SIP)--an established, long measure--and 4 short forms: the SF-36, Functional Status Questionnaire, shortened Arthritis Impact Measurement Scales, and Modified Health Assessment Questionnaire. Scores for physical, psychological, and global dimensions were constructed by aggregating subscales. Sensitivity to change, or responsiveness, was expressed with the standardized response mean (SRM), calculated as the mean change in score divided by the standard deviation of the change in score. The sampling distribution of the SRM was estimated with a jackknife procedure. Preoperative scores were moderately to highly correlated across instruments. The physical and global dimension SRMs of the brief health status measures ranged from 0.85 to 1.27 and were as large as or larger than the corresponding SIP SRMs. The SIP had the highest SRM on the psychological dimension. None of the instruments was significantly more sensitive than the others at the critical value (P = 0.005) adjusted for multiple comparisons. The brief health status measures were equally or more responsive than the SIP after total hip arthroplasty in the physical and global dimensions. Much larger samples are required to demonstrate statistically significant differences in SRMs among instruments.

A health-related quality of life instrument for patients evaluated for epilepsy surgery.

Abstract: The goals of surgery in treating intractable epilepsy are to eliminate seizures and improve quality of life. This report describes the development of the Epilepsy Surgery Inventory (ESI)-55, a 55-item measure of health-related quality of life for epilepsy patients. The ESI-55 includes the following scales (number of items in parentheses): health perceptions (9), energy/fatigue (4), overall quality of life (2), social function (2), emotional well-being (5), cognitive function (5), physical function (10), pain (2), and three separate scales of role limitations due to emotional, physical, or memory problems (5 items each). Also included is one change in health item. The ESI-55 was completed by 89% of 224 adults who had undergone a protocol evaluation for epilepsy surgery since 1974. Alpha internal consistency reliability coefficients ranged from 0.76 to 0.88 except for social function (alpha = 0.68). Multitrait scaling analyses supported item discrimination across scales. Factor analysis confirmed previously identified mental and physical health factors, and yielded a third factor defined by cognitive function and role limitations scales. Construct validity was supported by correlations of the ESI-55 with a mood profile instrument. Analysis of ESI-55 scale scores by seizure classification showed that the 44 patients who were seizure-free following surgery scored higher than did 55 patients who continued to have seizures (P less than 0.05 for all comparisons); 43 patients having seizures without loss of consciousness scored in between. Results of this study indicate that the ESI-55 is reliable, valid, and sensitive to differences in seizure status.

Recent developments and future issues in the use of health status assessment measures in clinical settings.

Abstract: This paper provides a broad overview of the assessment of health status in clinical practice in three parts. Yesterday: The nation has undergone a paradigm shift in health-related thinking. The former paradigm emphasized only disease; the new emphasizes health, functioning, well-being, and disease.

Clinical versus administrative data bases for CABG surgery. Does it matter

Abstract: This study compared the ability of a clinical and administrative data base in New York State to predict in-hospital mortality and to assess hospital performance for coronary artery bypass graft surgery. The results indicated that the clinical data base, the Cardiac Surgery Reporting System, is substantially better at predicting case-specific mortality than the administrative data base, the Statewide Planning and Research Cooperative System. Also, correlations between hospital mortality rates that are risk-adjusted using the two systems were only moderately high (0.75 to 0.80). The addition of new risk factors from the Statewide Planning and Research Cooperative System improved the predictive power of both systems but did not diminish the difference in effectiveness of the two systems. The three unique clinical risk factors in the Cardiac Surgery Reporting System (ejection fraction, reoperation, and more than 90% narrowing of the left main trunk) seemed to account for much of the difference in effectiveness of the two systems.

Methods for assessing condition-specific and generic functional status outcomes after total knee replacement.

Abstract: Many assume that, relative to generic measures, condition-specific health measures are both more sensitive to the condition's severity and more specific because they are less affected by other conditions. We analyzed the sensitivity and specificity of the generic SF-36, condition-specific scales based on the SF-36, and condition-specific measures based on the Knee Society's Clinical Rating System in a study of osteoarthritis patients following knee replacement. As hypothesized, knee-specific role function and pain measures were more specific than generic measures among patients with other comorbid conditions, and less so among patients with only knee problems. Physical function scales of both types were equally specific. Clinical indicators based on x-ray and range of motion were only weakly related to all measures of function.

Studying outcomes and hospital utilization in the elderly. The advantages of a merged data base for Medicare and Veterans Affairs hospitals.

Abstract: That veterans aged 65 years and older are eligible to receive care either in the Veteran Affairs (VA) health care system or in the private sector under Medicare confounds the analysis of veterans' health services utilization and outcomes in two ways First, changes in eligibility or financial barriers to access with regard to either system influence veterans' decisions about where to seek needed care Second, analyses of VA care for elderly veterans that rely solely on VA data sources underestimate both overall utilization and treatment complications Similarly, failure to consider the contribution of health care delivery in the VA system may confound analyses of health care utilization by the Medicare-eligible population To study the magnitude of such confounding influences, we linked the Medicare and VA health care administrative databases for residents of New England and New York Results indicated that, for ten surgical procedures commonly performed in the elderly, as well as for hospitalizations resulting from acute myocardial infarction and hip fracture, VA patients receive from 176% to 374% of hospital care outside the VA system Private hospitalizations account for 55% to 195% of the care received by veterans within 6 months after an initial episode of care in a VA hospital It was also found that initial hospitalizations for study conditions in the VA accounted for 36% of all such hospitalizations among elderly Medicare-eligible men Although overall hospital utilization appears to be underestimated in VA data sources, it was found that ascertaining mortality from sources available within the VA produced excellent results when compared with deaths recorded in the Medicare enrollment files A national, merged VA-Medicare data base is feasible and would enhance the validity of analyses of health care delivery both for elderly veterans and for the Medicare population

Patients as reliable reporters of medical care process. Recall of ambulatory encounter events.

Abstract: This study explores the reliability of a data source on the quality and content of care rarely used in studies comparing the performance of health care organizations, that is, patient reports obtained from surveys. Evidence of patient survey reliability and validity and report data on patient reporting accuracy were reviewed for ten events that may have occurred during an initial health assessment for new adult enrollees of a health maintenance organization (HMO). Reports of 380 patients obtained through telephone survey were compared with medical records. For chest radiograph, mammogram, and electrocardiogram (EKG), patient reports exhibited both sensitivity and specificity. For serum cholesterol test, patients proved to be sensitive but not specific reporters. For blood pressure measurement, stool kit, and rectal examination, false negative rates were low (less than or equal to 0.10); they were somewhat higher for breast self-examination instruction and pelvic examination (0.21 and 0.22, respectively). Only for testicular self-examination instruction did patient reports fail to confirm medical record documentation (false negative rate = 0.53). Multivariate analysis showed a small association between increasing patient age and decreasing confirmation. Gender did not affect reporting ability, and agreement did not deteriorate over a 2- to 3-month postencounter interval. Patient reports appear to merit greater use in comparative studies of technical quality of care. Key words: quality of health care; quality assurance; health care; ambulatory care; patient recall; patient reports.

Ownership and organizational performance. A comparison of technical efficiency across hospital types.

Abstract: Using a national data base of urban hospitals, the effect of ownership (government, nonprofit, and for-profit) on the technical efficiency of hospitals was examined. Efficiency scores were computed using a method called data envelopment analysis. Controlling for environmental and hospital characteristics, for-profit hospitals were found somewhat less frequently and government hospitals consistently more frequently in the efficient category. When examining highly inefficient hospitals as a percentage of those receiving inefficient scores, for-profit hospitals appeared to be highly inefficient relative to the other ownership forms. Government and nonprofit hospitals were somewhat indistinguishable from one another regarding their percentages of highly inefficient scores. For-profit hospitals also tended to use supply and capital asset (hospital size) inputs less efficiently, and service and labor inputs more efficiently than hospitals in the other ownership categories.

Prescribing problems and pharmacist interventions in community practice.

Abstract: Interventions performed by 89 community pharmacists in 5 states to correct the prescribing problems they identified on new prescription orders were documented by trained observers. Pharmacists intervened to resolve a prescribing-related problem in 623 (1.9%) of 33,011 new prescription orders that were screened and dispensed during the study period. A panel of three expert evaluators concluded that 28.3% of the prescribing problems identified during the study could have caused patient harm if the pharmacist had not intervened to correct the problem. The rate at which pharmacists identified prescribing problems was negatively related to the number of prescriptions they dispensed per hour, suggesting that in pursuing distributive efficiency, some pharmacists may be exceeding their safe dispensing threshold. The authors recommend that the interprofessional system of oversight and verification (i.e., "checks and balances") in the delivery of pharmaceutical care in the community setting should be maintained and strengthened.

Economic analysis in randomized control trials.

Abstract: In medical technology assessment, randomized control trials (RCTs) play an important role in determining the relative efficacy of compared treatments. As scarce resources necessitate choosing among options for care, comparing costs of alternative tests, treatments, or programs also becomes important. This study assessed the prevalence and completeness of economic analyses in RCTs published from January 1966 through June 1988. It was found that only 121 of over 50,000 published randomized trials (0.2%) included economic analyses. For a random sample of 51 of these 121 studies, results revealed a mean quality of research score of 0.32 (SD of measurement = 0.14) and a mean economic analysis completeness score of 0.52 (SD = 0.13) on scales of 0 to 1. It was also found that higher economic completeness scores were positively correlated with later dates of publication (r = 0.28, P = 0.046) and with the presence of a statement of study perspective (r = 0.38, P = 0.006). A near-zero correlation between the economic completeness and the quality of research scores was revealed. Also noted were several deficiencies among the economic analyses, including improper allocation of overhead costs, absence of sensitivity analyses, and the fact that only 28% of the 51 studies included some form of aggregation of treatment costs and consequences. Progress in health care depends on accurate assessments of both relative efficacy and costs. The quality of both needs improvement.

The impact of clinical pharmacists' consultations on physicians' geriatric drug prescribing. A randomized controlled trial.

Abstract: The impact of clinical pharmacists' consultations on geriatric drug prescribing was studied in a prospective randomized controlled trial of patients 65 years of age and over discharged on 3 or more medications for chronic conditions from a 450-bed community hospital. The pharmacists provided consultation to experimental patients and their physicians at hospital discharge and at periodic intervals for 3 months postdischarge. Using a standardized tool, a physician-pharmacist panel, blinded to study group assignment of patients, evaluated the appropriateness of prescribing for a random sample of 236 patients. Eighty-eight percent had at least one or more clinically significant drug problems, and 22% had at least one potentially serious and life-threatening problem. Drug-therapy problems were divided into six categories: 1) inappropriate choice of therapy; 2) dosage; 3) schedule; 4) drug-drug interactions; 5) therapeutic duplication; and 6) allergy. Experimental patients were less likely to have one or more prescribing problems in any of the categories (P = 0.05) or in the appropriateness (P = 0.02) or dosage (P = 0.05) categories. A summary score, measuring the appropriateness of the patient's total drug regimen, indicated that experimental patients' regimens were more appropriate than those of controls (P = 0.01). Results of this trial reveal that clinical pharmacists can improve the appropriateness of geriatric drug prescribing in outpatient settings.

Improving adherence to screening follow-up among women with abnormal Pap smears: results from a large clinic-based trial of three intervention strategies.

Abstract: In a large randomized trial involving over 2,000 women with abnormal cervical cytology (pap smear), three clinic-based interventions were tested as strategies to increase return rates for screening follow-up: 1) a personalized follow-up letter and pamphlet; 2) a slide-tape program on pap smears; and 3) transportation incentives (bus passes/parking permits). The three interventions were evaluated using a 2 x 2 x 2 factorial design. Results of this study confirm a high rate of loss to screening follow-up (i.e., no return visits) among women with abnormal pap smears (29% overall), with substantial variability among the 12 participating clinics (13% to 42/%). For the sample as a whole, both transportation incentives and the combined intervention condition of personalized follow-up and slide-tape program had a significant positive impact on screening follow-up. However, transportation incentives emerged as the dominant intervention condition among patient subgroups that can be characterized as more disadvantaged socioeconomically and at higher risk of developing cervical cancer, including patients receiving care from the county health department (odds ratio (OR) = 1.51; P less than .05); patients without health insurance (OR = 1.77; P less than .01); and patients with more severe pap smear results (OR = 1.71; P less than .05). In contrast, among patient subgroups that can be characterized as relatively more advantaged and at lower risk of developing cervical cancer, only the combined intervention condition of personalized follow-up and slide-tape program was associated with a higher patient return rate. Subgroups reflecting this pattern included patients seen in noncounty clinics (OR = 4.54; P less than .05) and patients with less severe pap smear results (OR = 5.16; P less than .01). The implications of these findings are discussed in terms of designing clinic-based interventions to improve screening follow-up.

Ongoing assessment of health status in patients with diabetes mellitus.

Abstract: In 1990, the Division of Endocrinology and Metabolism of Henry Ford Hospital established an Outcomes Management data base for patients with Type I and Type II diabetes. A first cohort of 117 patients completed a baseline and 6-month follow-up assessment; a second cohort of 116 patients completed the baseline assessment. Assessment at each time point includes: the Short Form--36 Questions (SF-36) health status instrument; a set of clinical variables known as the Diabetes TyPE scale Form 2.2 abstracted from the medical record; and the physicians' ratings of patient's health status along the major dimensions of the SF-36. Success with both face-to-face and mailed administration of the SF-36 has been good, with response rates of over 85% using both methods. Comparison of patient and physician ratings of patient health status indicated a significant discrepancy on ratings of general health status, with physicians' ratings higher than those of patients themselves. "Tight" glycemic control (as measured by glycosylated hemoglobin) was associated with somewhat lower ratings on the various SF-36 dimensions for all patients in the first cohort and for Type I patients in the second cohort. However, this effect did not seem to be attributable to those features of a complex regimen used to achieve tight control, but rather reflected a complex combination of age, education level, and number of daily injections associated with achieving good control.

Home blood pressure monitoring. Effect on use of medical services and medical care costs.

Abstract: The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BP) at home can reduce costs without compromising BP control The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements Patients in the UC group were referred back to their physicians Patients in the Home BP group were trained to measure their own BP and return the readings by mail Patients were given a standard procedure to follow in case of unusually high or low BP readings at home The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year Costs of care for hypertension were calculated by assigning relative value units to each outpatient service Trained technicians measured each patient's BP at entry into the study and 1 year later Home BP patients made 12 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 08, 17) Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was $8876 per patient per year in the Home BP group, 29% less than in the UC group (95% CI: $1611, $5474) The annualized cost of implementing the home BP system was approximately $28 per patient during the study year and would currently be approximately $15 After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings

The Effects of Psychological Distress and Psychological Well-Being on Use of Medical Services

Abstract: In this study, the authors determined whether mental health status affects the use of general medical services, with and without adjustment for the correlated effects of general health perceptions and physical health status on such use. Data were used from the RAND Health Insurance Experiment, which

Patient-based health status measures in outpatient dialysis. Early experiences in developing an outcomes assessment program.

Abstract: This paper describes the initial development of a patient-based outcomes assessment program in an outpatient dialysis unit. This project presented four logistical and practical issues that are discussed in this paper: patient acceptance of quarterly administrations of a generic health status survey (the SF-36); timing of administration during dialysis session; respondent burden; and staff burden. Also discussed are three issues related to the clinical use of these assessments: medical record status of SF-36 data; use in clinical decisionmaking; and clinicians' responses to aggregate data from patient-based health status assessments. The investigation reported presents strong evidence of patient acceptance of the SF-36. Data collection problems reflected the nature of a busy dialysis unit, and most have been corrected. Considering functional status, the role functioning of dialysis patients is most adversely affected; among well-being measures, patients are most compromised by pain and lack of energy. Clinicians' reviews of these results point to the need for normative data, information about severity of primary and comorbid diseases, and knowledge of relationships between SF-36 scores and physiologic parameters to make clinical use of generic health outcome assessments.

Variation in health service use among hiv-infected patients

Abstract: The effects of sociodemographic factors on health service use among people with human immunodeficiency virus (HIV) infection are assessed. Data are from a survey of 939 clients of the Robert Wood Johnson Foundation's AIDS Health Services Program in nine communities across the country. Dependent variables are the number of outpatient visits, use of the emergency room, and whether the respondent had been admitted as an inpatient. In the 3 months before the interview, the sample averaged 7.46 outpatient physician/clinic visits: 35.9% reported an emergency room visit, and 29.9% had been hospitalized. The data suggested differential patterns of health service use, such that those who are white, male, and non-intravenous drug users have higher rates of outpatient clinic/physician use, whereas those who are nonwhite, female, and intravenous drug users have higher rates of emergency room use. Whether these observed differences are attributable to the system's response to different socioeconomic groups, or to differences in individual orientations toward use of medical care is discussed.

Analyzing communication in medical consultations. Do behavioral measures correspond to patients' perceptions?

Abstract: When analyzing relationships between physician-patient communication and medical outcomes, researchers typically rely on quantitative measures of behavior (e.g., frequencies or ratios) derived from observer-coding of transcripts, audiotapes, or videotapes. Interestingly, rarely have researchers assessed whether quantitative measures of communication (e.g., the physician's information giving) correspond to patients' perceptions of physicians' communication (e.g., informative). This investigation of 115 pediatric consultations examined this issue and yielded several notable findings. First, less satisfied parents received more directives and proportionally less patient-centered utterances from physicians than did more satisfied parents. Second, findings were mixed regarding the degree to which behavioral measures related to analogue measures of parents' perceptions. For example, the doctors' use of patient-centered statements was predictive of parents' perceptions of physicians' interpersonal sensitivity and partnership building, but the amount of information physicians provided parents was unrelated to judgments of the doctors' informativeness. Third, with some important exceptions, relationships between behavioral measures and parents' evaluations did not vary for parents differing in education and anxiety about the child's health. Finally, behavioral measures in the form of frequencies tended to be better predictors of parents' perceptions than were measures in the form of proportions. Implications are discussed.

Instrumental and affective aspects of physician behavior.

Abstract: In a semi-replication study, 103 videotaped real-life general practice consultations of patients with hypertension were observed with Roter's interaction Analysis System (RIAS). RIAS consists of a detailed category system meant to measure each verbal utterance of physician and patient (distinguished in task-related behavior and socio-emotional behavior) and a set of global affect-ratings. In this article, only general practitioner (GP) behavior is studied. GP's behavior is related to panel-assessed quality of care on three separate dimensions (technical-medical, psychosocial, and the management of the physician-patient relationship). A remarkably high percentage of the variance in the quality assessments (ranging from 59% to 70%) was explained by RIAS. The global affect-ratings proved to have the strongest influence in all quality assessments. In addition, task-related behavior seems to be more important in medical technical behavior, whereas socio-emotional behavior, and especially the psychotherapeutic categories like reflecting, paraphrasing, showing agreement, and others, seem to be more important in the other quality measures. The results are compared with Roter's study; similarities and differences are discussed in light of adjustments in the methodology. A plea is made for cross-cultural comparisons in physician behavior.

Volume-outcome Relationships and Inhospital Mortality: The Effect of Changes in Volume Over Time

Abstract: This study examines whether patient outcomes are affected by changes in volume over time within hospitals and whether such effects are consistent with cross-sectional results previously reported in the literature. Investigating the existence of volume-outcome relationships longitudinally for specific groups of patients relates directly to the policy issue of whether, and how, specific inpatient services should be regionalized. The analysis uses up to 8 years of observations from a national sample of nearly 500 community hospitals. Outcomes are measured as inhospital mortality adjusted for case severity. Instrumental variables techniques are used to test and control for the possibility of selective referral. The results suggest that higher volume leads to better outcomes for certain groups of patients. Among the groups studied here, increases in volume lowered adjusted mortality rates for acute myocardial infarction, hernia repair, and respiratory distress syndrome in neonates; correlations were observed between volume and outcome for coronary artery bypass grafts, which seemed to be due primarily to referral patterns; and, no significant findings were found for hip replacements. In general, the effects of volume on outcome appear to be larger when estimated from longitudinal, rather than cross-sectional, data.

Predicting in-hospital mortality. A comparison of severity measurement approaches.

Abstract: Hospital mortality statistics derived from administrative data may not adjust adequately for patient risk on admission. Using clinical data collected from the medical record, this study compared the ability of six models to predict in-hospital death, including one model based on administrative data (age, sex, and principal and secondary diagnoses), one on admission MedisGroups score, and one on an approximation of the Acute Physiology Score (APS) from the revised Acute Physiology and Chronic Health Evaluation (APACHE II), as well as three empirically derived models. The database from 24 hospitals included 16,855 cases involving five medical conditions, with an overall in-hospital mortality rate of 15.6%. The administrative data model fit least well (R-squared values ranged from 1.9-5.5% across the five conditions). Admission MedisGroups score and the proxy APS score did better, with R-squared values ranging from 4.9% to 25.9%. Two empirical models based on small subsets of explanatory variables performed best (R-squared values ranged from 18.5-29.9%). The preceding models had the same relative performances after cross-validation using split samples. However, the high R-squared values produced by the full empirical models (using 40 or more explanatory variables) were not preserved when they were cross-validated. Most of the predictive clinical findings were general physiologic measures that were similar across conditions; only a fifth of predictors were condition-specific. Therefore, an efficient approach to risk-adjusting in-hospital mortality figures may involve adding a small subset of condition-specific clinical variables to a core group of acute physiologic variables. The best predictive models employ condition-specific weighting of even the generic clinical findings.

An overview of the development and refinement of the Resource-Based Relative Value Scale. The foundation for reform of U.S. physician payment.

Abstract: Responding to distortions in payment rates between services, policymakers in the United States have sought a systematic and rational foundation for determining physician fees. One such approach to paying physicians, the Resource-Based Relative Value Scale (RBRVS), determines fees by measuring the relative resource costs required to produce them. On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the RBRVS. This article provides a brief history of the RBRVS and a summary of the methods and data used to derive it. This overview represents the culmination of 6 years of research by the Harvard RBRVS study team and provides a road map to the study's concepts and definitions. The overview also provides a context for the articles in this issue that describe five major studies undertaken since 1988. The study's overall results are presented in the last article of the series.

Contractual Arrangements Between HMOs and Primary Care Physicians: Three-Tiered HMOs and Risk Pools

Abstract: Concern about certain contractual arrangements between health maintenance organizations (HMOs) and primary care physicians has led policymakers to consider curbing these arrangements; one law has already been passed. However, these arrangements are complex and their impact is neither obvious nor wel

Benefits and Obstacles of Health Status Assessment in Ambulatory Settings: The Clinician's Point of View

Abstract: In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.

Relationship between health utility and psychometric health status measures.

Abstract: This study examined the relationship between health utility and psychometric health status measures. Utility scores derived by standard gamble and categorical rating methods were also compared to determine if they produce equivalent preference scales. Health status and utility was assessed in 73 chr