Showing papers in "Medical Care in 1994"

The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups.

Abstract: The widespread use of standardized health surveys is predicated on the largely untested assumption that scales constructed from those surveys will satisfy minimum psychometric requirements across diverse population groups. Data from the Medical Outcomes Study (MOS) were used to evaluate data completeness and quality, test scaling assumptions, and estimate internal-consistency reliability for the eight scales constructed from the MOS SF-36 Health Survey. Analyses were conducted among 3,445 patients and were replicated across 24 subgroups differing in sociodemographic characteristics, diagnosis, and disease severity. For each scale, item-completion rates were high across all groups (88% to 95%), but tended to be somewhat lower among the elderly, those with less than a high school education, and those in poverty. On average, surveys were complete enough to compute scales scores for more than 96% of the sample. Across patient groups, all scales passed tests for item-internal consistency (97% passed) and item-discriminant validity (92% passed). Reliability coefficients ranged from a low of 0.65 to a high of 0.94 across scales (median = 0.85) and varied somewhat across patient subgroups. Floor effects were negligible except for the two role disability scales. Noteworthy ceiling effects were observed for both role disability scales and the social functioning scale. These findings support the use of the SF-36 survey across the diverse populations studied and identify population groups in which use of standardized health status measures may or may not be problematic.

Lower Medicare mortality among a set of hospitals known for good nursing care.

Abstract: The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these "magnet" hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multivariate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared using variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals' observed mortality rates are 7.7% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6% lower mortality rate (P = .026 [95% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients.

The performance of intensive care units: does good management make a difference?

Abstract: A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

What do global self-rated health items measure?

Abstract: One of the most frequently used health status measures consists of a single item that asks respondents to rate their overall health as excellent, good, fair, or poor. This study identified the conceptual domain that is assessed by this self-rated health measure. Findings from 158 in-depth interviews revealed that the same frame of reference is not used by all respondents in answering this question. Some study participants think about specific health problems when asked to rate their health, whereas others think in terms of either general physical functioning or health behaviors. The data further revealed that the specific referents that are used vary by age. In addition, more tentative findings suggest that the use of specific referents may also vary by education and race. Finally, the results suggest that certain referents may not be related to closed-ended health ratings in predictable ways.

Comparisons of the costs and quality of norms for the SF-36 health survey collected by mail versus telephone interview: results from a national survey.

Abstract: Many health status surveys have been designed for mail, telephone, or in-person administration. However, with rare exception, investigators have not studied the effect the survey mode of administration has on the way respondents assess their health and other important parameters (such as response rates, nonresponse bias, and data quality), which can affect the generalizability of results. Using a national sampling frame of noninstitutionalized adults from the General Social Survey, we randomly assigned adults to a mail survey (80%) or a computer-assisted telephone survey (20%). The surveys were designed to provide national norms for the SF-36 Health Survey. Total data collection costs per case for the telephone survey ($47.86) were 77% higher than that for the mail survey ($27.07). A significantly higher response rate was achieved among respondents randomly assigned to the mail (79.2%) than telephone survey (68.9%). Nonresponse bias was evident in both modes but, with the exception of age, was not differential between modes. The rate of missing responses was higher for mail than telephone respondents (1.59 vs. 0.49 missing items). Health ratings based on the SF-36 scales were less favorable, and reports of chronic conditions were more frequent, for mail than telephone respondents. Results are discussed in light of the trade-offs involved in choosing a survey methodology for health status assessment applications. Norms for mail and telephone versions of the SF-36 survey are provided for use in interpreting individual and group scores.

Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III).

Abstract: A case-mix classification system for nursing home residents is developed, based on a sample of 7,658 residents in seven states. Data included a broad assessment of resident characteristics, corresponding to items of the Minimum Data Set, and detailed measurement of nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. The Resource Utilization Groups, Version III (RUG-III) system, with 44 distinct groups, achieves 55.5% variance explanation of total (nursing and therapy) per diem cost and meets goals of clinical validity and payment incentives. The mean resource use (case-mix index) of groups spans a nine-fold range. The RUG-III system improves on an earlier version not only by increasing the variance explanation (from 43%), but, more importantly, by identifying residents with "high tech" procedures (e.g., ventilators, respirators, and parenteral feeding) and those with cognitive impairments; by using better multiple activities of daily living; and by providing explicit qualifications for the Medicare nursing home benefit. RUG-III is being implemented for nursing home payment in 11 states (six as part of a federal multistate demonstration) and can be used in management, staffing level determination, and quality assurance.

A new approach to the measurement of quality of life. The Patient-Generated Index.

Abstract: Quality of life has been defined as "the extent to which our hopes and ambitions are matched by experience." To improve a patient's quality of life through medical care would be to "narrow the gap between a patient's hopes and expectations and what actually happens." Using the above definition as a conceptual basis, we produced a self-administered, Patient-Generated Index (PGI) of quality of life. The PGI was completed by 359 patients presenting with low back pain. The validity of the measure was assessed by correlating patients' PGI scores with a well-validated health profile, the Short-Form 36-item Health Survey (SF-36), and with their scores on a clinical back pain questionnaire. Stepwise multiple regression was then used to model the relationship between the PGI score and the SF-36. Patients' PGI scores showed a high correlation with SF-36 scales measuring pain, social functioning, and role limitations attributable to physical problems, and with the clinical questionnaire. Together with whether a person was retired or not, these health variables were able to explain 25% of the variance in PGI scores. Patient generated index scores were significantly lower in patients referred to hospital compared with those managed solely in general practice and tended to reflect the general practitioner's assessment of symptom severity. We conclude that it is possible to construct a questionnaire that quantifies the effect of a medical condition on patients' quality of life in a way that has meaning and relevance in the context of their daily lives. The PGI has considerable potential for routine use in a wide range of clinical conditions for which the measurement of outcome has hitherto proved very difficult.

Identifying complications of care using administrative data.

Abstract: The Complications Screening Program (CSP) is a method using standard hospital discharge abstract data to identify 27 potentially preventable in-hospital complications, such as post-operative pneumonia, hemorrhage, medication incidents, and wound infection. The CSP was applied to over 1.9 million adult medical/surgical cases using 1988 California discharge abstract data. Cases with complications were significantly older and more likely to die, and they had much higher average total charges and lengths of stay than other cases (P < 0.0001). For most case types, 13 chronic conditions, defined using diagnosis codes, increased the relative risks of having a complication after adjusting for patient age. Cases at larger hospitals and teaching facilities generally had higher complication rates. Logistic regression models to predict complications using demographic, administrative, clinical, and hospital characteristics variables, had modest power (C statistics = 0.64 to 0.70). The CSP requires further evaluation before using it for purposes other than research.

In search of power and significance: issues in the design and analysis of stochastic cost-effectiveness studies in health care.

Abstract: Application of techniques such as cost-effectiveness analysis (CEA) is growing rapidly in health care. There are two general approaches to analysis: deterministic models based upon assumptions and secondary analysis of retrospective data, and prospective stochastic analyses in which the design of a

Evaluating the message: the relationship between compliance rate and the subject of a practice guideline.

Abstract: To explore the relationship between providers' compliance and some key aspects of the clinical messages in practice guidelines, studies published in the English language medical literature between 1980 and 1991 were retrieved through MEDLINE and through relevant review articles in the field. All published studies providing compliance rates with practice guidelines and endorsed by official organizations were eligible for the study. The clinical content and the reported compliance rate were gathered for each recommendation in the 23 studies selected. The medical and surgical procedures addressed by 143 recommendations were identified according to specialty area, type of procedure (diagnostic, surgical, etc.) and were independently classified by the authors as being high or low on characteristics thought to influence diffusion:complexity, trialability and observability. The mean compliance rate with the 143 clinical recommendations was 54.5% (95% CI: 50.2%-58.9%), with those in the specialty areas of cardiology and oncology showing the highest compliance (mean 63.6% and 62.2%, respectively). Recommendations concerning procedures with high complexity had lower compliance rates than those low on complexity (41.9% vs. 55.9%; P = 0.05), and those judged to be high on trialability had higher compliance rates than those low on trialability (55.6% vs 36.8%; P = 0.03). Overall, all the characteristics of the clinical recommendations considered in the practice guidelines could account for no more than 47% of the observed variability in compliance rates. The target area of practice and the complexity and trialability of the recommended procedure appear to be useful, if partial, predictors of the level of compliance with a practice guideline.

Bias in the coding of hospital discharge data and its implications for quality assessment

Abstract: t From the Department of Family Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. Presented in part at the Association for Health Services Research annual meeting, Chicago, IL, June 1992. This research was supported in part by the Agency for Health Care Policy and Research. Address correspondence to: Patrick S. Romano, MD, University of California Davis, Division of General Medicine, Primary Care Center, Room 3107, 2221 Stockton Boulevard, Sacramento, CA 95817. tions are underreported when patients die, for two possible reasons: coders identify all relevant diagnoses but the chronic codes are discarded when abstracts are truncated to

Satisfaction, gender, and communication in medical visits.

Abstract: The authors conducted two studies of routine medical visits, investigating the relation of physician gender, patient gender, and physician age to patient satisfaction, and the correlations between communication behaviors and satisfaction separately for different combinations of patient and physician gender. Study 1 was based on videotaped visits to a hospital-based internal medicine practice (n = 97 visits). Study 2 was based on audiotaped visits to 11 different community and hospital-based practices in the United States and Canada (n = 524 visits). In both studies, patients examined by younger physicians, especially younger female physicians, reported lower ratings of satisfaction. These findings were true for male and female patients; however, in both studies, the lowest satisfaction in absolute terms was among male patients examined by younger female physicians. The effects were not explained by patient and physician background characteristics or by measured communication during the visit. Correlations between verbal and nonverbal communication and satisfaction for different combinations of physician and patient gender suggested that gender-related values and expectations influence patients' reactions to physicians' behavior. There also was evidence that patient satisfaction is reflected in the patient's affective behavior during the visit.

The relationship between glycemic control and health-related quality of life in patients with non-insulin-dependent diabetes mellitus

Abstract: The relationship between glycemic control and health-related quality of life was examined in patients with non-insulin-dependent diabetes mellitus (NIDDM). Within the context of a randomized controlled trial, 275 patients with NIDDM receiving primary care from a Veteran's Administration general medical clinic were enrolled and monitored for 1 year. Glycemic control (glycosylated hemoglobin levels) and health-related quality of life (Medical Outcomes Study Short-Form 36-item Health Survey [SF-36]) were assessed at baseline and at 1 year. Multivariate regression modeling using baseline and change scores during a 1-year period did not find a linear or curvilinear relationship between glycosylated hemoglobin and SF-36 scores (P = .15); this was true even after controlling for five covariates identified a priori (insulin use, number of diabetic complications, duration of diabetes, education, number of hyper-, or hypoglycemic episodes during the preceding month). Health services researchers and clinicians alike need to be aware that these two important outcomes may not be directly related. This lack of association could contribute to the high noncompliance rates observed among patients prescribed complex diabetic regimens. Unless patients perceive a benefit from following such regimens, good glycemic control may continue to be an elusive therapeutic goal, especially in patients with long-standing disease.

Physician Burnout: An Examination of Personal, Professional, and Organizational Relationships

Abstract: This study presents an empirical assessment of burnout among physicians in two staff model HMOs and examines the critical relationships between physician burnout and personal, professional, and organizational/worklife factors The authors hypothesize that a substantial proportion (> 40%) of physicians will report high scores on emotional exhaustion, the key burnout dimension, and that high emotional exhaustion will be correlated with low evaluations of organizational/worklife factors The survey results found 58% of the physicians reported scores in high emotional exhaustion Regression analyses established that organizational measures, specifically, evaluative ratings of Workload/Scheduling and Input/Influence were the strongest predictors of emotional exhaustion The substantial proportion of physicians reporting scores high on the burnout dimensions, and the potential for management to intervene and improve the factors that foster burnout, suggests the need for organizations to examine the impact of their structures, policies, and procedures on physician stress and quality of worklife

The Willingness to Pay for In Vitro Fertilization: A Pilot Study Using Contingent Valuation

Abstract: The use of in vitro fertilization (IVF) has increased rapidly in recent years and debate has focused on whether health insurance should cover the procedure. We developed and disseminated a contingent valuation survey to investigate how individuals value IVF treatment. Couples pursuing in vitro fertilization can be viewed as purchasing an increased probability of conceiving and bearing a child. In our survey, respondents were asked if they would pay stated amounts for IVF, under various assumptions about the probability of success. The survey explores the ex post perspective, (respondents' willingness to pay (WTP) for IVF in the event that they are infertile), the ex ante perspective, (WTP for IVF insurance, assuming respondents do not know their infertility status), WTP for a public IVF program, and how respondents value IVF relative to mortality risk reduction. Among 150 respondents who were potential childbearers, average WTP was $17,730 for a 10% chance at having a child through IVF in the event of infertility. Average WTP was $865 for a lifetime insurance benefit providing access to a 10% chance. Among 231 respondents of all ages, average WTP was $32 per year in taxes for a public program giving 1,200 couples per year in Massachusetts a 10% chance. The estimated implied ex post WTP per statistical baby was $177,730, while ex ante WTP per statistical baby was $1.8 million. The results of regression analyses were consistent with theoretical predictions, (e.g., increasing WTP with household income). The contingent valuation method is a potentially useful tool in understanding how people value the benefits of IVF. Further research is needed to test the validity of this methodology.

The effect of gender and race on the measurement properties of the CES-D in older adults.

Abstract: Having observed a three-fold difference in the prevalence of significant symptoms of depression among four race-gender groups of elderly adults attending an urban primary care practice, we investigated the extent to which these differences might be explained by variability in the measurement properties of the Centers for Epidemiologic Studies depression scale (CES-D). Although the internal consistency of the CES-D was acceptable for all groups, 5% of our patients were excluded for inability to complete the minimum required number of CES-D items, and nearly 40% of patients required response imputation for the allowable one to four items that they could not answer. Imputation was most frequently required for items tapping positive affect. Principal components factor analysis was performed separately for respondents answering all items and for respondents with imputed values. In both analyses we found important race-gender differences in factor structure. Moreover, the factor structure for those with imputed values was markedly different from that of respondents answering all items, including a dissolution of the positive affect dimension. Neither the race-gender differences in factor structure nor the differences among those with and without imputed data were resolved by eliminating respondents with poor education, cognitive impairment, or alcoholism, or by varying the assumptions for data imputation. However, the disparities in factor structure were essentially resolved by eliminating five CES-D items, suggesting the need to modify the CES-D in populations like ours. Although eliminating these five items results in a more pure factor structure, it does not resolve the differences in prevalence of depressive symptoms. These differences may, however, be partially due to differential response tendencies among the race-gender groups.

The costs of interrupting antihypertensive drug therapy in a medicaid population

Abstract: This research explores the association between the interruption or termination of antihypertensive drug therapy and total health care costs among non-institutionalized Medicaid patients older than age 40 who survive the first year after treatment. Multivariate regression analysis was used to estimate the statistical relationship between post-treatment costs and patient demographic characteristics, prior use of services, the type of medication used as initial therapy and whether the patient maintained continuous therapy. Paid claims data from the California Medicaid (Medi-Cal) program were used in the analysis. Total cost of health care in the first year after the initiation of drug therapy was the primary outcome variable. Components of total costs (e.g., hospital, outpatient and physician services, prescription drugs) were also investigated. Nearly 86% of new antihypertensive drug therapy patients interrupted or discontinued purchasing any form of antihypertensive medication during the first year. Patients with interrupted antihypertensive drug therapy consumed an additional $873 per patient (P < .0001) in health care during the first year, not counting a reduction in prescription drug cost of $281 (P < .0001). Increased costs were primarily due to increased hospital expenditures of $637 (P < .0002).

Using Medicare Claims for Outcomes Research

Abstract: Medicare claims databases have several advantages for use in constructing episodes of care for outcomes research. They are population-based, relatively inexpensive to obtain, include large numbers of cases, and can be used for long-term follow-up. However, the sheer size of these claims databases, along with their primarily administrative (as opposed to clinical) nature, requires that researchers take special care in using them. The 10 PORTs using Medicare claims provided information on their approach to several key issues in working with these data, including: 1) identifying the index cases or patient cohorts to be studied; 2) defining the length of the episode; and 3) measuring outcomes. This paper reports the experience and knowledge gained by these PORTs in using these claims to create and analyze episodes of care.

A Case-Mix Classification System for Medical Rehabilitation

Abstract: Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

Measuring the necessity of medical procedures.

Abstract: This is a report on the extension of the concept of the appropriateness of a procedure to the necessity, or crucial importance, of that procedure. To state that a procedure is crucial means that withholding the procedure would be deleterious to the patient's health. Appropriateness and necessity ratings for six procedures were obtained using a modified Delphi panel process developed in earlier work. Panels were composed of practicing clinicians who were recognized leaders in their fields. The panels included both performers and nonperformers of the procedure under discussion. For most procedures and panelists, necessity was related to appropriateness, but was distinct from it. The proportion of indications for which the procedure was crucial varied in clinically consistent ways both among and within procedures. However, panelists did not achieve a consensus on necessity. Further research is suggested to refine the method to promote consensus and to validate further the ratings of necessity. In conclusion, necessity ratings can be used together with appropriateness ratings to address not only the overuse of procedures, but also to indicate limited access to care through underuse of procedures.

Responsiveness of self-reported and objective measures of disease severity in carpal tunnel syndrome.

Abstract: Responsiveness, the ability to detect meaningful clinical change, is a critical attribute of instruments used to evaluate outcomes of treatments. The authors hypothesized that self-administered symptom severity and functional status questionnaires are more responsive to clinical improvement after carpal tunnel release than traditional physical examination measures of strength and sensibility. Data were obtained from a randomized clinical trial of endoscopic versus open carpal tunnel release conducted in four university medical centers. Patients were evaluated before surgery and 3 months after surgery. Seventy-four patients indicating that they were more than 80% satisfied with the results of surgery were assumed to have clinically meaningful improvement and were the focus of the analysis. Evaluations included questionnaires assessing symptom severity, functional status, and activities of daily living as well as measurement of grip, pinch, and abductor pollicus brevis strength, and 2-point discrimination and Semmes-Weinstein pressure sensibility. Responsiveness was calculated with the standardized response mean (mean change/standard deviation of change) as well as the effect size (mean change/standard deviation of baseline values). The symptom severity scale was four times as responsive, and the functional status and activities of daily living scales were twice as responsive, as the measures of strength and sensibility. Self-administered symptom severity and functional status scales are much more responsive to clinical improvement than measures of neuromuscular impairment and should severe as primary outcomes in clinical studies of therapy for carpal tunnel syndrome.

Physician characteristics and the recognition of depression and anxiety in primary care.

Abstract: We examined physician characteristics associated with the recognition of depression and anxiety in primary care. Fifty-five physicians treating a total of 600 patients completed measures of psychosocial orientation, psychological mindedness, self-rating of sensitivity to hidden emotions, and a video test of sensitivity to nonverbal communication. Patients were classified as cases of psychiatric distress based on the CES-D scale and the Diagnostic Interview Schedule. Physician recognition was determined by notation of any psychosocial diagnosis in the medical charts over the ensuing 12 months. Of 192 patients scoring 16 or above on the CES-D, 44% (83) were recognized as psychiatrically distressed. Three findings were central to this study: 1) Physicians who are more sensitive to nonverbal expressions of emotion made more psychiatric or psychosocial assessment of their patients and appeared to be over-inclusive in their judgments of psychosocial problems; 2) Physicians who tended to blame depressed patients for causing, exaggerating, or prolonging their depression made fewer psychosocial assessments and were less accurate in detecting psychiatric distress; 3) False positive labeling of patients who had no evidence of psychiatric distress was rare. Surprisingly, more severe medical illness increased the likelihood of labeling and accurate recognition. Physician factors that increased recognition may indicate a greater willingness to formulate a psychiatric diagnosis and an ability notice nonverbal signs of distress.

The accuracy of self-reported disability days

Abstract: The Accuracy of Self-Reported Disability Days DENNIS REVICKI;DEBRA IRWIN;JOSEPH REBLANDO;GREGORY SIMON; Medical Care

Characteristics of patients with major depression who received care in general medical and specialty mental health settings.

Abstract: The purpose of this analysis was to compare depressed patients receiving care in the general medical setting with depressed patients receiving care in specialty mental health settings. The analysis was limited to 559 respondents from the NIMH Epidemiologic Catchment Area (ECA) study who met criteria for the diagnosis of major depression sometime in the year before the interview as defined by the Diagnostic Interview Schedule. Patients who received care in the general medical sector were more likely to be black, older than age 65, have a high school education or less, and to be women, and less likely to be in the highest socioeconomic quartile. A higher proportion of specialty mental health patients reported a lifetime history of delusions, met criteria for the diagnosis of panic disorder, obsessive-compulsive disorder, or schizophrenia, and had a lifetime history of psychiatric hospitalization. Depressed patients seen in the general medical sector had a lower chance of meeting criteria for major depression one year later than those seen in the specialty mental health sector. A multivariate analysis limited to an investigation of the relative importance of sociodemographic factors indicated that the following factors were significantly associated with receiving care in the specialty mental health care sector: age groups 31-50 and 51-65, and single marital status. Black race was inversely correlated with use of specialty mental health care. These results suggest that data generated from the specialty mental health sector can be generalized to the general medical sector only after assessing demographic differences between the two groups. Demographic differences could be associated with differences in knowledge, attitudes, interpretation of symptoms, and treatment preferences related to depression.

Costing Medical Care: Using Medicare Administrative Data

Abstract: This paper describes how the PORTS are using data from the Medicare administrative records systems to study the medical care costs of specific conditions. The general strengths and weaknesses of the Medicare databases for studying cost related issues are discussed, and the relevant data elements are examined in detail. Changes in the nature of the data collected over time are noted. Information is provided on how the PORTS are using these data to estimate the cost to Medicare of treating Medicare beneficiaries with specific conditions and the social (opportunity) cost of treating these patients. Furthermore, information is provided on how data from the Medicare administrative records system can be used to determine the cost of services for patients who have been identified through other large databases (i.e., state hospital discharge tapes) or who have been enrolled in prospective cohort studies.

Assessing adherence to asthma medication and inhaler regimens: a psychometric analysis of adult self-report scales.

Abstract: Poor adherence to recommended regimens is a substantial problem in the clinical management of adults with asthma and other chronic diseases. Research on adherence assessment is complicated by methodological difficulties including limitations associated with the use of self-report measures. In this study, psychometric techniques were used to analyze two self-report scales for assessing adherence to recommended medication and inhaler use regimens in adults with asthma. Results indicated that the two scales had standard deviations large enough to detect variation adherence, had adequate reliability, and reflected the impact of an intervention designed to improve adherence. The results supported the usefulness of these scales for research on adherence. Additional analyses indicated that the two scales could be combined if the research goal required an overall measure of adherence.

Measurement of quality of well being in a child and adolescent cystic fibrosis population.

Abstract: Substantial interest in the Quality of WellBeing Scale (QWB) has been shown recently, especially in chronic illness populations.1,2 Designed as a single metric to apply to general populations, the QWB combines physical symptoms and functionality in the areas of mobility, physical activity, and social activity. Although the QWB has been used for policy analysis, its application in clinical populations has been more limited.3

Promoting Screening Mammography in Inner-City Settings: A Randomized Controlled Trial of Computerized Reminders as a Component of a Program to Facilitate Mammography

Abstract: In a one-year randomized controlled trial, we assessed the effectiveness of a computerized mammography reminder system as a component of a program to increase the use of screening mammography in three health care organizations serving inner-city women in Detroit, Michigan (two sites of a health depa

Health care utilization: the effect of extending insurance to adults on Medicaid or uninsured.

Abstract: Current health care system reform proposals center on reducing the number of uninsured by extending private health insurance coverage Discussion has also included enrolling Medicaid recipients in private programs Much of the deliberation concerning extending coverage has centered on cost, but largely has not addressed the implications for health care utilization by these groups If private insurance is extended to those currently uninsured as well as the Medicaid population, what impact will it have on utilization? Using data from the 1987 National Medical Expenditure Survey, the results of this analysis show that utilization would increase for the uninsured if private insurance benefits were extended, whereas utilization would decrease for those with Medicaid, however, the magnitude of the increase depends on the type of care