Showing papers in "Medical Care in 1997"
TL;DR: The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for theStates for which no direct observations exist.
Abstract: OBJECTIVES. It has become increasingly common for preference-based measures of health-related quality of life to be used in the evaluation of different health-care interventions. For one such measure, The EuroQol, designed to be used for these purposes, it was necessary to derive a single index value for each of the 243 health states it generates. The problem was that it was virtually impossible to generate direct valuations for all of these states, and thus it was necessary to find a procedure that allows the valuations of all EuroQol states to be interpolated from direct valuations on a subset of these. METHODS. In a recent study, direct valuations were elicited for 42 EuroQol health states (using the time trade-off method) from a representative sample of the UK population. This article reports on the methodology that was adopted to build up a "tariff" of EuroQol values from this data. RESULTS. A parsimonious model that fits the data well was defined as one in which valuations were explained in terms of the level of severity associated with each dimension, an intercept associated with any move away from full health, and a term that picked up whether any dimension in the state was at its most severe level. CONCLUSIONS. The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for the states for which no direct observations exist.
4,324 citations
TL;DR: The relationship between three dimensions of patient satisfaction and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status) are examined.
Abstract: OBJECTIVES. The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status). METHODS. A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis. RESULTS. Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores. CONCLUSIONS. Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.
413 citations
TL;DR: Early readmission is significantly associated with the process of inpatient care and is increased by 55% when care is of relatively low quality, that is, substandard or normative instead of normative or exceptional.
Abstract: Objectives.To help resolve the current controversy over the validity of early readmission as an indicator of the quality of care, the authors critically reviewed the literature using meta-analysis to derive summary estimates of effect and evaluate inter-study heterogeneity.Methods.The authors select
386 citations
TL;DR: The SF-36 appeared to be the most suitable measure of health status in this relatively healthy population on the basis of the results of the psychometric analyses.
Abstract: OBJECTIVES: An empirical, head-to-head comparison of the performance characteristics of four generic health status measures. METHODS: The Nottingham Health Profile, the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), the COOP/WONCA charts, and the EuroQol instrument were simultaneously employed in a controlled survey measuring the impact of migraine on health status. The feasibility (number of missing cases per item), internal consistency (Cronbach's alpha), construct validity (correlation patterns and common factor analysis), and discriminative ability (Receiver Operating Characteristics analyses) of the four measures were investigated. RESULTS: The Nottingham Health Profile produced the lowest missing value rate. The internal consistency of the Nottingham Health Profile scales was lower than the scales of the SF-36. Combined factor analyses with data of the four instruments together resulted in two-factor solutions with a physical and a mental factor, explaining approximately 50% of variance. The SF-36 exhibited the best ability to discriminate between groups. Test-retest reliability and sensitivity to change over time could not be tested because of the cross-sectional character of the study. CONCLUSIONS: None of the instruments performed uniformly as "best" or "worst." Purely on the basis of the results of the psychometric analyses, the SF-36 appeared to be the most suitable measure of health status in this relatively healthy population. In general, the choice of the most suitable instrument for generic health status assessment in a particular study should be guided by the special features of each candidate instrument under consideration.
382 citations
TL;DR: This study demonstrates the feasibility of linking a large health survey with administrative data and the validity of self-reports in estimating the prevalence of chronic diseases, especially diabetes and hypertension.
Abstract: OBJECTIVES A cardiovascular health survey of a representative sample of the adult population of Manitoba, Canada was combined with the provincial health insurance claims database to determine the accuracy of survey questions in detecting cases of diabetes, hypertension, ischemic heart disease, stroke, and hypercholesterolemia. METHODS Of 2,792 subjects in the survey, 97.7% were linked successfully using a scrambled personal health insurance number. Hospital and physician claims were extracted for these individuals for the 3-year period before the survey. RESULTS The authors found no benefits to using restrictive criteria for entrance into the study (ie, requiring more than one diagnosis to define a case). Using additional years of data increased agreement between data sources. Kappa values indicated high levels of agreement between administrative data and self-reports for diabetes (0.72) and hypertension (0.59); kappa values were approximately 0.4 for the other conditions. Using administrative data as the "gold standard," specificity was generally very high, although cases with hypertension and hypercholesterolemia (diagnosed primarily by laboratory or physical measurement) were associated with a lower specificity than the other conditions. Sensitivity varied markedly and was lowest for "other heart disease" and "stroke". For diabetes and hypertension, inclusion criteria calling for more than one diagnosis reduced the accuracy of case identification, whereas increasing the number of years of data increased accuracy of identification. For diabetes and hypertension, self-reports were fairly accurate in detecting "true" past history of the illness based on physician diagnosis recorded on insurance claims. CONCLUSIONS This study demonstrates the feasibility of linking a large health survey with administrative data and the validity of self-reports in estimating the prevalence of chronic diseases, especially diabetes and hypertension. A linked data set offers unusual opportunities for epidemiologic and health services research in a defined population.
332 citations
TL;DR: Kaplan et a15 found that effectiveness of information gathering by patients, more conversation by patients relative to physicians, and more affective exchange between patients and physicians were specific aspects of patient-physician communication associated with better health outcomes.
Abstract: Limited research has compared the wellbeing functioning of patients from different ethnic backgrounds with chronic medical conditions. Given that ethnic differences in attitudes, beliefs, and behavior have been reported on health-related issues such as cigarette smoking and cancer, patient reports of well-being and functioning and other outcomes also may differ by ethnicity because of cultural factors.1-4 Cultural factors may affect a patient's communication with their physician and, as a result, influence health outcomes. Kaplan et a15 found that effectiveness of information gathering by patients, more conversation by patients relative to physicians, and more affective exchange between patients and physicians were specific aspects of patient-physician communication associated with better
292 citations
TL;DR: The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes and demonstrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research.
Abstract: Objectives. The rapidly changing organizational context within which health care is delivered is altering provider-patient relations and processes of clinical decision-making, with significant implications for patient outcomes. Yet definitive research on such effects is lacking. The authors seek to underscore the contribution of organizational research to studies of clinical outcomes and demonstrates several approaches to further such efforts. Methods. The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes. They use case examples from their ongoing research on hospitals to illustrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research. Results. Several methodological issues are explored: (1) exploiting "targets of opportunity" and "natural experiments" is a promising strategy for studying patient outcomes related to organizational reform; (2) indices of organizational traits, constructed from individual survey responses, can illuminate the operant mechanisms by which structure affects outcomes; and (3) secondary data sources and innovative statistical matching procedures provide a feasible strategy for constructing study comparison groups. Extending the organizational outcomes research strategy to new areas of inquiry offers an opportunity to enhance our understanding of how nursing organization affects outcomes. Conclusions. Improving the effectiveness of medical care in a health-care system undergoing fundamental restructuring requires greater understanding of how organizational context affects clinical outcomes. A higher priority should be placed on organizational outcomes research by researchers and funding agencies.
285 citations
TL;DR: ICD-9-CM codes in discharge abstracts are poor measures of complication occurrence, and are concluded to be inadequate measures of complications occurrence through chart review.
Abstract: Objectives.The authors tested the ability of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in discharge abstracts to identify medical inpatients who experienced an in-hospital complication, using complications identified through chart review as the go
253 citations
TL;DR: The results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence) are essential for the success of guideline implementation.
Abstract: Objectives The authors examine whether physician education has enduring effects on treatment of depression. Methods Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes. Results No lasting educational effect was observed consistently in any of the outcomes measured. Conclusions There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.
229 citations
TL;DR: Regression results revealed inability to meet expenses, having few or no reliable helpers, and impairment severity to be key determinants of unmet need.
Abstract: OBJECTIVES.This article investigates the prevalence, determinants, and consequences of unmet need for assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and transportation in a randomly selected sample of adults with disability residing in Springfield
219 citations
TL;DR: The goals of this article are to review the current use of patient perceptions and to review what is known about the sensitivity of patient perception for discerning variations in care across delivery systems, and to establish relations between alternative frameworks for measuring perceptions.
Abstract: OBJECTIVES. Patient perceptions are increasingly used to measure quality of care in a diversity of health-care delivery settings. The goals of this article are to review the current use of patient perceptions and to review what is known about the sensitivity of patient perceptions for discerning variations in care across delivery systems. METHODS. This article first provides a rationale for using patient perceptions to evaluate delivery systems and reviews proposed frameworks for measuring perceptions. It then reviews illustrative studies that have used patient perceptions to compare delivery systems or that have examined associations between patient perceptions and other health-care indicators. RESULTS. Although the results of these studies suggest some general relations between patient perceptions and characteristics of delivery systems, findings are often inconsistent across individual studies. These inconsistencies may be related to several potential methodological limitations, including failure to account for the impact of patient mix, ceiling effects of patient responses, nonresponse bias, differences in data collection methods and timing of surveys, use of proxy respondents, and differences in survey instruments. CONCLUSIONS. The discussion concludes with five conceptual challenges and recommendations for further research: (1) to establish the sensitivity of patient perceptions for discerning differences across delivery systems; (2) to establish relations between alternative frameworks for measuring patient perceptions; (3) to standardize the measurement of patient perceptions; (4) to define optimal ways of presenting patient perceptions data to users; and (5) to broaden the "patient" populations in which perceptions of care have been measured.
TL;DR: The results of validity and reliability tests conducted to date testify to the relevance of the 39-item questionnaire (Diabetes-39) as a valid discriminative instrument, one which shows significant correlations with an overall quality-of-life assessment, the pattern of diabetes severity, and comorbidity.
Abstract: Objectives.The aim of this 2-year research project was to develop an instrument specifically designed to assess the quality of life of people with diabetes.Methods.The project was divided into two phases. In the first phase, information from a detailed literature review, from existing quality-of-lif
TL;DR: In general, patients and their significant others provide similar ratings of the patients' quality of life and discrepancies between patient-proxy ratings should not be interpreted, a priori, as evidence of the inaccuracy or biased nature of proxy-generated data.
Abstract: Objectives.The use of self-report questionnaires for the assessment of health-related quality of life (HRQOL) is increasingly common in clinical research. This method of data collection may be less suitable for patient groups who suffer from cognitive impairment, however, such as patients with brain
TL;DR: The acute care studies are not conclusive regarding the extent to which the organizational features of care delivery systems positively influence such bottom-line outcomes as mortality, given that adverse events appear more closely related to organizational factors than in mortality.
Abstract: OBJECTIVES. This article evaluates the state of the science with respect to morbidity, mortality, and adverse effects as outcomes indicative of variations in organizational variables in care delivery systems. METHODS. Eighty-one research papers research examining relations among organizational structures or processes and mortality/adverse effects were reviewed, assembled from electronic and manual searches of the biomedical and health services research literature. RESULTS. Most research relating mortality and other adverse outcomes to organizational variables has been conducted in acute care hospitals since 1990, with these outcome indictors linked more frequently to organizational structures than to organizational or clinical processes. There is support in some studies, but not in others, that nursing surveillance, quality of working environment, and quality of interaction with other professionals distinguish hospitals with lower mortality and complications from those with higher rates of these adverse effects. Increasing sophistication of risk adjustment methods suggests that variations in mortality and complications are influenced by patient variables more than by organizational variables. Adverse events may be a more sensitive marker of differences in organizational quality in acute care hospitals and long-term care. CONCLUSIONS. Taken together, the acute care studies are not conclusive regarding the extent to which the organizational features of care delivery systems positively influence such bottom-line outcomes as mortality. As severity-adjustment methods become more refined for hospital patients, many of the small differences currently seen in mortality and complications may disappear. However, given that adverse events appear more closely related to organizational factors than is mortality, researchers need to refine and better define such events that are logically related to the coordinative organizational processes among caregivers. Finally, researchers need to go much beyond mortality, morbidity, and adverse events in evaluating the linkage between the organization of care and outcomes.
TL;DR: The authors conclude that although many aspects of job satisfaction are diminished, some factors predicting low satisfaction and turnover may be amenable to change by hospital administrators.
Abstract: Objectives.Among the consequences of downsizing and cost containment in hospitals are major changes in the work life of nurses. As hospitals become smaller, patient acuity rises, and the job of nursing becomes more technical and difficult. This article examines the effects of changes in the hospital
TL;DR: Computer-generated algorithms for assessing compliance based on refill patterns should be used by practitioners with caution, because they are not only markers for potential drug taking compliance problems, but also for discrepancies between the medical chart, pharmacy records and verbal advice given to the patient.
Abstract: Systematic approaches for compliance problem detection and intervention are needed if the benefits of prescribed drug therapy in chronic disease management are to be optimized. As with all measures of compliance, computer algorithms based on refill patterns have advantages and disadvantages. They are unobtrusive and easily determined, but they measure the timeliness of prescription refills, not actual drug-taking. Computer-generated algorithms for assessing compliance based on refill patterns should be used by practitioners with caution, because they are not only markers for potential drug taking compliance problems, but also for discrepancies between the medical chart, pharmacy records and verbal advice given to the patient. Because patients may obtain refills before depleting their supply, compliance rates using this methodology are best determined across several refills. In particular, we urge caution in applying them over time periods of less than 60 days. Longer minimum time periods further decrease the likelihood of "false positives" but limit the number of patients for whom a compliance measure can be computed. For the health professional (eg, the pharmacist) responsible for monitoring drug-taking compliance of patients, the message seems clear: when reviewing computer-generated noncompliance "flags," the first task is to fully explore the possibility of discrepancies in drug records before initiating compliance-related interventions.
TL;DR: Although some of the characteristics identifying those with a regular source of care suggest differential patterns of behavior across subgroups, others suggest differential advantage in access to care and a lack of fit between the needs of the homeless and the organization of health services.
Abstract: Objectives.The authors explore the determinants of having a regular source of care in a community-based probability sample of homeless adults in Los Angeles. Results from this study should be more representative than those from previous studies of the homeless that are clinic- or shelter-based. In a
TL;DR: No consistent relationships were observed between increasedCopayments per dispensing and medical care utilization and expense, and future research needs to address the impact on the classes of medications received and related health status, and the impact of larger increases in copaymentsper dispensing on medical care and health-related factors.
Abstract: OBJECTIVES.The nature and extent of prescription drug benefits for the elderly are a continuing concern for health-care managers and policy makers. This study examined the impact of increased prescription drug cost-sharing on the drug and medical care utilization and expenses of the elderly.METHODS.
TL;DR: The working group produced a "methodological manifesto," a summary list of seven recommended methodological guidelines for research on alternative medicine that emphasize the robustness of existing research methods and analytic procedures despite the substantive unconventionality of alternative medicine.
Abstract: OBJECTIVES.This article summarizes the deliberations of the Quantitative Methods Working Group convened by the National Institutes of Health (NIH) in support of the NIH Office of Alternative Medicine.METHODS.The working group was charged with identifying methods of study design and data analysis tha
TL;DR: There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units, which achieve higher levels of satisfaction than general medical units.
Abstract: OBJECTIVES This study sought to determine whether there were differences in acquired immunodeficiency syndrome (AIDS) patients' satisfaction with inpatient nursing care on dedicated AIDS units compared with conventional, multidiagnosis medical units. METHODS Interview data were collected from more than 600 consecutive AIDS admissions in 40 patient care units in 20 hospitals in 11 high AIDS incidence cities. Ten hospitals with dedicated AIDS units were matched with comparable hospitals treating AIDS patients on multidiagnosis medical units. AIDS patients' satisfaction with nursing care on dedicated AIDS units was compared with AIDS patients' satisfaction with care on scattered-bed units in the same hospital and with AIDS patients' satisfaction on scattered-bed units in different, matched hospitals without dedicated units. Interhospital differences that were not controlled by design were controlled statistically, as were differences in patient characteristics and illness severity. RESULTS Acquired immunodeficiency syndrome patients receiving care on dedicated AIDS units were significantly more satisfied with their nursing care. In hospitals with units of both types, dedicated AIDS units had a higher proportion of white patients, men, and homosexuals, whereas scattered-bed units had more minority patients and intravenous drug users. Controlling for these factors as well as for differences in illness severity and interhospital differences in patient satisfaction did not diminish the positive AIDS unit effect on patient satisfaction. CONCLUSIONS Dedicated AIDS units achieve higher levels of satisfaction among patients with AIDS than general medical units. There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units.
TL;DR: This study demonstrates that valid risk-adjusted outcome measures of quality can be developed based on data collected for reimbursement purposes, and measures based on ADL decline, deterioration in decubiti, and physical restraints rates met all validity criteria.
Abstract: OBJECTIVES This study examines the use of the patient review instrument (PRI), a reimbursement reporting system used by the New York State Department of Health, to assess quality of care based on risk-adjusted outcomes. METHODS Data for all residents in approximately 550 nursing homes in upstate New York are used to develop five risk-adjusted outcome measures. The five measures are rates of decline in functional status activities of daily living (ADL), rates of increases in severity of decubitus ulcers, physical restraints rates, dehydration rates, and rates of major accidents. Logistic models are used to adjust for individual patients' risk factors. The face validity, content, construct, and criterion validity of these measures is examined. RESULTS Measures based on ADL decline, deterioration in decubiti, and physical restraints rates met all validity criteria and were correlated significantly with deficiency citations. Measures based on accident rates and rates of dehydration did not perform as well. There was significant variation in these quality measures across regions and between for-profit and nonprofit nursing homes. CONCLUSIONS Information about quality of care is important to the efficient operation of competitive markets. Such information, however, often is costly to obtain and not available to individual patients. This study demonstrates that valid risk-adjusted outcome measures of quality can be developed based on data collected for reimbursement purposes.
TL;DR: Cross-national studies of the impact of restructuring inpatient care on patient outcomes would yield valuable lessons about the cost-quality tradeoffs in hospital redesign and re-engineering, as well as inform national planning about the numbers and types of nurses needed in the coming decades.
Abstract: OBJECTIVES. This article describes the extent and nature of hospital restructuring across the United States, Canada, and Western Europe, countries with differently organized and financed health-care systems, and assesses the feasibility of international research on the outcomes of hospital restructuring. METHODS. The conceptual background, context, and focus for the Bellagio conference on Hospital Restructuring in North America and Western Europe held in November 1996 is provided, illustrating key issues on hospital and workforce trends using the US data with international comparisons. RESULTS. Hospital systems internationally are undertaking very similar restructuring interventions, particularly ones aimed at reducing labor expenses through work redesign. Nursing has been a prime target for work redesign, resulting in changes in numbers and skill mix of nursing staff as well as fundamental reorganizing of clinical care at the inpatient unit level. Yet little is known about the outcomes of such organizational interventions and there are few efforts in place to critically evaluate these actions. CONCLUSIONS. Restructuring of the hospital workforce and redesign of work in inpatient settings is widespread and markedly similar across North American and Europe, and warrants systematic study. Cross-national studies of the impact of restructuring inpatient care on patient outcomes would yield valuable lessons about the cost-quality tradeoffs in hospital redesign and reengineering, as well as inform national planning about the numbers and types of nurses needed in the coming decades.
TL;DR: Multivariate analyses suggested that dental attitudes were important to understanding the use of dental care services for this diverse group of adults, and that race and poverty contributed independently to dental care use even with dental attitudes taken into account.
Abstract: ObjectivesBlacks and poor persons share a greater burden of oral disease and are less likely to seek dental care on a regular basis The role of dental attitudes and knowledge of services on this circumstance is unclear The authors quantified group differences in dental attitudes and knowledge of
TL;DR: Patients' report of prescription drug counseling activities after withdrawal of the pilot program to require patient package inserts in 1980 and implementation of Omnibus Budget Reconciliation Act of 1990 counseling requirements in 1993 indicate small increases in verbal counseling but larger increases in the delivery of written information provided at the pharmacy.
Abstract: Objectives.The authors determined patients' report of prescription drug counseling activities after withdrawal of the pilot program to require patient package inserts in 1980 and implementation of Omnibus Budget Reconciliation Act of 1990 counseling requirements in 1993.Methods.Four cross-sectional
TL;DR: The results indicate that the disease-specific measures are more sensitive to change than the generic measures of outcome.
Abstract: thral resection of the prostate with laser vaporization prostatectomy for benign prostatic hypertrophy. METHODS. Patients entered into the trial completed the following questionnaires prior to treatment and at follow-up at 3 months and 1 year. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) is a generic measure that produces an eight-dimension profile as well as two summary measures of health status (the physical component score and the mental component score). The EuroQol provides two single index measures of health status; one intended to convey the utility (or lack of) that an individual derives from his or her own health state compared with alternative states and a second simple visual analog scale "thermometer" of health status. The American Urological Association symptom score and the Bothersome index are disease-specific indices of health status for use specifically with benign prostatic hypertrophy patients. RESULTS. The EuroQol indicates no statistically significant improvements with time for either arm of the trial. The SF-36 physical and general health perceptions domains indicates statistically significant improvements for the transurethral resection of the prostate arm alone at 3 months and 1 year, as do the physical summary score at the 3-month follow-up visit. The effect sizes of these improvements, however, are small, using standard criteria. In contrast, statistically significant differences are found with time for both transurethral resection of the prostate and laser prostatectomy on both disease-specific measures, which also indicate statistically significant superior outcome for the transurethral resection of the prostate arm compared with the laser arm.
TL;DR: There was considerable variation in lifetime use among demographic groups and the distribution of lifetime use was highly skewed, providing support for efforts to spread risk through public or private insurance.
Abstract: OBJECTIVES Information on lifetime nursing home use is needed to design and evaluate long-term care financing reforms. Whereas a number of studies have estimated mean lifetime use or its distribution, very little is known about variation in use among subgroups of the population, the timing of use, the number of distinct episodes of care experienced by nursing home users, and the risk and expected use at ages other than age 65. The purpose of the study was to fill these gaps in knowledge. METHODS The study used a data base constructed to represent decedents who used nursing homes. The sample was derived from the sample of discharges collected as part of the 1985 National Nursing Home Survey. Weights were constructed for the purpose of making projections of remaining lifetime nursing home use at selected ages in 1995. RESULTS There was considerable variation in lifetime use among demographic groups. Overall, estimates of the amount of use remaining at selected ages tended to be relatively constant at approximately 1 year. Mean years until nursing home admission, however, decreased sharply from almost 40 years at age 45 to approximately 5 years at age 85. CONCLUSIONS The distribution of lifetime use was highly skewed, providing support for efforts to spread risk through public or private insurance. With roughly one quarter of all use occurring after 5 years of nursing home residence, however, a substantial share of use would exceed benefit maximums that are part of many proposals for public financing of long-term care as well as private insurance policies.
TL;DR: Findings suggest employed women experience problems in well-being at approximately seven months postpartum, andVariables associated with improved health include: longer maternity leaves, fewer prenatal mental health symptoms, fewer concurrent physical symptoms, more sleep, increased social support, increased job satisfaction, less physical exertion on the job, fewer infant symptoms, and less difficulty arranging child care.
Abstract: Objectives.Parental and maternity leave policies are a popular fringe benefit among childbearing employed women and a benefit employers frequently are required to offer. However, few rigorous evaluations of the effect of maternal leave on maternal health exist.Methods.Using a hybrid of the household
TL;DR: Policy and interventions that focus on the most visible differences that exist between rural women of differing socioeconomic levels and do not simultaneously address knowledge, attitudinal, and health-care access barriers will fall short of their goal to increase breast and cervical cancer screening.
Abstract: OBJECTIVES. Despite substantial evidence of socioeconomic differences in the use of breast and cervical cancer screening, the mechanisms explaining these differences, and therefore their policy implications are not well understood. We investigated the way that education and income influence rural women's use of mammograms and Pap tests, including financial barriers to medical care, knowledge and attitudinal barriers, and nonfinancial factors related to health-care access. METHODS. Data were from a population-based telephone survey of 2,346 rural Wisconsin women aged 40 years and older. Logistic regression analyses and simulation exercises were conducted. RESULTS. The strongest barriers to screening in this rural population were nonfinancial impediments to access. Removing economic barriers did not lead to significant increases in screening when other types of barriers were present. CONCLUSIONS. Policies and interventions that focus on the most visible differences that exist between rural women of differing socioeconomic levels (ie, differences in the ability to afford health services) and do not simultaneously address knowledge, attitudinal, and health-care access barriers will fall short of their goal to increase breast and cervical cancer screening.