Search PubMed⌕ Search

Biomedical subjects

A M Epstein

Publications and source records attributed to A M Epstein.

108 records · Page 6Linked to original sources
PubMed1985

Effects of patients' socioeconomic status and physicians' training and practice on patient-doctor communication.

To determine characteristics of patients and doctors that are associated with effective communication, patient-doctor communication was studied in 100 ambulatory patients who underwent echocardiography to evaluate previously undefined cardiac problems. As a marker for effective communication, this report examined how often the patient and doctor agreed about basic aspects of care, including symptoms, test results, therapy, and prognosis. Communication between the patient and physician was less effective when the patient was of lower socioeconomic status, as determined by occupation or insurance coverage. Characteristics of physician's training and practice were not significantly associated with better communication. Physicians were unable to predict when their responses would or would not agree with those of their patients. These findings suggest that there is the risk of less effective communication between patients of lower socioeconomic status and their physicians, and that physicians may be unaware that less effective communication is occurring.

Adult↗
PubMed1985

The effects of patient characteristics on ambulatory test ordering.

To investigate the relationship of patient characteristics and the use of ambulatory testing services, we examined patterns of test use for 351 patients with chronic uncomplicated hypertension, cared for by 30 private practice internists. We studied the use of visits and diagnostic tests in relation to patients' sex, marital status, obesity, employment status, occupational class, insurance coverage and severity of illness in terms of age, extent of blood pressure elevation and number of medications used in treatment. Testing services accounted for 63% of the total expenditure for testing and physician services. Females and patients with greater severity of disease had higher visit rates, and age was significantly related to increased test use. Marital status, obesity and socioeconomic characteristics were not strongly associated with patterns of testing. Our results suggest that patterns of testing for hypertensive patients are related to severity of illness in terms of age but not to patients' socioeconomic characteristics.

Age Factors↗
PubMed1985

Physician characteristics and organizational factors influencing use of ambulatory tests.

A number of studies have suggested that there is considerable variation in the frequency with which physicians order particular tests. This paper reviews the relationship of variations in ambulatory testing to characteristics of physicians' training and practice; and organizational factors such as physician group size, method of reimbursement, and ease of access to technical services. Results from previous investigations suggest that specialty training, more recent physician graduation, and large group practice settings are associated with significantly higher test use. Information available about other physician characteristics and organizational factors is equivocal. The extent of variations in practice has important implications for the cost and quality of medical care. Greater effort should be made to document the effects of nonmedical factors and to clarify how those effects are mediated and how they might be modified to improve the use of medical resources.

Ambulatory Care↗
PubMed1984

A comparison of ambulatory test ordering for hypertensive patients in the United States and England.

We compared British and American patterns of ambulatory testing for chronic uncomplicated hypertensive patients by examining test use for 351 American patients cared for by 30 community-based internists in Massachusetts and 511 British patients cared for by 18 general practitioners in Greater London. For each of 13 tests examined, utilization was equal or higher for American patients. Significantly more ECGs, chest roentgenograms, plain roentgenograms (other than chest roentgenograms), blood cell counts, urinalyses, cervical cytological tests, barium enema examinations, and intravenous pyelograms were ordered. Differences ranged from four to 40 times higher in the United States. This investigation documents a marked difference in test use. Further study is needed to determine whether the conservative use of diagnostic services adversely affects patient outcomes or represents a more cost-effective form of care.

Clinical Laboratory Techniques↗
PubMed1984

Aspirin and its expensive substitutes: prescribing patterns and cost implications.

Relatively expensive nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed products, although many rheumatologists continue to recommend aspirin as the initial drug of choice for a variety of musculoskeletal problems. We reviewed 100 charts of patients given NSAIDs in a VA clinic to see how many had relative contraindications for aspirin, such as previous salicylate intolerance, peptic ulcer disease, gastrointestinal bleeding, or failure to respond to aspirin. Only 28% of patients on the expensive preparations had any of these problems noted in their charts. With an average retail cost difference of $14 to $29 per month, large potential savings exist for those who purchase anti-inflammatory products, if physicians would initially prescribe aspirin for appropriate patients.

Anti-Inflammatory Agents↗
PubMed1984

Physician beliefs, attitudes, and prescribing behavior for anti-inflammatory drugs.

Psychologists have distinguished between "beliefs" and "attitudes" to help explain human behavior. To investigate the relationship between physician beliefs, attitudes, and their prescribing behavior for anti-inflammatory medication, 30 doctors in two Veterans Administration clinics were surveyed by questionnaire, and 1,265 of their prescriptions were collected. Their estimates of drug costs and the percent of patients who would have response to therapy or side effects were considered "beliefs." The "attitudes" measured were the relative importance physicians placed on six factors when choosing therapy: effectiveness, side effects, likelihood of compliance, placebo effect, cost, and the patient's perception of the physician. Physicians believed that efficacy of the different proprietary nonsteroidal anti-inflammatory agents and aspirin compounds was comparable. They perceived indomethacin as more toxic than other nonsteroidal anti-inflammatory drugs (p less than 0.01), and enteric-coated aspirin as less toxic than plain aspirin (p less than 0.01). Physicians wrote 5.7 times as many prescriptions for proprietary nonsteroidal anti-inflammatory agents as for aspirin compounds. A correlation was not observed between relative use of proprietary agents versus aspirin compounds and beliefs about costs, response rates, or side effects rates; however, attitudes regarding the importance of cost and placebo effects were correlated with prescribing behavior (p less than 0.05).

Anti-Inflammatory Agents↗
PubMed1984

Office laboratory tests. Perceptions of profitability.

Theoretic modeling suggests that common office tests as a group are profitable. To determine whether practicing internists perceive this profitability and whether their perceptions differ for different tests or for patients with different types of insurance coverage, the authors surveyed 111 physicians in private office practice. Respondents' estimates of receipts for tests done on patients with Medicare or Blue Cross/Blue Shield coverage were higher than their estimated costs for the testing. Estimates of receipts from Medicaid patients were lower than estimated costs of testing. After standardizing the estimated receipts from patients with different insurance coverages, the authors found that the average estimated profits for different tests on an "average insured patient" varied sixfold, from $5.99 for an electrocardiogram to $1.01 for a urinalysis. The authors suggest that perceived financial incentives are extremely variable by test. Different insurance coverages are perceived as providing varying financial incentives for testing; Medicaid provides a disincentive. Appropriate reform of the existing fee schedules should be selective by test and coverage.

Attitude to Health↗
PubMed1984

The effects of physicians' training and personality on test ordering for ambulatory patients.

We studied records of 351 hypertensive patients cared for by 30 internists in private office practice. We correlated the use of outpatient diagnostic tests with personal characteristics of the prescribing physicians. Doctors trained in medical schools with academic orientations used more tests than other physicians. Patterns of use were not strongly related to the number of years since medical school graduation, or physicians "intolerance of ambiguity" as measured by a standard psychological instrument. These findings suggest that certain types of training may predispose physicians to be high testers.

Adult↗
PubMed1983

The effects of group size on test ordering for hypertensive patients.

There has been a tremendous increase in the number of patients receiving care from physicians in group practice rather than in solo practice. To determine whether group size influences the number of tests ordered for ambulatory patients, we studied the records of 351 hypertensive patients cared for by 30 internists in group or solo private practice. Patients of physicians who were members of large groups received twice as many tests (6.4 per patient per year) as patients of physicians in small groups (3.5) or in solo practice (3.3) (P less than 0.001). The charges for testing were also nearly double for patients of physicians in large groups ($123 vs. $58 and $71, P less than 0.01). A multiple regression analysis of individual tests showed that large group practices were associated with increased use of electrocardiography (P less than 0.001), blood counts (P less than 0.01), urinalysis (P less than 0.05), and chest radiography (P less than 0.05). These effects were independent of the patient's age and sex, the year the physician graduated from medical school, and the availability of testing machinery at the practice site. These findings suggest that membership in a large group practice is associated with increased test ordering for hypertensive patients. This may be due to self-selection of particular types of physicians or patients, or to a property of the organizational structure itself.

Adult↗
PubMedDate not supplied

Quality of care for two common illnesses in teaching and nonteaching hospitals.

Teaching hospitals are recognized for treating rare diseases, but their value in caring for common illnesses is less clear. To assess quality of care for congestive heart failure and pneumonia, we reviewed the medical records of Medicare beneficiaries in major teaching, other teaching, and nonteaching hospitals in four states. Overall quality was rated better in major and other teaching hospitals than in nonteaching hospitals by physician reviewers and explicit process criteria, but the results varied for different subsets of explicit measures. Future studies should assess whether outcomes differ between teaching and nonteaching hospitals.

Aged↗
PubMedDate not supplied

For-profit and not-for-profit health plans participating in Medicaid.

The proliferation of for-profit health plans has heightened concerns about quality of care, particularly with respect to Medicaid. We undertook this study to compare for-profit and not-for-profit health plans that participate in Medicaid, examining processes of care and the organizational characteristics related to utilization management, financial incentives, and quality of care. Our findings demonstrate that for-profit and not-for-profit plans appear to be more similar than dissimilar in many areas of management, although for-profit plans are more likely to use aggressive utilization review and have slightly less developed quality management systems. On balance, these findings should reassure critics of for-profit health care.

Health Facilities, Proprietary↗
PubMedDate not supplied

Scale and structure of capitated physician organizations in California.

Physician organizations in California broke new ground in the 1980s by accepting capitated contracts and taking on utilization management functions. In this paper we present new data that document the scale, structure, and vertical affiliations of physician organizations that accept capitation in California. We provide information on capitated enrollment, the share of revenue derived by physician organizations from capitation contracts, and the scope of risk sharing with health maintenance organizations (HMOs). Capitation contracts and risk sharing dominate payment arrangements with HMOs. Physician organizations appear to have responded to capitation by affiliating with hospitals and management companies, adopting hybrid organizational structures, and consolidating into larger entities.

California↗
PubMedDate not supplied

The emergency department as a pathway to admission for poor and high-cost patients.

BACKGROUND: --To determine the importance of the emergency department as the means of access to the hospital for the poor and the fiscal implications of providing these services, we examined the relationship between patients' socioeconomic status and admission via the emergency department. We also determined the association between entering the hospital via the emergency department and hospital resource use. METHODS: --We conducted a study of 20,089 patients admitted to five Massachusetts hospitals (three community, two tertiary care) during a 6-month period. We determined the proportions of patients within various socioeconomic and disease groupings who entered through the emergency department. We compared length of stay and charges for patients admitted through the emergency department with those for patients admitted through other routes. RESULTS: --Overall, 51% of patients entered via the emergency department. Elderly patients (age greater than 65 years; odds ratio, 1.87) and patients with lower socioeconomic status as measured by income, occupation, and education (odds ratios, 2.38, 1.47, and 1.69, respectively) were more likely to enter the hospital via the emergency department than other patients. After adjustment for diagnosis related group, severity as measured by DRGSCALE, and socioeconomic status as measured by income, and excluding outliers, patients admitted via the emergency department stayed 27% longer and incurred 13% higher charges than other patients (P less than .001). CONCLUSIONS: --Our data indicate that patients with lower socioeconomic status are more likely than other patients to use the emergency department as their means of access to the hospital and that patients admitted via the emergency department use far more resources than patients in the same diagnosis related group admitted by other means. Hospitals that make emergency department services more available may be more likely to hospitalize socioeconomically disadvantaged patients and may be at a substantial financial disadvantage under per-case reimbursement systems such as Medicare.

Adolescent↗
PubMedDate not supplied

Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area.

Rising competitive pressures may place uninsured patients at risk for receiving fewer services than insured patients with similar medical conditions. To examine this possibility we studied the case mix, length of stay, and number of procedures for 65,032 patients listed as self-pay or free care, Blue Cross, or Medicaid at 52 hospitals in the Boston, Mass, area during 1983. We found that the overall case mix severity index (based on expected length of stay per diagnosis related group) for uninsured patients was 30% higher in public hospitals and 8% higher in major teaching hospitals compared with other institutions. Across all hospitals, the severity index of uninsured patients was similar to that of insured patients. However, after adjusting for diagnosis related group case mix, uninsured patients had, on average, 7% shorter stays (5.36 vs 5.79 days) and underwent 7% fewer procedures (1.16 vs 1.25) than Blue Cross patients, the differences varying with hospital type. Uninsured patients also had shorter stays on average than Medicaid patients (5.36 vs 5.87 days), but they underwent a similar number of procedures. These results suggest that patients who lack insurance may receive unequal treatment even after being hospitalized.

Adolescent↗