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Biomedical subjects

A R Davies

Publications and source records attributed to A R Davies.

At least 19 recordsLinked to original sources
PubMed1992

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

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

Activities of Daily Living↗
PubMed1992

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

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

Activities of Daily Living↗
PubMed1992

HMOs for Medicaid: the road to financial independence is often poorly paved.

During the 1980s both the federal government and the private sector articulated policies to encourage the development and participation of health maintenance organizations (HMOs) in the Medicaid program. However, the policies, intended to save costs, limited the ability of new HMOs to achieve financial independence. New plans that emphasize Medicaid participation have few, if any, options on benefit design or in setting capitation rates. Relative to fee-for-service Medicaid programs, their costs to provide services may be quite high, as they have neither the buying power not the ability to impose discounts. As a consequence, plans must focus their financial planning efforts on targeting and attaining a stable enrollment base and on controlling the amount of services provided, tasks that are difficult for all HMOs. Achieving a stable enrollment base is particularly hard because Medicaid eligibles have few incentives to enroll and once enrolled often lose their Medicaid eligibility. Traditional HMOs control the amount of services provided through physician selection, financial incentives on physicians, and monitoring and utilization review. Lack of information and the difficulty inherent in attracting sufficient provider participation limit the first two strategies, so new plans often adopt organization structures that rely heavily on monitoring activities. Unfortunately, management information systems for HMOs are often the weakest link. We discuss the tasks and present data on financial planning, on putting financial plans into operation, and on monitoring progress toward financial independence for a set of ten demonstration projects sponsored by the Robert Wood Johnson Foundation.

Cost Control↗
PubMed1991

Failure of physicians to recognize functional disability in ambulatory patients.

OBJECTIVE: To assess the ability of internists to identify functional disabilities reported by their patients. DESIGN: Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. SETTING: A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. SUBJECTS: Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. MEASUREMENTS AND MAIN RESULTS: Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. CONCLUSIONS: Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.

Activities of Daily Living↗
PubMed1991

The patient comment card: a system to gather customer feedback.

Continuous patient feedback can give important information to hospitals about the quality of care they provide. The Patient Comment Card (PCC), a brief form that can be used to gather open-ended comments from patients and to measure quality, was developed during a two-year period and was extensively evaluated in a series of three pilot tests involving more than 2,000 patients discharged from five hospitals. Evaluation results demonstrate that the questionnaire elicits useful comments from patients and can generate statistically reliable scores and valid quality measures. However, in a field trial in four hospitals, low response rates (15%-27%) reflected, first, lack of follow-up of non-respondents, and second, the fact that most of the PCC quality scores were upwardly biased; these inflated scores were likely to reflect the low response rate. Tools such as the PCC should be used judiciously, given the possible abuses and misinterpretations of hospital quality scores.

Bias↗
PubMed1990

Section 47.

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Legislation, Medical↗
PubMed1989

Improving patient function: a randomized trial of functional disability screening.

STUDY OBJECTIVES: To test whether a 34-item functional status questionnaire measuring physical, psychological, and social function can be used by physicians in practice to help improve their patients' outcomes. DESIGN: Prospective randomized trial. SETTING: Community internal medicine practices. PATIENTS: Five hundred and ten continuing patients with functional disabilities who saw their physicians at least four times a year. PHYSICIANS: Seventy-six UCLA clinical volunteer faculty who are internists in community office practices. INTERVENTIONS: Physicians and their patients were randomly assigned to the experimental or the control group. Experimental group physicians attended a 2-hour multimedia educational session and received four functional status reports on each of their study patients over a 1-year period. Control group physicians received no education and no functional status feedback. Control group and experimental group patients were tested for functional status with the functional status questionnaire every 4 months for 1 year. Both groups also completed monthly diaries that measured use of health services. Experimental group physicians answered an anonymous evaluation questionnaire at 6 months after study entry. MEASUREMENTS AND MAIN RESULTS: Forty-three percent of experimental group physicians reported that they had used the functional status questionnaire to change therapy. Ninety-five percent reported that it was useful and accurate. Patient diaries did not show any difference between experimental group patients and control group patients in number of medications used, visits to physicians or other health professionals, equipment purchased, diet, or exercise programs. There were no significant differences between experimental and control group patients at exit from the study on any functional status or health outcome measure. CONCLUSION: A more powerful intervention than a 2-hour educational session and the regular provision of functional status information is needed to help office-based internists improve patient outcomes.

Activities of Daily Living↗
PubMed1988

AIDS testing.

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HIV Seropositivity↗
PubMed1987

Educating physicians and treating patients in the ambulatory setting. Where are we going and how will we know when we arrive?

We evaluated 15 group practices in general internal medicine in university hospitals with regard to access to and quality of care, patients' satisfaction with that care, and quality of residency education provided. We used these data to speculate about potential changes in ambulatory care programs in university teaching hospitals. All 15 practices participated for 4 years. One third of their patient population had no medical insurance. Practice patients had twice as many chronic illnesses as did the general population, and two fifths of patients stayed at least 2 years in the practice. Few faculty members spent more than 14 hours weekly in the practices, and housestaff worked an average of 4 hours per week. Patient waiting times did not meet ideal standards, but patient satisfaction was higher than in a general population. Compliance with quality of care criteria was not exceptional; for example, 10% of eligible patients received an annual influenza vaccination. Housestaff assigned a relatively low ranking to their educational experience in the practices. We recommend the institution of additional experimental programs in ambulatory care and housestaff education to improve the quality of care in the ambulatory setting.

Continuity of Patient Care↗
PubMed1986

Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care.

To determine whether health outcomes in a health maintenance organisation (HMO) differed from those in the fee-for-service (FFS) system, 1673 individuals ages 14 to 61 were randomly assigned to one HMO or to an FFS insurance plan in Seattle, Washington for 3 or 5 years. For non-poor individuals assigned to the HMO who were initially in good health there were no adverse effects. Health outcomes in the two systems of care differed for high and low income individuals who began the experiment with health problems. For the high income initially sick group, the HMO produced significant improvements in cholesterol levels and in general health ratings by comparison with free FFS care. The low income initially sick group assigned to the HMO reported significantly more bed-days per year due to poor health and more serious symptoms than those assigned free FFS care, and a greater risk of dying by comparison with pay FFS plans.

Adolescent↗
PubMed1986

Consumer acceptance of prepaid and fee-for-service medical care: results from a randomized controlled trial.

Do consumers find the care provided by health maintenance organizations (HMOs) and that provided in the fee-for-service (FFS) system equally acceptable? To address this question, we randomly assigned 1,537 people ages 17 to 61 either to FFS insurance plans that allowed choice of physicians or to a well-established HMO. We also studied 486 people who had already selected the HMO (control group). Those who had chosen the HMO were as satisfied overall with medical care providers and services as their FFS counterparts. The typical person assigned to the HMO, however, was significantly less satisfied overall relative to FFS participants. Attitudes toward specific features of care favored both FFS and HMO, depending on the feature rated. Four differences (length of appointment waits, parking arrangements, availability of hospitals, and continuity of care) favored FFS; two (length of office waits, costs of care) favored the HMO. HMO versus FFS differences in ratings of access to care and availability of resources mirror differences in the organizational features of these two systems that are generally considered responsible for the significantly lower medical expenditures at HMOs. Regardless of their origin, less favorable attitudes toward interpersonal and technical quality of care in the HMO have marked consequences: dissatisfaction and disenrollment.

Adolescent↗