Search PubMed⌕ Search

Biomedical subjects

C M Clancy

Publications and source records attributed to C M Clancy.

At least 19 recordsLinked to original sources
PubMed2000

Supplemental insurance and mortality in elderly Americans. Findings from a national cohort.

CONTEXT: As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing. OBJECTIVE: To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance. DESIGN: Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures. SETTING: The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index. PARTICIPANTS: A total of 3751 persons aged 65 years and older. MAIN OUTCOMES MEASURES: Five-year mortality rate. RESULTS: After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9). CONCLUSIONS: Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.

Aged↗
PubMed1999

Does skepticism towards medical care predict mortality?

OBJECTIVES: Attitudes towards medical care have a strong effect on utilization and outcomes. However, there has been little attention to the impact on outcomes of doubts about the value of medical care. This study examines the impact of skepticism toward medical care on mortality using data from the 1987 National Medical Expenditure Survey (NMES). METHODS: A nationally representative sample from the United States comprising 18,240 persons (> or = 25 years) were surveyed. Skepticism was measured through an 8-item scale. Mortality at 5-year follow-up was ascertained through the National Death Index. RESULTS: In a proportional hazards survival analysis of 5-year mortality that controlled for age, sex, race, education, income, marital status, morbidity, and health status, skepticism toward medical care independently predicted subsequent mortality. That risk was attenuated after adjustment for health behaviors but not after adjustment for health insurance status. CONCLUSION: Medical skepticism may be a risk factor for early death. That effect may be mediated through higher rates of unhealthy behavior among the medically skeptical. Further studies using more reliable measures are needed.

Attitude to Health↗
PubMed1999

Compliance with post-hospitalization follow-up visits: rationing by inconvenience?

OBJECTIVES: Appointment-keeping after hospitalization is a poorly understood link between inpatient and outpatient care. We investigated how health care system and patient characteristics influence appointment-keeping after discharge from an acute care hospitalization. DESIGN: Prospective cohort study. SETTING: Urban public teaching hospital. SUBJECTS: All 372 consecutive eligible patients admitted over a 15 week period to medicine wards. METHODS AND MEASURES: We interviewed patients during hospitalization and after discharge, searched the hospital's electronic databases, and reviewed charts. We measured medication compliance, health care access and use, health status (SF-36), previous appointment compliance, and physician recommended follow-up appointments. Main outcome was appointment adherence after discharge. RESULTS: Patients were primarily African American (71%), uninsured (64%), female (53%), and had a mean age of 48 years; 64% of first appointments after discharge were kept. Adjusted odds ratios (95% confidence intervals) for appointment-keeping were 3.3 (1.7, 6.5) for receiving a written appointment at discharge, and 0.50 (0.27, 0.90) for previous difficulty with obtaining health care. Readmission rates were not associated with appointment adherence. CONCLUSION: Modifiable system, as well as patient, characteristics are associated with follow-up appointment-keeping. The practice of not giving patients written appointments at the time of discharge may constitute an implicit form of "rationing by inconvenience." Further studies should also evaluate potential associations between appointment-keeping and re-hospitalization.

Aftercare↗
PubMed1998

Skepticism toward medical care and health care utilization.

OBJECTIVES: As health care moves toward systems that assume accountability for defined populations, there has been increasing emphasis on developing performance measures for those systems and their providers, with little attention given to patient demand or attitudinal factors. The impact of skepticism toward health care providers on health behavior and health care utilization was assessed using a cross-sectional analysis of data from the 1987 National Medical Expenditure Survey (NMES). METHODS: A nationally representative sample from the United States comprising 18,240 persons 25 years and older was surveyed. Skepticism, defined as doubts about the ability of conventional medical care to appreciably alter one's health status, was assessed through a 4-item scale. Outcome measures included health behavior, access (health care insurance, having a regular source of care, and physician type), utilization (annual number of physician or emergency department visits and hospitalizations), total annual health care expenditures, and preventive health care behavior (having had a Pap smear within 3 years or ever having had a mammogram). RESULTS: In multivariate analyses, skepticism was associated with younger age, white race, lower income, less education, and higher health perceptions. After adjusting for these variables, skepticism was associated with less healthy behavior, with not having health insurance, not having one's own physician, choice of a physician, fewer physician and emergency department visits, less frequent hospitalizations, lower annual health care expenditures, and less prevention compliance. CONCLUSIONS: Medical skepticism represents a relevant patient demand factor that demonstrates significant associations with a variety of health care access and utilization measures with important policy implications.

Adult↗
PubMed1998

Changes in usual sources of medical care between 1987 and 1992.

This study is a secondary analysis of data from the 1987 and 1992 National Health Interview Surveys. Analyses compared adults who do not have a usual source of care and those who identified usual sources of care in 1987 and 1992. Between these years, the estimated number of adult Americans without a usual source of care rose from 29.7 to 39.4 million. Adults were 0.75 times less likely to identify a physician's office and 1.8 times more likely to identify an outpatient clinic as that source of care in 1992 than they were in 1987. These changes were observed among Americans of all demographic and socioeconomic backgrounds. Increasing numbers of adult Americans without a usual source of care and shifts in care from physicians' offices to outpatient clinics may reflect deteriorating access to care. This may affect quality and costs of medical care, demanding continued surveillance of sources and access to care.

Adolescent↗
PubMed1997

Emergency medicine in population-based systems of care.

EDs and emergency physicians play a critical role in health care delivery--providing care to those with life-threatening conditions, as well as serving as provider of last resort to those without options for primary care. This diversity of functions provides unique opportunities for identifying important unmet community needs and developing solutions to address these needs. Future challenges for emergency medicine include assessing and improving the quality of care provided within the ED and identifying the role of the ED in systems of care. Health services research can help define the optimal functions of emergency medicine in enhancing population health.

Community Health Planning↗
PubMed1997

Defining primary care. Empirical analysis of the National Ambulatory Medical Care Survey.

OBJECTIVES: Efforts to contain health care costs have increased interest in defining which specialties provide primary care and in developing tools to assess the delivery of primary care services. METHODS: Using data from the 1985-1991 National Ambulatory Medical Care Surveys, the authors examined the activities of 29 physician specialty groups to determine whether the recent Institute of Medicine definition of primary care could be operationalized. Ten elements were identified that addressed comprehensiveness (first-contact care, a Herfindahl Index, previous contact for other problems, prevention, and care through the life cycle), coordination (referrals), continuity (any previous contact), and accessibility (care provided to black patients, those on Medicaid, and patients in rural areas). RESULTS: Principal component and factor analyses suggested that each element, except care through the life cycle, contributed to the construct of primary care. Principal component analysis enabled ordering of specialties according to their "primary careness," suggesting that specialties other than family/general practice, pediatrics, and internal medicine make significant contributions to primary care. Factor analysis suggested that two factors related to process and content underlie the definition of primary care and emphasize the importance of integration of services provided. This analysis provides a basis for further empirical work to develop measures of primary care performance. CONCLUSIONS: National surveys need to be modified to provide a more comprehensive assessment of primary care in the United States.

Ambulatory Care↗
PubMed1997

Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance.

BACKGROUND: Increasing enrollment in managed care organizations and dissatisfaction with policies to restrict direct access to specialists have intensified interest in referrals from primary care physicians to specialists. We examined the associations of demographic factors and insurance with referrals of adult patients by primary care physicians. METHODS: Office visits of adult patients to primary care physicians (general practitioners, family physicians, and internists) reported in the National Ambulatory Care Survey for the years 1985 through 1992 were used to examine referrals by primary care physicians. Regression analyses were adjusted for patient factors (age, sex, race, insurance, case mix, diagnostic category, new problem or not, new patient or not, and visit length), physician factors (age, sex, specialty, and degree of specialization), and practice factors (proportion of HMO patients, rural location, region, and study year). RESULTS: Overall, 4.5% of patients were referred compared with 7.5% of patients with HMO insurance. After adjustment, an increased likelihood of referral was associated with being a male patient, having fewer medications prescribed, not being seen before for the presenting problem, a longer visit, less physician specialization, seeing a female physician, seeing an internist, and seeing a physician with a greater proportion of patients with HMO insurance. Among patients with HMO insurance, no gender disparity in referral rate was observed, and patients who also had Medicaid or Medicare insurance were more likely to be referred. CONCLUSIONS: Male patients are more likely to be referred. HMO insurance may reduce this gender disparity and increase the access of patients with Medicaid and Medicare to specialty care.

Adult↗
PubMed1997

Utilization of specialty and primary care: the impact of HMO insurance and patient-related factors.

BACKGROUND: Appropriate utilization of primary and specialty care has stimulated substantial debate, but the portion of the discussion focused on policies that restrict or discourage direct access to specialists has been largely uninformed by empirical analysis. Using data from the National Ambulatory Care Survey (1985 to 1992 surveys), we examined the associations of patient and physician demographics and health maintenance organization (HMO) insurance status with the utilization of primary compared with specialty care. METHODS: Office visits for adult patients seen by primary care physicians and specialists were analyzed for: (1) patient-initiated utilization of specialists (patient self-referral) compared with that of primary care physicians; and (2) utilization of specialists compared with that of primary care physicians, stratified by HMO insurance status. RESULTS: After multivariate adjustment, patient self-referral was less likely among black patients (adjusted odds ratio [AOR] = 0.67; 95% confidence interval [CI] = 0.59 to 0.76), self-pay (AOR = 0.81; 95% CI = 0.74 to 0.88), or patients with Medicaid (AOR = 0.51; 95% CI = 0.43 to 0.61). The proportion of non-HMO patients seeing specialists remained stable (44.9%). For HMO patients, the proportion of total visits made to specialists increased from 27.6% in 1985 to 41.3% in 1991, then dropped to 33.2% in 1992. Disparities in utilization of specialists by women, blacks, and patients with Medicaid observed among non-HMO patients were not found in the HMO population. Specialists were more likely to see HMO patients for follow-up of a known problem, whereas non-HMO patients were more likely to have specialist follow-up visits for new problems. CONCLUSIONS: The results suggest greater utilization of specialists by male, white, and privately insured patients. The findings may partially account for disparities in specialty procedure use, and suggest that HMO insurance may reduce some of these disparities. The less frequent and more selective use of specialists among HMO patients suggests an evolving role for specialists in managed care.

Adult↗