Truth's search for power in health policy: critical applications to community-oriented primary care and small area analysis.
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California↗
Biomedical subjects
F A Hubbell
Publications and source records attributed to F A Hubbell.
Local advocacy for the medically indigent: strategies and accomplishments in one county.
Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.
California↗
Resting electrocardiograms as baseline tests: impact on the management of elderly patients.
PURPOSE: We evaluated management decisions of house staff in a university hospital emergency department (ED) to determine the impact of baseline electrocardiogram (ECG) results on the care of elderly patients. SUBJECTS AND METHODS: The study employed a prospective before-after research design. The subjects included internal medicine house staff assigned to the ED and the 47 elderly patients treated by them during 58 ED visits. The measures of impact on patient care included how often and in what ways comparison of baseline and ED ECG results changed the house staff's diagnostic impressions and treatment plans. To determine changes, we asked house staff to indicate their impressions and management plans before and after comparing baseline and ED ECG results. In addition, a panel of faculty members used a modification of the nominal group process to determine treatment changes and to estimate benefit to patients from the changes. RESULTS: House staff indicated that baseline ECG results led them to change diagnostic impressions during 13 (22%) and treatment plans during eight (14%) of the 58 visits. Six of the patients benefited from the treatment changes. The faculty judges indicated that baseline ECG findings would have altered their diagnostic impressions in eight (14%) and treatment decisions in three (5%) of the 58 cases, one of which would have benefited from the change. All patients for whom there were changes of impression or plan had prior histories of cardiovascular disease. CONCLUSION: We conclude that baseline ECGs provide ED house staff with diagnostic information that often leads to changes in management of elderly patients with prior histories of cardiovascular disease. Future studies should evaluate the efficacy of baseline ECGs in patients without such histories.
Aged↗
Community-oriented primary care.
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California↗
Access to medical care for documented and undocumented Latinos in a southern California county.
To determine local access to medical care among Latinos, we conducted telephone interviews with residents of Orange County, California. The survey replicated on a local level the national access surveys sponsored by the Robert Wood Johnson Foundation. We compared access among Latino citizens of the United States (including permanent legal residents), undocumented Latinos, and Anglos, and analyzed predictors of access. Among the sample of 958 respondents were 137 Latino citizens, 54 undocumented Latinos, and 680 Anglos. Compared with Anglos, Latino citizens and undocumented immigrants had less access to medical care by all measures used in the survey. Although undocumented Latinos were less likely than Latino citizens to have health insurance, by most other measures their access did not differ significantly. By multivariate analysis, health insurance status and not ethnicity was the most important predictor of access. Because access to medical care is limited for both Latino citizens and undocumented immigrants, policy proposals to improve access for Latinos should consider current barriers faced by these groups and local differences in access to medical care.
Adult↗
Local advocacy for the medically indigent. Strategies and accomplishments in one county.
Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program ensures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. We report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence state and national policies that affect local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system that guarantees access, they can substantially improve the availability of local services.
California↗
Functional status and financial barriers to medical care among the poor.
We compared the functional status of 94 poor patients with financial barriers to recommended medical care with that of 94 poor control patients without such barriers in a university-affiliated community clinic. Financial barriers existed when an insured patient's health insurance failed to cover recommended care or when an uninsured patient could not afford recommended care. Patients with financial barriers scored significantly lower than control subjects on the psychologic function/mental health component of the functional status questionnaire and tended to score lower on all other functional status measures. The results suggest that poor patients with financial barriers to recommended medical care may be sicker than other poor patients.
Adult↗
Evaluating health-care needs of the poor: a community-oriented approach.
PURPOSE: Concern has arisen over the provision of health care for the poor. In a project sponsored by a local community hospital, we conducted a telephone survey to determine unmet health-care needs of low-income families living in Orange County, California, and made recommendations to address those needs. METHODS: The survey assessed demographic characteristics and access to medical care of 652 adults and their families. RESULTS: In general, we found that the poor (incomes below 125% of the poverty level), the uninsured, and the Latino respondents had lower access measures than the nearly poor (incomes between 125% and 200% of the poverty level), insured, and Anglo subjects. However, insurance status was the strongest predictor of access in this low-income population. Important unmet health-care needs included prenatal care and preventive care. In response to our findings, the sponsoring hospital has instituted new health-care programs to help meet these needs. CONCLUSION: This community-oriented approach for improving problems of access to medical care for the poor may be appropriate for other localities.
California↗
Financial barriers to medical care: a prospective study in a university-affiliated community clinic.
Access to medical care in the United States is deteriorating, particularly for the poor. The authors evaluated patients who could not afford medical care recommended by physicians in a university-affiliated clinic that serves a predominantly indigent population. The authors determined the patients' demographic characteristics, their medical problems, and the types of care for which financial barriers existed. In addition, the authors compared the patients' demographic characteristics and medical illnesses with those of a control group of patients from the clinic who did not experience financial barriers to medical care. Of the 1,950 patients evaluated, 94 (4.8%) were unable to afford care recommended by their physicians. Sixty-seven percent were US citizens, 73% were unemployed, 63% had monthly family incomes of less than $500, and only 33% had health insurance. The patients had a variety of medical problems, ranging from hearing loss, for which they could not obtain hearing aids, to breast masses, for which they could not obtain mammographies or biopsies. When compared to patients who did not experience financial barriers to recommended care, the study patients tended to be poorer, more likely to be undocumented, more likely to be uninsured, and less likely to have acute, self-limited illnesses. Our findings support the argument that the nation's current piecemeal approach to providing indigent health care may lead to serious financial barriers to access in some localities.
California↗
Biochemical testing in patients with alcoholic liver disease.
We evaluated physicians' laboratory utilization patterns for hospitalized patients with alcoholic liver disease and examined the relationship between the frequency of test ordering and certain variables in clinical outcome. During the study, 185 patients with alcoholic liver disease were hospitalized 378 times at the VA Medical Center, Long Beach, California. Physicians ordered liver panels (including serum albumin, alkaline phosphatase, total bilirubin, lactic dehydrogenase, glutamic pyruvate transaminase, and glutamic oxaloacetic transaminase) an average of 7.4 times per hospitalization. Increased biochemical testing did not decrease length of stay or improve clinical outcomes such as development of complications or survival of hospitalization. Since the treatment of alcoholic liver disease is largely supportive and not dependent upon frequent biochemical testing, we recommend that these tests be ordered only when patients are admitted to or discharged from the hospital, and when there has been a clinical change.
Diagnostic Tests, Routine↗
Routine admission laboratory testing for general medical patients.
We evaluated the usefulness of commonly ordered routine admission laboratory tests in 301 patients admitted consecutively to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three Department of Medicine faculty members reviewed the charts of admitted patients to determine the impact of the test results on patient care. The evaluated tests were the urinalysis, hematocrit, white blood cell count, platelet count, six-factor automated multiple analysis (serum sodium, potassium, chloride, bicarbonate, glucose, and blood urea nitrogen), prothrombin time, partial thromboplastin time, chest x-ray, and electrocardiogram. Forty-five percent of the 3,684 tests were ordered for patients without recognizable medical indications. Twelve percent of these routine tests were abnormal, 5% led to additional laboratory testing, but only 0.5% led to change in the treatment of patients. We conclude that the impact of routine admission laboratory testing on patient care is very small and that there is little justification for ordering tests solely because of hospital admission.
Academic Medical Centers↗
Efficacy of the routine admission urinalysis.
The clinical efficacy of routine admission urinalyses was evaluated in 301 patients admitted to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three Department of Medicine faculty members reviewed the patients' charts to determine which tests were performed routinely and which test results led to diagnostic or therapeutic management changes. Of the 243 urinalyses performed, 123 (51 percent) were ordered routinely for patients without recognizable medical indications. Results of the routine urinalyses were abnormal in 42 (34 percent) of the patients and led to additional laboratory testing in 20 (16 percent) of the cases. However, the test results led to therapeutic changes in only three (2.4 percent) of the patients, and in two of these patients, the treatment instituted probably was unnecessary. It is concluded that the impact of routine admission urinalysis on patient care is very small and that there is little justification for ordering this test for all patients admitted to the hospital.
Adult↗
Electrolyte, blood urea nitrogen and glucose level screening in medical admissions. Impact on patient management.
Investigators have failed to show the usefulness of screening electrolyte-sodium, potassium, chloride and bicarbonate-blood urea nitrogen and glucose levels. In spite of this, we observed that that practice continues to be widely used at our university medical center. Using a form of consensus analysis, we examined the records of 301 admissions to the medicine service to determine whether laboratory tests were done for diagnostic or screening purposes and whether screening test results led to changes in patient management. Of the 1,764 tests done, 716 (40.6%) were for screening purposes. Only 2 (0.3%) screening test abnormalities led to any therapeutic changes, and many false-positive tests led to unnecessary diagnostic retesting.
Blood Glucose↗
Deciding against corporate management of a state-supported academic medical center.
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Academic Medical Centers↗
The impact of routine admission chest x-ray films on patient care.
We evaluated the impact of routine chest x-ray films, obtained on admission, on the treatment of patients on internal medicine wards of the Veterans Administration Medical Center, Long Beach, California--a population known to have a high prevalence of cardiopulmonary disease. The reasons for ordering chest films were determined prospectively, and three Department of Medicine faculty members reviewed the charts of admitted patients to determine the impact of chest-film results on patient care. Routine chest x-ray films were ordered for 294 (60 per cent) of the 491 patients studied. Abnormalities were noted in 106 (36 per cent) of these 294 patients. The findings were previously known, chronic, and stable in 86 patients; they were new in only 20. Treatment was changed because of chest-film results in only 12 (4 per cent) of the patients. In only one of these patients would appropriate treatment probably have been omitted if a chest film had not been obtained, and the patient's outcome was not improved by the treatment instituted. We conclude that the impact of routine admission chest x-ray films on patient care is very small, even in a population with a high prevalence of cardiopulmonary disease. We recommend that such films not be ordered solely because of admission.
Adult↗
Mood changes during the internship.
A prospective study using two standardized psychological tests, the Profile of Mood States (POMS) and the Self-Rating Depression Scale (SDS), was conducted in an effort to quantify the emotional changes experienced by internal medicine house staff members during the internship. In contrast to instruments used in previous investigations of this type, the POMS and the SDS are standardized tests with proven reliability and validity. The six mood factors measured, "tension-anxiety," "depression-dejection," "anger-hostility," "vigor-activity," "fatigue-inertia," and "confusion-bewilderment," are reported to be among those factors most often affected by the internship experience. Twenty-three interns completed both tests at four-month intervals during one academic year. One-way analysis of variance for repeated measures revealed that the level of only anger-hostility of the mood factors changed significantly during the year. The intensity of this factor increased between the first and third testing periods before dropping at the end of the year. In contrast to findings in previous studies, the depression and fatigue factors did not increase during the year. By characterizing interns' reactions to the stresses of postgraduate medical education, standardized psychological tests can contribute to improved understanding of these reactions and to more intelligent planning of support systems.
Anger↗
Comparative antihypertensive and endocrinologic effects of clonidine and prazosin in patients with essential hypertension.
The acute and chronic effects of fixed dosages of clonidine and prazosin on supine and upright blood pressure, the renin-angiotensin-aldosterone system, and plasma catecholamines were compared in 24 patients with essential hypertension. The patients were randomized into two groups; 11 received chlorthalidone (50 mg daily) throughout the protocol, but 13 received no diuretic. Clonidine was generally more effective in lowering systolic and diastolic blood pressure in the supine posture throughout the study; prazosin tended to decrease blood pressure in the upright posture more effectively, especially during the first week of treatment. The only truly significant difference was found after four weeks of treatment when the decrease in supine systolic blood pressure by clonidine of 26.5 +/- 8.9 mm Hg was greater than that of 1.7 +/- 5.6 mm Hg produced by prazosin (P less than .05).
Adult↗
Effects on the renin-angiotensin system of agents acting at central and peripheral adrenergic receptors.
Although the principal actions of clonidine are linked to its centrally mediated suppression of sympathetic activity, its inhibition of the renin axis also may contribute to its antihypertensive effects. In patients with essential hypertension studied in a clinical research center, clonidine-induced decreases in diastolic blood pressure and in plasma renin activity (PRA) correlated closely after one day of treatment, but not thereafter. Moreover, high-renin patients experienced significantly greater blood pressure decrements than low-renin patients during the first day of treatment, but subsequent blood pressure decreases were equal in the two groups, confirming that the sympathoinhibitory action of clonidine is probably independent of the renin-angiotensin system. However, responders to clonidine treatment exhibited significantly greater decrements in aldosterone excretion rate than nonresponders. When compared with propranolol in an outpatient study, clonidine reduced aldosterone levels to the same extent as propranolol despite a significantly weaker inhibitory effect on PRA. Indeed, in a further comparative study with prazosin, during which neither agent decreased renin levels, clonidine significantly lowered aldosterone excretion. Thus, clonidine appears to have two separate actions on the renin-aldosterone axis: an early antirenin action primarily in high-renin patients, and a longer-term suppressive effect on aldosterone. This latter action is possibly independent of changes in renin, and perhaps reflects an effect on aldosterone release mediated through central mechanisms.
Adult↗