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Biomedical subjects

N Lurie

Publications and source records attributed to N Lurie.

At least 37 records · Page 2Linked to original sources
PubMed1998

Changes in the process of care for Medicaid patients with schizophrenia in Utah's Prepaid Mental Health Plan.

OBJECTIVE: Changes in the process of psychiatric care received by Medicaid beneficiaries with schizophrenia were examined after the introduction of capitated payments for enrollees of some community mental health centers (CMHCs) under the Utah Prepaid Mental Health Plan. METHODS: Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the records of 200 patients in nonparticipating CMHCs, which remained in a fee-for-service reimbursement arrangement. Using the Process of Care Review Form, trained abstracters gathered data characterizing general patient management, social support, medication management, and medical management before implementation of the plan in 1990 and for three follow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by treatment site. RESULTS: By year 3 at the CMHCs participating in the plan, psychotherapy visits decreased, the probability of a patient's terminating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the probability of treatment for a month or longer with a suboptimal dosage of antipsychotic medication increased. Only modest changes in the process of care were observed at the nonplan CMHCs. CONCLUSIONS: Change in the process of psychiatric care was more evident at the sites participating in the plan, where traditional therapeutic encounters were de-emphasized in response to capitation. The array of changes raises questions about the vigor of care provided to a highly vulnerable group of patients.

Adult↗
PubMed1998

Monitoring the consequences of uninsurance: a review of methodologies.

The proportion of the United States population without health insurance continues to grow. How will this affect the health of the nation? Prior research suggests that the uninsured are at risk for poor health outcomes. They use fewer medical services and have higher mortality rates than do insured persons. The episodic nature of uninsurance and its prevalence among disadvantaged groups makes it difficult to ascertain the health effects of uninsurance. The goal of this review is to assist researchers and policy makers in choosing methodologies to assess the effects of uninsurance. It provides a compendium of methods that have been used to examine the health consequences of uninsurance, the populations in which these methods have been used, and the strengths and weaknesses of different approaches. The review highlights the need for more longitudinal studies that focus on community-based samples of the uninsured.

Adult↗
PubMed1997

Who is still uninsured in Minnesota? Lessons from state reform efforts.

OBJECTIVE: To describe Minnesota's health care system reform efforts and their implications for other state and national reform initiatives, document the rate of uninsurance in 1990 and 1995 with special attention to childrens' access to health insurance, and examine the effectiveness of MinnesotaCare, a voluntary state-subsidized health care plan, in serving its target population. DESIGN: Three cross-sectional telephone surveys: 2-stage random samples of Minnesotans of all ages in 1990 and 1995 and a stratified random sample of MinnesotaCare enrollees in 1994. PARTICIPANTS: For the 2 statewide surveys, 10310 respondents participated in 1990 and 11519 in 1995; more detailed information was collected on approximately 1600 respondents in each survey. Eight hundred MinnesotaCare enrollees participated in the third survey conducted in 1994. MAIN OUTCOME MEASURE: Changes in rates of uninsurance. RESULTS: While the rate of uninsurance increased at the national level, the point-in-time Minnesota rate remained stable and low at 6% between 1990 and 1995. The proportion of children uninsured for 12 months or more decreased from 5.2% in 1990 to 3.1% in 1995, while the proportion of uninsured single adults remained stable at approximately 11%. There was no evidence that MinnesotaCare enrollees are gaming the program, or that the program has resulted in significant erosion from the private market. CONCLUSIONS: MinnesotaCare has enabled the state to maintain a low rate of uninsurance and has reduced this rate among its primary target: children. The program has been less effective in enrolling single adults, although it may be too early to witness the effects of recent expansions targeting this group. Minnesota's experience suggests that other state and national reform efforts aimed at reducing uninsurance, particularly among children, are likely to be successful.

Adult↗
PubMed1997

Are all health plans created equal? The physician's view.

CONTEXT: The health care market is demanding increasing amounts of information regarding quality of care in health plans. Physicians are a potentially important but infrequently used source of such information. OBJECTIVE: To assess physicians' views on health plan practices that promote or impede delivery of high-quality care in health plans and to compare ratings between plans. SETTING: Minneapolis-St Paul, Minn. PARTICIPANTS: One hundred physicians in each of 3 health plans. Each physician rated 1 health plan. MAIN OUTCOME MEASURES: Likert-type items that assessed health plan practices that promote or impede delivery of high-quality care. RESULTS: A total of 249 physicians (84%) completed the survey. Fewer than 20% of all physicians gave plans the highest rating (excellent or strongly agree) for health plan practices that promote delivery of high-quality care (such as providing continuing medical education for physicians, identifying patients needing preventive care, and providing physicians feedback about practice patterns). Barriers to delivering high-quality care related to sufficiency of time to spend with patients, covered benefits and copayment structure, and utilization management practices. Ratings differed across health plans. For example, the percentage of physicians indicating that they would recommend the plan they rated to their own family was 64% for plan 1, 92% for plan 2, and 24% for plan 3 (P<.001 for all comparisons). CONCLUSIONS: Physician surveys can highlight strengths and weaknesses in health plans, and their ratings differ across plans. Physician ratings of health plan practices that promote or impede delivery of high-quality care may be useful to consumers and purchasers of health care as a tool to evaluate health plans and promote quality improvement.

Attitude of Health Personnel↗
PubMed1997

Why do patients of female physicians have higher rates of breast and cervical cancer screening?

OBJECTIVE: Women are more likely to receive breast and cervical cancer screening if they see female physicians. We studied whether this is due to differences between male and female physicians, or to differences in their patients. SETTING: Large midwestern, independent practice association style of health plan. DESIGN: We surveyed male and female primary care physicians matched for age and specialty and a stratified random sample of three of each physician's women patients. Physicians reported on their practice setting, their attitudes and practices regarding prevention, and their comfort and skill with various examinations. Patients reported on their sociodemographic characteristics, their attitudes and practices regarding prevention, and their preferences for physician gender. Claims data were used to calculate mammography and Pap smear screening rates for the physicians. PARTICIPANTS: We studied 154 female and 190 male internists and family physicians and 794 of their patients. MEASUREMENTS AND MAIN RESULTS: We compared the responses of male and female physicians and their patients and used multivariable analysis to identify the patient and physician factors that accounted for the differences in screening rates between male and female physicians. Female physicians were more likely to ask new patients about components of prevention, to believe in the effectiveness of mammography, to feel more personal responsibility for ensuring that their patients received screening, and to report more comfort in performing Pap smears and breast examinations. Patients of female physicians were more educated and less likely to be married, but did not differ in other sociodemographic characteristics. They had similar attitudes and practices regarding prevention, except that patients of male physicians were more likely to smoke. Significantly more patients of female physicians preferred a female for some component of care. In multivariable analyses, practice organization, patient preference for a female physician, and prevention orientation of female physicians accounted for up to 40% of screening rate differences between female and male physicians for Pap smears, and 33% for mammography. CONCLUSIONS: Differences in beliefs of male and female physicians and patient preference for a female provider contribute independently to the higher rate of breast and cervical cancer screening by female physicians.

Adult↗
PubMed1997

Development and testing of a process measure of nursing home quality of care.

OBJECTIVE: To develop and test quality of care process measures for three medical conditions of nursing home patients: fever, shortness of breath, and chest pain. DESIGN: Flowsheets designed to capture the critical elements of care for the above conditions were developed by an expert panel. Nursing home residents charts were reviewed retrospectively using the flow sheets. The reviews were translated into clinical scenarios, and the quality of care the scenarios represented was rated by an expert panel. SETTING: All nursing homes in Hennepin County, MN, that care for Medicaid patients. PATIENTS: A random sample of 1405 Medicaid nursing home residents from 1984 and 1988. MEASURES: Measures of quality of physician assessment and intervention, quality of nurse assessment and intervention, and global quality were developed and the intra- and interrater reliability were tested. The measures' validity was assessed by their ability to predict resident death. RESULTS: Intrarater reliability was measured as the correlation of the ratings of blinded duplicates. The correlation for the global scale and the four subscales ranged from .74 to .88 (P < .001 for all). Interrater reliability was tested by examining what percentage of the quality ratings were within one unit (1-5 scale) for all three raters. All three raters were within one unit for more than 72% scenarios for all scales. The subscale of quality of physician assessment was able to predict resident death when the worst episode of care (OR = .47, 95% CI(.31-.74)) or the mean episode of care (OR .54, 95% CI(.30-.99)) was used. None of the other subscales or the global measure predicted death. CONCLUSIONS: Through the use of an expert panel, measures of nursing home quality of care were developed for shortness of breath, fever, and chest pain. These measures have reasonable reliability and significant face validity. Their validity is supported further by the ability of one of the measures to predict resident death.

Aged↗
PubMed1997

An instrument to evaluate the process of psychiatric care in ambulatory settings.

As part of an evaluation of the Utah Prepaid Mental Health Plan, the Process of Care Review Form was developed to assess the quality of the process of psychiatric care provided by Utah's community mental health centers (CMHCs) to clients with schizophrenia. This article briefly reviews issues in the measurement of quality of care and describes the development and implementation of the form. The 67-item form was designed for use by a trained abstracter to gather data from CMHC medical records in six areas: general management of the patient, medication management, medical management, social support, psychiatric hospitalization, and psychiatric assessment. A 59-item version of the form that omits the section on psychiatric assessment has been used in three waves of data collection to document data spanning five years (1990-1994) in the evaluation of the process of psychiatric care in the Utah plan. It is currently being used longitudinally to examine differences between Utah CMHCs receiving capitated payments and those paid on a fee-for-service basis by Medicaid.

Ambulatory Care↗
PubMed1996

Health of the public: The private-sector challenge.

The rapid growth of managed care poses challenges and opportunities for the health of the public. The fundamental risk is that both mission and accountability will be defined too narrowly; the opportunity lies in broadening both. What would a socially responsible managed care system look like? Such a system would provide excellent individual care to its enrollees, yet it would also include programs and activities that address broader populations and policies. We propose 8 attributes of such a system that can be used as a guide by managed care systems and to judge whether a managed care system is a responsible, accountable, and responsive contributor to the health of its community. As the role of the public sector shrinks, the private sector must expand its responsibility. It is both prudent and reasonable for managed care systems to seize their unique opportunity to improve the health of the public.

Delivery of Health Care↗
PubMed1996

The role of black and Hispanic physicians in providing health care for underserved populations.

BACKGROUND: Patients who are members of minority groups may be more likely than others to consult physicians of the same race or ethnic group, but little is known about the relation between patients' race or ethnic group and the supply of physicians or the likelihood that minority-group physicians will care for poor or black and Hispanic patients. METHODS: We analyzed data on physicians' practice locations and the racial and ethnic makeup and socioeconomic status of communities in California in 1990. We also surveyed 718 primary care physicians from 51 California communities in 1993 to examine the relation between the physicians' race or ethnic group and the characteristics of the patients they served. RESULTS: Communities with high proportions of black and Hispanic residents were four times as likely as others to have a shortage of physicians, regardless of community income. Black physicians practiced in areas where the percentage of black residents was nearly five times as high, on average, as in areas where other physicians practiced. Hispanic physicians practiced in areas where the percentage of Hispanic residents was twice as high as in areas where other physicians practiced. After we controlled for the racial and ethnic makeup of the community, black physicians cared for significantly more black patients (absolute difference, 25 percentage points; P < 0.001) and Hispanic physicians for significantly more Hispanic patients (absolute difference, 21 percentage points; P < 0.001) than did other physicians. Black physicians cared for more patients covered by Medicaid (P = 0.001) and Hispanic physicians for more uninsured patients (P = 0.03) than did other physicians. CONCLUSIONS: Black and Hispanic physicians have a unique and important role in caring for poor, black, and Hispanic patients in California. Dismantling affirmative-action programs as is currently proposed, may threaten health care for both poor people and members of minority groups.

Black or African American↗
PubMed1996

Double-blind placebo-controlled study of the efficacy of oral terfenadine in the treatment of chronic fatigue syndrome.

BACKGROUND: There is no established treatment for chronic fatigue syndrome (CFS), an illness characterized by disabling fatigue exacerbated by physical activity. A variety of immunologic abnormalities have been reported, including a high incidence of atopy and hypoergy or anergy. OBJECTIVE: Because of anecdotal reports and uncontrolled trials showing antihistamine efficacy in CFS, we evaluated the clinical efficacy of the antihistamine terfenadine (60 mg twice daily) in a placebo-controlled study. METHODS: Thirty patients with CFS were enrolled in a 2-month, double-blind, placebo-controlled trial of terfenadine. Participants underwent a battery of both immediate- and delayed-type hypersensitivity skin tests and completed a self-assessment questionnaire used to measure severity of symptoms, physical and social functioning, health perceptions, and mental health before each of six biweekly visits. RESULTS: Twenty-eight patients completed the trial. History of atopy and positive immediate skin test results were prevalent, 73% and 53%, respectively. No evidence for hypoergy or anergy after delayed-type hypersensitivity skin testing was found. No therapeutic benefit from terfenadine could be detected in terms of symptom amelioration, improved physical or social functioning, health perceptions, or mental health. A high incidence of atopy in patients with CFS was confirmed. CONCLUSION: Although this trial involved a small number of patients, the results suggest that terfenadine is unlikely to be of clinical benefit in treating CFS symptoms.

Administration, Oral↗
PubMed1996

Measuring seriousness of hospital quality of care issues.

BACKGROUND: A 1995 article showed that the discipline of the person who determines what constitutes a serious quality of care issue is significantly associated with the type of issues identified as serious. Moreover, what is a serious issue for one organization or provider may be a minor issue for another. METHODS: Six hundred hospital administrators, physicians, nurses, and quality managers in 72 hospitals rated the seriousness of issues they had identified in their own hospitals. A panel of 90 external hospital administrators, physicians, and quality managers rated a condensed set of the same issues. RESULTS: Across all the hospitals, internal scores were significantly lower (less serious) than external scores. Internal respondents consistently rated issues identified in their hospital lower than did external raters. The mean internal rating was .60 times the score for the anchor issue ("late lab or x-ray results," assigned a score of 300), while the mean external rating was 1.73 times the anchor score. DISCUSSION: Convergence of internal and external perceptions of the seriousness of quality of care issues in hospitals cannot be assumed. This raises questions about the effects of applying external judgments on seriousness of quality of care issues, such as those used in report cards or other external reports on hospital quality of care. CONCLUSION: There is greater conformity of viewpoint when respondents are asked to adopt an industrywide perspective rather than an internal one. External raters are more likely to consider problems serious than are internal raters, possibly because they do not have local knowledge of mitigating circumstances.

Attitude of Health Personnel↗
PubMed1996

Preparing physicians for practice in managed care environments.

The author first describes the evolution and characteristics of managed care and its emphasis on the care of populations as well as individuals. She then reviews managed care's implications for medical education; for example, managed care physicians must know non-office-based approaches to keeping their patients healthy. She identifies and defines eight domains of knowledge in which physicians must be competent for practice in environments dominated by managed care. These are epidemiologic thinking, human behavior, organizational behavior, information systems, quality measurement and improvement, health system financing and delivery, ethics, and systems based care. Teaching students to practice in managed care environments is a challenge partly because there are few role models of the new breed of physician among medical school faculties. The author suggests strategies and attitudes to remedy this situation (for example, faculty must understand that managed care is not homogeneous and that it is not all bad; medical schools should develop "master teachers" for the rest of the faculty; and interactive CD-ROM-driven problem-based learning sets could be used). Focusing on training faculty for the new era and on emphasizing the eight knowledge better physicians, whether they practice inside or outside managed care.

Behavior↗
PubMed1996

Physician practice style and rates of hospitalization for chronic medical conditions.

Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. The authors surveyed a random sample of 1,530 emergency physicians, general internists, and family and general practitioners in these areas, and measured clinical admission threshold by asking physicians whether they would hospitalize patients presented in 15 vignettes of graded severity. The authors measured social admission predisposition by asking how physicians' admission decisions would be influenced by social characteristics that increase patients' vulnerability to illness, including homelessness and drug use; 1,090 physicians responded (71%). There was significant variation across areas in both the clinical (P < 0.0001) and social (P < 0.001) admission scores. Variation in hospitalization rates correlated with physicians' clinical (r = .34, P = 0.03) and social (r = .36, P = 0.02) admission scores. However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.

Adult↗
PubMed1996

Causes of increasing mortality in a nursing home population.

OBJECTIVE: To examine the roles played by changes in case-mix, quality of care, and aggressiveness of care in explaining the 42% increase in mortality of the Medicaid nursing home population of Hennepin County, Minnesota, between 1984 and 1988. DESIGN: Retrospective chart review. SETTING: All nursing homes in Hennepin County, MN, that care for Medicaid patients. PATIENTS: A random sample of 1605 Medicaid nursing home residents from 1984 and 1988 stratified by year and by whether the resident died in that year. Sampling was disproportionate to allow approximately 400 individuals per stratum. A total of 1405 charts (87%) were reviewed; the remainder were either lost or destroyed. MAIN OUTCOME MEASURES: Measures included case-mix (Charlson index, functional status, implicit reviewer assigned severity [range 1-4]), aggressiveness of care (orders limiting care), quality of care (process of care for tracer conditions [range 1-5], falls), and resident death. RESULTS: Implicitly rated severity of illness worsened between 1984 and 1988 (2.77 vs 2.91; P = .009), but other measures of case-mix were unchanged. A greater percentage of residents had a DNR order in 1988 (12% in 1984 vs 37% in 1988; P < .001), and more received less aggressive care (31% vs 40%; P = .006). Overall process of care improved between 1984 and 1988 (2.88 vs 3.01; P < .05). With adjustment of the mortality rates and with logistic regression controlling for age and gender, changes in quality of care alone accounted for less than 5% of the mortality rate change between 1984 and 1988, case-mix alone accounted for 49%, and aggressiveness of care alone accounted for nearly 100%. CONCLUSIONS: The nursing home population became sicker between 1984 and 1988, but process of care improved. These changes had a modest effect on the mortality rate. The increase in less aggressive care between 1984 and 1988 accounts for nearly all of the increase in mortality.

Aged↗