Older women helping older women: Employing senior workers in community research.
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Aged↗
Biomedical subjects
N Lurie
Publications and source records attributed to N Lurie.
Preventable hospitalizations and access to health care.
OBJECTIVE: To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style. DESIGN: Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas. SETTING: Community based. PARTICIPANTS: A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities. MAIN OUTCOME MEASURES: We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style. RESULTS: Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions (R2 = 0.50; P < .001). In a multivariate analysis that included a measure of access, the prevalence of conditions, health care seeking, and physician practice style to predict cumulative hospitalization rates for chronic medical conditions, both self-rated access to care (P < .002) and the prevalence of the conditions (P < .03) remained independent predictors. CONCLUSION: Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.
Adult↗
Developing a measure of health outcomes in survivors of childhood cancer: a review of the issues.
The success of treatment for childhood cancer has prompted greater attention to issues of quality of life for the survivors. Work on health-related quality of life has proceeded faster for adults than for children. This paper reviews the results of such work for adults and points to the potential for applications in children. Specific problems in adapting measures and in interpreting the results in the context of a child's development are discussed. An approach to the assessment of the health-related quality of life for survivors of childhood cancer is proposed.
Adolescent↗
Physician gender and screening.
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Humans↗
Omeprazole use at an urban county teaching hospital.
To determine the appropriateness of use of omeprazole, all outpatient prescriptions over one year from a single county hospital pharmacy were analyzed. Appropriateness of omeprazole use was assessed by literature review and expert opinion. Two hundred twenty-one prescriptions were evaluated; 112 (56%) were inappropriate. Women received more inappropriate prescriptions (61% vs 44%, p = 0.01) and received endoscopy less frequently (52% vs 71%, p < 0.02) than did men. When age, gender, and prescribing clinic were examined as predictors of inappropriate use, only gender was significant (OR = 2.01, 95% CI = 1.52-2.66). This study, from a single institution, showed a high rate of inappropriate omeprazole use.
Drug Utilization Review↗
Capitated Medicaid and the process of care of elderly hypertensives and diabetics: results from a randomized trial.
PURPOSE: To measure the quality of care for hypertensive and diabetic elderly Medicaid beneficiaries enrolled in managed care versus fee-for-service (FFS) plans. METHODS: Individuals enrolled in the Medicaid Demonstration Project in Hennepin County, Minnesota, were randomly assigned to receive their care either in one of seven managed care health plans in which the Medicaid payment for their care was capitated or in an FFS plan. Two hundred ninety-one hypertensives and 96 diabetics who were aged 65 years or over at the beginning of the evaluation were interviewed at baseline and followed for 1 year. Drug and nondrug therapy, monitoring, monthly medication costs, and access to medications were assessed. RESULTS: The prepaid and FFS did not differ in drug or nondrug therapy, with the exception that slightly more FFS enrollees were on human insulin after 1 year. Mean monthly medication costs and access to medications were similar for both groups. CONCLUSIONS: In this randomized trial, we were unable to detect differences in the process of care for hypertensive and diabetic Medicaid enrollees.
Aged↗
Is quality in the eye of the beholder?
BACKGROUND: Relatively ignored in the literature on quality improvement (QI) in health care is the question of who defines the issues in quality of care and decides how those issues will be addressed. METHODS: In late 1992, 669 hospital administrators, quality assurance (QA) coordinators, physicians, and nurses in 72 hospitals in six states were surveyed by telephone. Respondents were asked to identify the most serious issue related to quality of care in their hospital. RESULTS: Of all the respondents, hospital administrators were most likely to identify quality issues related to organizational/institutional issues. QA coordinators, most of whom had nursing backgrounds, were most likely to identify organizational and patient care issues. Physician responses were distributed approximately evenly across issues related to physicians, to the organization, and to patient care. Nurses were most likely to identify issues related to patient care and patient satisfaction. DISCUSSION: The findings validate the viewpoint that "quality is in the eye of the beholder" and that the eye is conditioned by the discipline in which hospital staff have been trained and socialized. As total quality management and continuous quality improvement approaches are implemented, and participants from many disciplines are involved in QI, a wide range of issues that have both a direct and indirect effect on patient care are likely to be addressed. CONCLUSION: The findings of this study suggest that surveys that specifically target certain disciplinary groups may yield important information about issues related to quality of care.
Attitude of Health Personnel↗
Utah's Prepaid Mental Health Plan: the first year.
This DataWatch analyzes the effect of the Utah Prepaid Mental Health Plan (UPMHP) on use of mental health services by and mental health treatment expenditures for Medicaid beneficiaries from July 1991 to June 1992. During this period three community mental health centers (CMHCs) provided mental health services to Medicaid beneficiaries in their catchment areas in return for capitated payments. Utilization and expenditure rates per beneficiary per month were analyzed using a "fixed-effects" statistical modeling approach, controlling for categories of beneficiary, time trends, seasonal effects, and CMHC grouping (capitated urban, capitated rural, noncapitated urban, and noncapitated rural). The results of the analysis suggest that the UPMHP reduced admissions for inpatient mental health treatment, inpatient mental health expenditures, and total mental health expenditures for Medicaid beneficiaries. These findings must be regarded as preliminary because of the relatively short time period covered by the data.
Community Mental Health Centers↗
California physicians' willingness to care for the poor.
Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.
Adult↗
The outcomes of elective laparoscopic and open cholecystectomies.
BACKGROUND: The demand for evidence of effectiveness for medical care has prompted the development of epidemiologic approaches to relating the outcomes of care to treatment. This study compares the outcomes of care for patients undergoing the newly introduced laparoscopic cholecystectomy with the results from conventional open cholecystectomies. METHODS: Consecutive cases of elective cholecystectomy from 35 hospitals (all of the metropolitan and selected rural hospitals in Minnesota) were enrolled in the study. Patients were interviewed on admission to establish baseline symptoms and functional status and to confirm risk factors. Their medical records were abstracted to yield information on risk factors, treatment, and hospital complications. To establish outcomes, patients were sent a questionnaire about their symptoms and functional status six months postoperatively. RESULTS: Of 3,448 patients studied, 2,490 (72 percent) had a laparoscopic procedure, including 195 cases that were converted to open cholecystectomies. Functional status data were obtained on 2,481 cases (76 percent). Laparoscopic operation was associated with more operative complications (odds ratio 3.02, p < 0.001), but with fewer general complications (odds ratio 0.32, p < 0.001). The mean time to return to work was 15 days for laparoscopic cases compared to 31 days for open procedures (p < 0.001). The only functional outcome difference between the two procedures was that patients who underwent laparoscopic cholecystectomies were more likely than those with conventional cholecystectomies to be able to perform their usual activities at follow-up evaluation (p < .001). There was evidence of a learning curve; the more laparoscopic procedures a surgeon performed, the fewer the operative (p < 0.01) and general (p < 0.0001) complications. There was no indication that the availability of laparoscopic operation was associated with more operations being performed. CONCLUSIONS: Laparoscopic operation seems to represent a significant advance in getting patients back to a normal life sooner. More attention needs to be given to which patients are most likely to benefit from cholecystectomy of either type. Epidemiologic approaches can be useful in assessing the effectiveness of care. Partnerships between providers and researchers can produce useful effectiveness data by supplementing available clinical records with more detailed outcome data.
Cholecystectomy↗
The effects of capitation on health and functional status of the Medicaid elderly. A randomized trial.
PURPOSE: To determine the effect on health and functional status outcomes of enrollment of noninstitutionalized elderly Medicaid recipients in prepaid plans compared with traditional fee-for-service Medicaid. DESIGN: A randomized controlled trial. Beneficiaries were randomly assigned to prepaid care in one of seven capitated health plans compared with fee-for-service care. Only the Medicaid portion of their care was capitated. Patients were followed for 1 year. SETTING: The Medicaid Demonstration Project in Hennepin County, Minnesota, which includes Minneapolis. PATIENTS: 800 Medicaid beneficiaries who were 65 years or older at the beginning of the evaluation. Beneficiaries were interviewed at baseline (time 1) and 1 year later (time 2). Ninety-six percent of beneficiaries were available for follow-up interviews at time 2. MAIN OUTCOME MEASURES: General health status, physical functioning, mental health status, activities of daily living, instrumental activities of daily living, corrected visual acuity, and blood pressure and glycosylated hemoglobin measurements for hypertensive and diabetic persons, respectively. RESULTS: There were no differences between prepaid and fee-for-service groups in the number of deaths (20 compared with 24, P > 0.2), the proportion in fair or poor health (56.5% compared with 59.7%, P > 0.2), physical functioning, activities of daily living, visual acuity, or blood pressure or diabetic control. Patients in the prepaid group reported a trend toward better general health rating scores (10.2 compared with 9.8, P = 0.06) and well-being scores (10.0 compared with 9.7, P = 0.07) than patients in the fee-for-service group. The difference in the likelihood of a patient in the prepaid group having a physician visit relative to the fee-for-service group was -16.5% (adjusted odds ratio, 0.46; 95% CI, 0.29 to 0.74) and for an inpatient visit was -11.2% (adjusted odds ratio, 0.55; CI, 0.32 to 0.94). CONCLUSIONS: There was no evidence of harmful effects of enrolling elderly Medicaid patients in prepaid plans, at least in the short run. Whether these findings also apply to settings in which health maintenance organizations are formed exclusively for Medicaid patients should be studied further.
Activities of Daily Living↗
Changes in orders limiting care and the use of less aggressive care in a nursing home population.
OBJECTIVE: To examine changes in the aggressiveness of care of the nursing home population and to determine the factors that predict whether care is limited. DESIGN: Retrospective chart review. SETTING: All nursing homes in Hennepin County, Minnesota that care for Medicaid patients. PATIENTS: A random sample of 1605 residents of Hennepin County, MN nursing homes from 1984 and 1988 who were also Medicaid beneficiaries. The sample was stratified by year and by whether the resident died in that year. The residents were sampled disproportionately to allow approximately 400 individuals in each stratum. A total of 1405 charts (87%) was reviewed; the remainder had either been lost or destroyed. MAIN OUTCOME MEASURE: Orders limiting care (do not resuscitate, supportive care only, etc.), care that was less aggressive than care usually given to a person of that age (eg, not using antibiotics for a clear infection or not sending a resident to the hospital for an illness for which someone would "usually" be sent to the hospital), determined implicitly through chart review. RESULTS: The demographic characteristics of the nursing home population did not change between 1984 and 1988, but the population had significantly greater severity of illness in 1988. The percentage of residents with 'do not resuscitate' orders (DNR) increased from 12% to 37% (P < 0.0001), and the use of other orders to limit care (do not hospitalize, supportive care only, etc.) increased from 12% to 17% (P < 0.05). The use of CPR did not change between the two years but the percentage of residents who were found to receive less aggressive care through implicit chart review increased from 31% to 40% (P < 0.01). The year the resident was in the nursing home, the severity of illness, functional status, and dementia were significant predictors of DNR status. Factors that predict receipt of less aggressive care were similar except that age was also a significant predictor. CONCLUSIONS: The nursing home population received less aggressive care in 1988 than in 1984. Further, there was a discrepancy between what was ordered and what was delivered in the nursing home in that residents with DNR orders had care limited beyond the withholding of CPR.
Advance Directives↗
Urban and rural differences in health insurance and access to care.
This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies. Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P < 0.01). These differences were confirmed by multivariate analysis. Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.
Adult↗
Preventive care for women. Does the sex of the physician matter?
BACKGROUND: Emphasis on ensuring women's access to preventive health services has increased over the past decade. Relatively little attention has been paid to whether the sex of the physician affects the rates of cancer screening among women. We examined differences between male and female physicians in the frequency of screening mammograms and Pap smears among women patients enrolled in a large Midwestern health plan. METHODS: We identified claims for mammography and Pap tests submitted by primary care physicians for 97,962 women, 18 to 75 years of age, who were enrolled in the health plan in 1990. The sex of the physician was manually coded, and the physician's age was obtained from the state licensing board. After identifying a principal physician for each woman, we calculated the frequency of mammography and Pap smears for each physician, using the number of women in his or her practice during 1990 as the denominator. Using unconditional logistic regression, we also calculated the odds ratio of having a Pap smear or mammogram for women patients with female physicians as compared with those with male physicians, controlling for the physician's and the patient's age. RESULTS: Crude rates for Pap smears and mammography were higher for the patients of female than male physicians in most age groups of physicians. The largest differences between female and male physicians were in the rates of Pap smears among the youngest physicians. For the subgroup of women enrolled in the health plan for a year who saw only one physician, after adjustment for the patient's age and the physician's age and specialty, the odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians as compared with those of male physicians. For women 40 years old and older, the odds ratio for having a mammogram was 1.41 (95 percent confidence interval, 1.22 to 1.63). For both Pap smears and mammography, the differences between female and male physicians in screening rates were much more pronounced in internal medicine and family practice than in obstetrics and gynecology. CONCLUSIONS: Women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.
Adolescent↗
Now is the time: physician involvement in health care reform.
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Health Policy↗
Predictors of failure to attend scheduled mammography appointments at a public teaching hospital.
OBJECTIVE: To identify patient, institutional, and physician characteristics that predict failure to attend scheduled mammography appointments. DESIGN: Retrospective chart review. SETTING: Medicine clinic at an urban public teaching hospital. PATIENTS: All 907 women aged 40 years and more scheduled for mammography from March 1990 to June 1991. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was whether a woman kept her scheduled mammography appointment. Potential predictor variables included patient age, race, marital status, and insurance status; waiting interval to obtain a mammography appointment; and physician gender, level of training, country of training, and native language. The rate of failed mammography appointments was 23%. Univariate analysis showed that appointment failure was associated with age (p = 0.03), with the lowest failure rates (19%) among women aged 60 years and more. Appointment keeping varied significantly by race (p = 0.01), largely because of the higher failure rate among Native American women (36%). Insured women had a failure rate of 22% vs 33% for uninsured women (p = 0.01). The rate of failed appointments varied significantly by waiting interval (p = 0.05), with a peak failure rate of 27% for appointments scheduled 14-27 days in advance. None of the physician variables was associated with appointment failure. Multivariate analysis confirmed these results. CONCLUSIONS: Interventions to improve completion of breast cancer screening should include additional efforts targeted at groups with high rates of appointment failure, such as women under the age of 60, the uninsured, and Native Americans. Long waiting intervals to obtain mammography appointments may decrease compliance.
Adult↗
Residency reform and health care research.
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Delivery of Health Care↗
Are things different in the light of day? A time study of internal medicine house staff days.
PURPOSE: To determine how internal medicine house staff spend their days and compare activities during the day with those previously observed during night call. SETTING: University-affiliated Veterans Affairs Medical Center. DESIGN: Two internal medicine house staff teams (one PGY-1 [postgraduate year] and one PGY-2 or PGY-3) observed during 5 short call admitting days. MEASUREMENTS: Time in each activity recorded by trained observers, computed, summed, and compared with that of similar activities of house staff on night call. RESULTS: House staff admitted an average of two patients each day. They spent, on average, 25 minutes per patient performing new patient histories and physical examinations, 29 minutes charting new patient information, and were interrupted after an average of 12 minutes during the new patient evaluation compared with 20, 19, and 7 minutes at night (p > 0.05). The average house officer spent 44 minutes in nonphysician duties and 11 minutes answering pages during the day. On average, house staff spent 3 minutes each day talking in person with patients' families. CONCLUSIONS: A significant amount of time each day was spent performing nonphysician duties. Little time was spent evaluating each patient or in person with patients' families and similar amounts of time were spent in charting and in patient evaluation. House staff appeared to spend more time with new patients during the day than they did at night, although this finding was not statistically significant. As noted during night call, evaluations were frequently interrupted. Future studies should examine why house staff choose to distribute their time in the manner described in this and similar studies.
Hospitals, Teaching↗