Biomedical subjects

Paul D Cleary

Publications and source records attributed to Paul D Cleary.

At least 37 records · Page 2Linked to original sources

PubMed2004

Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients.

BACKGROUND: Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care. OBJECTIVES: To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes. DESIGN: Prospective cohort study. PATIENTS AND SETTING: A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1717 patients eligible for PI treatment and the 367 providers who cared for them. MEASUREMENTS: Providers' attitude toward prescribing PIs to nonadherent patients, time until patients' first receipt of PIs, mortality, and physical health status. MAIN RESULTS: Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P =.05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers' prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P =.04), after controlling for baseline physical health status and other patient and provider covariates. CONCLUSIONS: Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.

Adult↗

PubMed2003

A hospitalization from hell: a patient's perspective on quality.

Patients usually cannot assess the technical quality of their care; however, examining a hospitalization through the patients' eyes can reveal important information about the quality of care. Patients are the best source of information about a hospital system's communication, education, and pain-management processes, and they are the only source of information about whether they were treated with dignity and respect. Their experiences often reveal how well a hospital system is operating and can stimulate important insights into the kinds of changes that are needed to close the chasm between the care provided and the care that should be provided. This article examines the case of a patient admitted for ankle arthrodesis due to severe hemophilia-related arthritis. The surgery was successful, but the hospital stay was marked by inefficiency and inconveniences, as well as events that reveal fundamental problems with the hospital's organization and teamwork. These problems could seriously compromise the quality of clinical care. Unfortunately, most of these events occur regularly in U.S. hospitals. Relatively easy and inexpensive ways to avoid many of these problems are discussed, such as reducing variability in non-urgent procedures and routinely asking patients about their experiences and suggestions for improvement.

Ankle↗

PubMed2003

Guideline recommendations for treatment of schizophrenia: the impact of managed care.

BACKGROUND: Medicaid-managed care has been shown to reduce the number and length of psychiatric hospitalizations, but little is known about the clinical and social consequences of such managed care programs. The purpose of this study was to compare the treatment of schizophrenia for disabled Medicaid beneficiaries who were and were not enrolled in managed care. METHODS: This was a prospective observational study of patients who sought care for a psychiatric crisis from June 7, 1997, to May 13, 1999. Patients were followed up for 6 months. Inpatient and outpatient mental health facilities in Massachusetts were studied. The participants included 420 adult Medicaid beneficiaries, aged 24 to 64 years, who were treated for schizophrenia; 784 eligible beneficiaries were originally contacted and invited to participate (53.6% response). A private managed behavioral health care organization administered the Medicaid mental health benefit for about half the patients in the study. The other half were enrolled in the dually insured fee-for-service Medicare/Medicaid plan. The main outcome measures were adherence to the Schizophrenia Patient Outcomes Research Team treatment recommendations from inpatient and outpatient medical records, self-reported quality of interpersonal interactions between patient and clinician, self-reported care experiences and outcomes, and clinician-reported outcomes. RESULTS: There were no differences between the managed care plan and the unmanaged fee-for-service plan in adherence to the schizophrenia treatment guidelines. However, much outpatient care in both programs was inconsistent with treatment guidelines. Inpatient treatment was far more likely to conform to guidelines than outpatient treatment. Patient ratings of their care were positive and not different between plans. Clinical outcome and health-related quality of life were not different between plans. CONCLUSIONS: A major change in Massachusetts in the way mental health care is organized and financed had neither a negative nor a positive effect on care quality. However, adherence to nationally accepted guidelines for care was only modest, suggesting a need to improve the delivery of treatment to the most disabled highest-risk adults with schizophrenia.

Adult↗

PubMed2003

What do collaborative improvement projects do? Experience from seven countries.

BACKGROUND: Health care organizations are increasingly adopting multiorganizational collaborative approaches to quality improvement. Collaboratives have been conducted in many countries. There are large variations in the way collaboratives are structured and run, but there is no widely accepted framework for describing the components of collaboratives. Thus, it is difficult to study which approaches are most effective. METHOD: The authors conducted semistructured interviews with 15 leaders of collaboratives to ascertain the common components of collaboratives and identify variations in the ways these components are implemented. RESULTS: The study identified seven features of collaboratives that the leaders interviewed thought were critical determinants of how effective the collaboratives were: sponsorship, topic, ideas for improvements, participants, senior leadership support, preliminary work and learning, and strategies for learning about and making improvements. For example, every interviewee mentioned that having participants collect data, perform audit work, or analyze the system they were in before the collaboration started was important to understanding their organization and the nature of the problems they had and to developing baseline data for later comparison. The authors describe variations in how these features have been implemented and possible functions of these features. CONCLUSION: Systematically studying the impact of variations in the seven key features of collaboratives could yield important information about their role and impact.

Cooperative Behavior↗

PubMed2003

Patterns of coping among persons with HIV infection: configurations, correlates, and change.

This study examines coping in response to HIV infection, using longitudinal data from a nationally representative sample (n = 2,864) of HIV-infected persons. We investigated configurations of coping responses, the correlates of configuration membership, the stability of coping configurations, and the relationship of coping to emotional well-being. Four coping configurations emerged from cluster analyses: relatively frequent use of blame-withdrawal coping, frequent use of distancing, frequent active-approach coping, and infrequent use of all three coping strategies ("passive" copers). Passive copers had few symptoms, high levels of physical functioning, and high emotional well-being; blame-withdrawal copers had the opposite pattern. Of those completing a second interview 1 year after baseline, 46% had the same coping configuration. Increases in the number of HIV-related symptoms raised the probability of blame-withdrawal coping at follow-up, whereas decreases raised the probability of passive coping. Infrequent use of coping responses at baseline was related to greater emotional well-being 1 year later. This result, in conjunction with the high levels of emotional well-being in the passive cluster, suggests that high levels of distress can induce blame-withdrawal coping whereas coping efforts are minimal when social support and emotional well-being are high. Results highlight issues in ascertaining the causal direction between coping and psychological outcomes, as well as in specifying the nature of stressful situations with which people are coping.

Adaptation, Psychological↗

PubMed2003

Physician specialization and antiretroviral therapy for HIV.

BACKGROUND: Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection. OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART). DESIGN: Observational cohort study of patients under care for HIV infection and their physicians. PATIENTS AND SETTING: This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians. MEASUREMENTS: Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor. RESULTS: Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations. CONCLUSIONS: Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.

Adult↗

PubMed2003

The World Health Organization Health and Work Performance Questionnaire (HPQ).

This report describes the World Health Organization Health and Work Performance Questionnaire (HPQ), a self-report instrument designed to estimate the workplace costs of health problems in terms of reduced job performance, sickness absence, and work-related accidents-injuries. Calibration data are presented on the relationship between individual-level HPQ reports and archival measures of work performance and absenteeism obtained from employer archives in four groups: airline reservation agents (n = 441), customer service representatives (n = 505), automobile company executives (n = 554), and railroad engineers (n = 850). Good concordance is found between the HPQ and the archival measures in all four occupations. The paper closes with a brief discussion of the calibration methodology used to monetize HPQ reports and of future directions in substantive research based on the HPQ.

Absenteeism↗

PubMed2003

Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey.

OBJECTIVE: To estimate the reliability and validity of survey measures used to evaluate health plans and providers from the consumer's perspective. DATA SOURCES: Members (166,074) of 306 U.S. health plans obtained from the National CAHPS Benchmarking Database 2.0, a voluntary effort in which sponsors of CAHPS surveys contribute data to a common repository. STUDY DESIGN: Members of privately insured health plans serving public and private employers across the United States were surveyed by mail and telephone. Interitem correlations and correlations of items with the composite scores were estimated. Plan-level and internal consistency reliability are estimated. Multivariate associations of composite measures with global ratings are also examined to assess construct validity. Confirmatory factor analysis is used to examine the factor structure of the measure. FINDINGS: Plan-level reliability of all CAHPS 2.0 reporting composites is high with the given sample sizes. Fewer than 170 responses per plan would achieve plan-level reliability of .70 for the five composites. Two of the composites display high internal consistency (Cronbach's alpha > or = .75), while responses to items in the other three composites were not as internally consistent (Cronbach's alpha from .58 to .62). A five-factor model representing the CAHPS 2.0 composites fits the data better than alternative two- and three-factor models. CONCLUSION: Two of the five CAHPS 2.0 reporting composites have high internal consistency and plan-level reliability. The other three summary measures were reliable at the plan level and approach acceptable levels of internal consistency. Some of the items that form the CAHPS 2.0 adult core survey, such as the measure of waiting times in the doctor's office, could be improved. The five-dimension model of consumer assessments best fits the data among the privately insured; therefore, consumer reports using CAHPS surveys should provide feedback using five composites.

Benchmarking↗

PubMed2003

Beneficiary reported experience and voluntary disenrollment in Medicare managed care.

Disenrollment rates have often been used as indicators of health plan quality, because they are readily available and easily understood by purchasers, health plans, and consumers. Over the past few years, however, indicators that more directly measure technical quality and consumer experiences with care have become available. In this observational study, we examined the relationship between voluntary disenrollment rates from Medicare managed care (MMC) plans and other measures of health plan quality. The results demonstrate that voluntary disenrollment rates are strongly related to direct measures of patient experiences with care and are an important complement to other measures of health plan performance.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2002

The influence of patient characteristics on ratings of managed behavioral health care.

Despite current emphasis on consumer-based performance measures, little is known about factors that influence consumer ratings of behavioral health care. This study examines the influence of patient characteristics, health care use, and insurance coverage on patients' ratings of their managed behavioral health care in both commercial and public plans. Older and healthier patients rated their behavioral health care and health plan more highly than did other patients. Patients with less education and those whose insurance paid all costs of care gave consistently higher plan ratings. Women and frequent users enrolled in commercial plans gave more positive care ratings. After adjusting for enrollee characteristics and coverage, there were no differences between ratings of patients in commercial and public plans. These results are consistent with other research that illustrates the importance of adjusting health care ratings for patient characteristics when comparing plans.

Adolescent↗

PubMed2002

How are patients' specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians?

CONTEXT: Few data are available regarding the consequences of patients' problems with interpersonal aspects of medical care. OBJECTIVE: To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want. DESIGN: Telephone survey during 1997. PARTICIPANTS: Patients (N=2,052; 58% response) insured by a large national health insurer. MEASUREMENTS: Patient trust, overall ratings of physicians, and having considered changing physicians. RESULTS: Most patients (78%) reported at least 1 problem experience. In multivariable analyses, each problem experience was independently associated with lower trust (all P <.001) and 5 of 6 with lower overall ratings (P <.001). Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3 to 3.0), not always taking enough time to answer questions (OR, 3.3; 95% CI, 2.2 to 5.2), and not always giving enough medical information (OR, 4.0; 95% CI, 2.4 to 6.6). CONCLUSIONS: Problem experiences in the ambulatory setting are strongly related to lower trust. Several are also associated with lower overall ratings and with considering changing physicians, particularly problems related to communication of health information. Efforts to improve patients' experiences may promote more trusting relationships and greater continuity and therefore should be a priority for physicians, educators, and health care organizations.

Adult↗

PubMed2002

Specialty training and specialization among physicians who treat HIV/AIDS in the United States.

OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with HIV-specific knowledge, referral patterns, and HIV-related education activities. DESIGN: Cross-sectional survey. SETTING: The United States. PARTICIPANTS: Physicians caring for patients in the HIV Costs and Service Utilization Study, a study of a probability sample of HIV-infected individuals in the United States. MEASUREMENTS AND MAIN RESULTS: Measures included physicians' reports of specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities. Approximately 72% (379) of the eligible physicians completed a survey. Of these, 152 (40%) had infectious disease (ID) training, and 213 (56%) were generalists; 4% of ID-trained physicians and 37% of generalist physicians did not consider themselves HIV experts. The median current caseloads were 150 and 200 patients for ID experts and generalist experts, respectively. In contrast, the median caseload for non-expert generalists was 5. Mean scores on the knowledge scale were similar for ID and generalist experts (9.0 items correct out of 11 vs 8.5; P=not significant), but lower for generalist non-experts (6.5 items correct; P <.01). Experts had attended more local and national HIV meetings than non-experts (9.3 vs 2.7; P <.01, and 2.3 vs.40; P <.01, respectively) in the past year. Fewer ID experts ever referred than generalist experts (13.0% vs 27.3%; P=.01). In multivariable models that included specialty training and caseload, physicians with caseloads of 20 to 49 and >50 were more likely to have a high knowledge score (defined as 80% or more correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P <.001, respectively), and the effect of specialty was attenuated (OR, 2.7; P=.02 decreased from OR, 7.8; P <.001 in a model without caseload). In the models predicting referral practices, both experience (OR,.25; P <.01 and OR,.17; P <.01 for caseloads of 20 to 49 and >50, respectively) and specialty (OR,.19; P <.01 and OR,.09; P <.01 for generalist and ID experts, respectively) were significant. CONCLUSIONS: In a national sample of physicians, HIV-specific knowledge was more strongly associated with HIV caseload than with specialty training. In addition, although referral practices were related to both experience and specialty, generalist experts and ID physicians reported similar behaviors. This suggests that generalist physicians, through clinical experience and self-education, can develop specialized knowledge in HIV care.

Acquired Immunodeficiency Syndrome↗

PubMed2002

Using telephone interviews to reduce nonresponse bias to mail surveys of health plan members.

OBJECTIVE: To assess the nonresponse bias associated with mail-survey returns and the potential for telephone interviews with nonrespondents to reduce that bias. METHODS: A mail survey about health care experiences was conducted with samples of 800 members in each of four health plans. Subsequent attempts were made to interview nonrespondents by telephone. RESULTS: Response rates for the mail surveys averaged 46%; the telephone effort raised the average to 66%. On 17 of 19 measures of health status or need and use of health services, mail respondents were in poorer health and needed more services than interviewed nonrespondents. Thirteen of 36 reports and ratings of health care also differed significantly between the two groups. Based on administrative data, telephone interviews of mail nonrespondents improved the demographic representativeness of the responding samples. Adjusting mail returns to sample population characteristics could not replicate the dual-mode results. CONCLUSIONS: Returns to mail surveys are likely to be related to survey content and hence are potentially biased. Nonresponse to phone surveys is less directly related to survey content. Telephone interviews with mail nonrespondents not only increase response rates but also can produce less biased samples than mail-only protocols.

Adult↗

PubMed2002

Similarities and differences in choosing health plans.

BACKGROUND: Increasingly, consumers have multiple health insurance options. New information is being developed to help consumers with these choices. OBJECTIVES: To study similarities and differences in how the publicly and privately insured choose health plans. To explore the effect of traditional enrollment materials and reports developed by the Consumer Assessment of Health Plans Study (CAHPS) on consumers' perceptions and decision-making. RESEARCH DESIGN: Using data from eight CAHPS demonstrations, we tested for significant differences across consumers with employer-sponsored insurance, Medicaid, and Medicare. SUBJECTS: Approximately 10,000 consumers with employer-sponsored, Medicaid, and Medicare health plans. MEASURES: Perceptions of the health plan selection process, use of information sources, and reactions to and use of traditional enrollment materials and CAHPS reports. RESULTS: Most consumers with all types of insurance thought that choosing a health plan was important and obtained information from multiple sources. Choosing a plan was more difficult for Medicare and Medicaid recipients than for the privately insured. When choosing a plan, Medicaid recipients cared most about convenience and access, whereas the privately insured emphasized providers and costs. The percentage of consumers who looked at and remembered the CAHPS report varied widely from 24% to 77%. In all but one of the demonstration sites, most consumers spent less than 30 minutes looking at the CAHPS report. CONCLUSIONS: Group sponsors and the developers of information interventions such as CAHPS may need to invest in developing and testing different reporting approaches for Medicare, Medicaid, and privately insured consumers.

Consumer Advocacy↗

PubMed2002

Factors affecting response rates to the Consumer Assessment of Health Plans Study survey.

OBJECTIVES: Assess the determinants of nonresponse to a consumer health care survey. METHODS: The first (1997; CAHPS 1.0) and third (1999; CAHPS 2.0) Medicare managed care (MMC) CAHPS surveys collected data on 215 and 365 health plan reporting units, respectively. Data indicated which beneficiaries responded by mail, responded by phone, could not be located, and did not respond. InterStudy data described plan characteristics. chi2 tests and logistic regression models, adjusted for clustering by plan, were used to test associations of individual and plan characteristics with availability of good contact information and response given good contact information. RESULTS: Response rates in the 1997 and 1999 surveys were 75% and 80%, respectively. Older and disabled beneficiaries, women, nonwhite beneficiaries, and persons living in areas with more residents who were nonwhite, on public assistance, and less educated had lower response rates. These associations were partly explained by the distribution of bad contact information, but even among beneficiaries who could be located plan response rates varied greatly. For-profit plans are significantly more likely to have high rates of bad contact information and lower response rates. Telephone follow-up improved the sociodemographic representativeness of the sample, for both high and low response rate plans. CONCLUSION: CAHPS-MMC survey procedures, in particular telephone follow-up, have resulted in high response rates, and current case-mix strategies compensate for some of the remaining effects of differing response rates on comparisons among plans. Further efforts to explore the determinants of response rates are warranted.

Age Distribution↗

PubMed2002

Dimensions of plan performance for sick and healthy members on the Consumer Assessments of Health Plans Study 2.0 survey.

BACKGROUND: The quality of health plan care may differ for members in good and poor health. OBJECTIVE: To determine whether reports from sick and healthy members reflect distinct aspects of plan performance. RESEARCH DESIGN: Mean health plan scores were analyzed on the 1998 and 1999 Medicare Managed Care (MMC) Consumer Assessments of Health Plans (CAHPS) surveys, treating responses from sick and healthy members as separate plan measures. Alternative definitions of health were compared and the one that defined groups with the most distinct experiences was selected. Using factor analysis, composites of report items defined for these groups were identified. Mean ratings were regressed on these composites. SUBJECTS: Two hundred ninety thousand seven hundred thirty-nine Medicare managed care beneficiaries from 381 health plan-reporting units. MEASURES: MMC-CAHPS survey responses, including four overall ratings and 30 specific report items. RESULTS: A question about general health status best defined subgroups with distinct experiences. Report items grouped into eight factors: care for healthy members, care for sick members, finding and communicating with a doctor for sick members, plan customer service, plan-provided medical services and equipment, vaccinations, prescriptions, and smoking cessation advice. Ratings by each subgroup were generally most strongly predicted by reports on care for the same subgroup and by customer service and plan-provided services (for ratings of plan) and access to doctors. CONCLUSIONS: Reports from sick and healthy members measure distinct dimensions of health plan quality, especially in the domain of patient care. Distinguishing these dimensions might help in informing consumers and targeting quality improvement efforts.

Aged↗

PubMed2002

HIV patients' experiences with inpatient and outpatient care: results of a national survey.

CONTEXT: Little is known about HIV patients' care experiences. OBJECTIVE: To assess HIV patients' experiences with inpatient and outpatient care, and to assess the relationship and relative influence of patient characteristics and site of care on care experiences. DESIGN: Cohort study. SETTING: Patients with HIV receiving care outside of emergency rooms, prisons, or the military throughout the continental United States. One thousand seventy-four patients provided ratings of an inpatient stay and 2204 rated an outpatient visit; 818 patients provided evaluations of both inpatient and outpatient care. PATIENTS: A national probability sample of persons in care for HIV from the HIV Cost and Services Utilization Study. MEASUREMENTS: Outcome variables were rates of problems with, and global ratings of, inpatient and outpatient care. RESULTS: Mean problem rates were 20.9% and 8.4% (lower score means fewer problems) for inpatient and outpatient care, respectively. On 9 of 10 of the individual inpatient report items, 15% or more of respondents reported problems. Global ratings of inpatient and outpatient care were 65.3 and 75.0 (0-100 scale, higher scores indicate better ratings), respectively. In multivariable models that controlled for site effects, the only patient characteristic that was consistently associated with problem rates and global ratings of care was mental health (P <0.0001 for both inpatient and outpatient care). Models including site effects explained two to four times as much variance as models excluding site effects. CONCLUSIONS: Inpatients with HIV reported higher problem rates with inpatient than outpatient care. Better provider-patient communication during inpatient stays is needed. For both inpatient and outpatient care, quality improvement efforts may be most productively focused on providers and processes of care at sites rather than on specific patient subgroups.

Adult↗

PubMed2002

Evolving dissatisfaction among primary care physicians.

OBJECTIVE: To examine trends in career satisfaction among physicians working with managed care plans. STUDY DESIGN: Cross-sectional surveys conducted in 1996 and 1999. PARTICIPANTS AND METHODS: We surveyed primary care physicians (PCPs) affiliated with 5 large health plans in Massachusetts and assessed physicians' ratings of overall satisfaction with their current practice situation and with managed care. RESULTS: A total of 1336 PCPs (56%) responded to the 1996 survey and 966 (42%) responded to the 1999 survey. In 1996, 19.8% of physicians were somewhat or very dissatisfied with their current practice situation vs 33.4% in 1999, an increase of more than 50% (P < .001). Overall dissatisfaction with managed care increased from 28.3% to 62.2% (P < .001). In multivariable models, external influences on physicians' practices were important predictors of overall dissatisfaction. Physicians whose choice of hospitals was restricted (odds ratio, 2.23; 95% confidence interval, 1.30-3.78) and those who reported that managed care plans influenced their practice "a lot" (odds ratio, 1.85; 95% confidence interval, 1.10-3.11) were more likely to be dissatisfied. Adequacy of reimbursement was an important predictor of overall satisfaction and satisfaction with managed care, and ways physicians experienced financial incentives were associated with managed care dissatisfaction. CONCLUSIONS: Primary care physicians in Massachusetts are increasingly dissatisfied with their practice and with managed care. Continued erosion of physician satisfaction could have significant implications for quality of care and the quality of the workforce attracted to medicine as a career.

Attitude of Health Personnel↗