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Biomedical subjects

R H Brook

Publications and source records attributed to R H Brook.

At least 199 records · Page 11Linked to original sources
PubMed1986

Variations in the use of medical and surgical services by the Medicare population.

We measured geographic differences in the use of medical and surgical services during 1981 by Medicare beneficiaries (age greater than or equal to 65) in 13 large areas of the United States. The average number of Medicare beneficiaries per site was 340,000. We found large and significant differences in the use of services provided by all medical and surgical specialties. Of 123 procedures studied, 67 showed at least threefold differences between sites with the highest and lowest rates of use. Use rates were not consistently high in one site, but rates for procedures used to diagnose and treat a specific disease varied together, as did alternative treatments for the same condition. These results cannot be explained by the actions of a small number of physicians. We do not know whether physicians in high-use areas performed too many procedures, whether physicians in low-use areas performed too few, or whether neither or both of these explanations are accurate. However, we do know that the differences are too large to ignore and that unless they are understood at a clinical level, uninformed policy decisions that have adverse effects on the health of the elderly may be made.

Aged↗
PubMed1986

Chronic bronchitis: prevalence, smoking habits, impact, and antismoking advice.

Although the prevalence of chronic bronchitis has been measured in several populations, its impact on quality of life has not been assessed. We report the prevalence and impact of chronic bronchitis (defined as having phlegm on most days for at least 3 months during the previous year) among 4,708 adults ages 20 to 69 representative of the nonaged U.S. population. Men reported chronic bronchitis more frequently than women (12 vs 8%); smokers, regardless of age and sex, reported chronic bronchitis more frequently than former or never smokers. Among both men and women 35 years of age or older, current smokers--as opposed to ex- or never smokers--with chronic bronchitis had the poorest forced expiratory volume in 1 sec (FEV1). The most commonly reported impact of chronic bronchitis was worry, followed by pain and restricted activity days, regardless of age, sex, or smoking habits. Of those current and ex-smokers who had seen a physician about their chronic bronchitis, 65% of men and 44% of women had decreased or stopped smoking. Among those current and ex-smokers with chronic bronchitis who did not consult a physician, the proportion of those who had decreased or stopped smoking was 29% for men and 37% for women. Finally, only 43% of male current smokers and 55% of female current smokers who had chronic bronchitis reported that a physician had advised them to decrease or stop smoking.

Adult↗
PubMed1986

Setting standards of performance for program evaluations: the case of the teaching hospital general medicine group practice program.

Program evaluation is like research in its use of the scientific method. An important difference is that evaluations result in judgments of merit. What are the standards for making the judgments? Little attention has been paid to their selection and use. This article reports on how standards were set in an evaluation of the structure of fifteen of the nation's university hospitals who participated in the Teaching Hospital General Medicine Group Practice Program (sponsored by the Robert Wood Johnson Foundation). Many sources were used to select standards including a review of the literature, expert advice and actual data from two years of the programs's performance. Also, the standard-setting process was a participatory one in which all potentially competing views were provided with a forum for discussion. Finally, standards were set in advance of the collection of information, facilitating the selection of study designs and analysis techniques. Almost all project directors stated that the process helped them in program planning and gave them ideas for research and evaluation. Because standard-setting has mutual benefits, we recommend that it take place during program planning.

Evaluation Studies as Topic↗
PubMed1986

Evaluation of ambulatory care training by graduates of internal medicine residencies.

In 1984, 154 physicians who had completed residencies in internal medicine at 15 major teaching hospitals in 1982 evaluated their residency training in ambulatory care. A majority of the physicians would have liked more experience in practical areas related to career planning and office management, more input from subspecialties such as orthopedics and dermatology, greater knowledge about the management of psychosocial problems, and more information about exercise and nutrition. Although many physicians also wanted more time devoted to several other topics, less than 20 percent recommended spending less time on 26 of the 27 topics being evaluated. Since these recommendations are similar to those reported in evaluation studies published over the past 25 years, it appears that training programs in internal medicine have not been successful in restructuring their curricula to meet many of the needs of practicing physicians.

Ambulatory Care↗
PubMed1986

Physician ratings of appropriate indications for six medical and surgical procedures.

We convened three panels of physicians to rate the appropriateness of a large number of indications for performing a total of six medical and surgical procedures. The panels followed a modified Delphi process. Panelists separately assigned initial ratings, then met in Santa Monica, California where they received reports showing their initial ratings and the distribution of the other panelists ratings. They discussed the indications and revised the indications lists, then individually assigned final ratings. There was generally better agreement on the final ratings than on the initial ratings. Based on reasonable criteria for agreement and disagreement, and excluding one outlying procedure, the panelists agreed on ratings for 42 to 56 per cent of the indications, and disagreed on 11 to 29 per cent.

Angiography↗
PubMed1986

The practices of general and subspecialty internists in counseling about smoking and exercise.

We compared the practices of subspecialists and general internists in counseling about smoking and exercise, using data from a study of recent graduates of United States training programs in internal medicine. Information on the characteristics of physicians and their clinical practices was obtained from self-report questionnaires. The internists most likely to counsel smokers regardless of the presence or absence of diseases associated with smoking are cardiologists, pulmonary specialists, nephrologists, and generalists trained in a primary care residency funded by the Robert Wood Johnson Foundation or Health Resources Administration. Most internists practice tertiary prevention by counseling a high percentage of smokers with heart or lung disease. Rheumatologists counsel a higher percentage of all patients with poor exercise habits but a lower percentage of such patients with heart disease than do other internists. The differences in counseling related to training are not explained by different levels of involvement as a primary care physician. Rather, these differences appear to reflect training and subspecialty-specific priorities for counseling.

Adult↗
PubMed1986

Medicare capitation and quality of care for the frail elderly.

Previous studies have shown that the quality of care provided in health maintenance organizations (HMO's) is either similar or better than that in fee-for-service settings; however, few studies have included sufficiently large numbers of older persons. Although it is reasonable to believe that healthy older patients will do as well in HMO's as younger people, the outcome for the frail elderly is less certain. This population may not do as well in the conservative medical practice environment of HMO's, and decreased hospitalization may have detrimental effects on their health. On the other hand, this population may benefit from the improved continuity of care and potential for comprehensive assessment in HMO's. The quality of care received by the frail elderly will be an important test of the success of Medicare capitation.

Aged↗
PubMed1986

Changing physician payment for Medicare patients. Projected effects on the quality of care.

Congress and the Reagan Administration, in an effort to "contain" costs, are considering changes in the way physicians are paid when they care for Medicare patients. By examining the effects on quality of care of several alternative ways physicians might be paid, including modified fee for service, physician diagnosis-related groups and capitation through health maintenance organizations, we can predict the kinds of effects on quality of care most likely to occur and the kinds of patients most likely to be affected. Under each of the payment alternatives, poorer and sicker patients are at greatest risk for reduced access to care and quality of care. These findings underline the need for rigorous experiments to assess the effects of changes in physician payment on quality of care and the need for monitoring and assurance of quality in a new payment system.

Humans↗
PubMed1986

Consumer acceptance of prepaid and fee-for-service medical care: results from a randomized controlled trial.

Do consumers find the care provided by health maintenance organizations (HMOs) and that provided in the fee-for-service (FFS) system equally acceptable? To address this question, we randomly assigned 1,537 people ages 17 to 61 either to FFS insurance plans that allowed choice of physicians or to a well-established HMO. We also studied 486 people who had already selected the HMO (control group). Those who had chosen the HMO were as satisfied overall with medical care providers and services as their FFS counterparts. The typical person assigned to the HMO, however, was significantly less satisfied overall relative to FFS participants. Attitudes toward specific features of care favored both FFS and HMO, depending on the feature rated. Four differences (length of appointment waits, parking arrangements, availability of hospitals, and continuity of care) favored FFS; two (length of office waits, costs of care) favored the HMO. HMO versus FFS differences in ratings of access to care and availability of resources mirror differences in the organizational features of these two systems that are generally considered responsible for the significantly lower medical expenditures at HMOs. Regardless of their origin, less favorable attitudes toward interpersonal and technical quality of care in the HMO have marked consequences: dissatisfaction and disenrollment.

Adolescent↗
PubMed1986

Chronic disease in a general adult population. Findings from the Rand Health Insurance Experiment.

Using questionnaire and physical screening examination data for a general population of 4,962 adults aged 18 to 61 years enrolled in the Rand Health Insurance Experiment, we calculated the prevalence of 13 chronic illnesses and assessed disease impact. Low-income men had a significantly higher prevalence of anemia, chronic airway disease and hearing impairment than their high-income counterparts, low-income women a higher prevalence of congestive heart failure, diabetes mellitus, hypertension, hearing impairment and vision impairment. Of our sample, 30% had one chronic condition and 16% had two or more. Several significant pairs or "clusters" of chronic illnesses were found. With few exceptions (diabetes, hypertension), the use of physician care in the previous year for a specific condition tended to be low. Disease impact (worry, activity restriction) was widespread but mild. Persons with angina, congestive heart failure, mild chronic joint disorders and peptic ulcer disease reported a greater impact than persons with other illnesses.

Adolescent↗
PubMed1986

Quality of care for psychotropic drug use in internal medicine group practices.

To evaluate the care given by internists in group practices at 16 academic medical centers to patients who used minor tranquilizers or antidepressants, data were abstracted from medical records and compared with specific criteria for quality care.Of 1,532 continuing care patients, 18% used minor tranquilizers and 7% used antidepressants. Almost 90% of antidepressants were prescribed for depression and 50% of minor tranquilizers were prescribed for mental health problems. The group practice internists performed well on concrete aspects of care, such as avoiding giving minor tranquilizers intravenously or intramuscularly and scheduling follow-up visits. Relatively few patients, however, had an adequate treatment plan noted in the chart. About 25% of users of minor tranquilizers did not have an acceptable indication for the drug noted in the chart. Less than 10% of users of minor tranquilizers had a plan for discontinuing the drug use; yet, 35% had long-term regular use.

Group Practice↗
PubMed1986

Childhood enuresis: prevalence, perceived impact, and prescribed treatments.

Childhood enuresis can indicate an underlying problem as benign as developmental immaturity or as serious as urinary tract obstruction. As part of a large population-based study, parents of 1,753 children aged 5 to 13 years were asked about the presence and frequency of enuresis, perceived impact, and physician-prescribed treatments. Enuresis at least once during a 3-month period was reported for 14% of this general population of children. Boys were significantly more likely to experience enuresis than girls (16% v 12%; P less than .01). The prevalence of enuresis at least once a week was similar among boys and girls (7% v 6%). Parents reported that more than half of the children are distressed by their enuresis, and two thirds of parents expressed concern. Thirty-eight percent of bed wetters have seen a physician about their condition. More than one third of these children have been treated with a drug. The most commonly recommended regimen in the literature, the bed alarm, was prescribed to only 3% of bed-wetting children who saw a physician.

Adolescent↗
PubMed1985

How free care reduced hypertension in the health insurance experiment.

In a controlled trial of the effects of medical insurance on spending and health status, we previously reported lower average (0.8 mm Hg) diastolic blood pressures with free care than with cost-sharing plans. We show herein that for clinically defined hypertensives, blood pressures with free care were significantly lower (1.9 mm Hg) than with cost-sharing plans, with a larger difference for low-income hypertensives than for high-income hypertensives (3.5 vs 1.1 mm Hg), but similar differences for blacks and whites. The cause of the difference was the additional contact with physicians under free care; this led to better detection and treatment of hypertensives not under care at the start of the study. Free care also led to higher compliance by hypertensives with diet and smoking recommendations and higher use of medication by those who needed it.

Adolescent↗
PubMed1985

The impact of cost sharing on emergency department use.

We studied the effect of insurance coverage on the use of emergency department services, using data from a national trial of cost sharing in health insurance. A total of 3973 persons below the age of 62 years were randomly assigned to fee-for-service health insurance plans with coinsurance rates of 0, 25, 50, or 95 per cent, subject to an income-related upper limit on out-of-pocket expenses. Persons with no cost sharing had emergency department expenses that were 42 per cent higher than those for persons on the 95 per cent plan (P less than 0.01) and about 16 per cent higher than those for persons with smaller amounts of cost sharing. Without cost sharing, emergency department visits for less serious diagnoses (e.g., abrasions) increased three times as much as did visits for more serious diagnoses (e.g., lacerations). After control for insurance, persons in the lower third of the income distribution had emergency department expenses that were 64 per cent higher than those in the upper third (P less than 0.001) and received a greater proportion of their ambulatory care in the emergency department. We conclude that the absence of cost sharing results in significantly greater emergency department use than does insurance with cost sharing. A disproportionate amount of the increased use involves less serious conditions.

Ambulatory Care↗
PubMed1985

Physician and patient satisfaction as factors related to the organization of internal medicine group practices.

The present study compares patient satisfaction scores with job satisfaction scores of the physicians providing their care in 16 general internal medicine teaching hospital group practices. Practice sites with more satisfied patients were also more likely to have more satisfied housestaff and faculty physicians. Additionally, higher satisfaction scores for both physician groups and patients were consistently associated with a greater percentage of patients experiencing continuity of care, lower patient no-show rates, more efficient use of ancillary staff in providing direct patient care, and more reasonable charges for a routine follow-up visit. These findings suggest that improving physician and patient satisfaction may have economic as well as psychological and social benefits.

Consumer Behavior↗