Access, health, and the general internist.
Explore the source record for details and available documents.
Health Services Accessibility↗
Biomedical subjects
R H Brook
Publications and source records attributed to R H Brook.
Work satisfaction and career aspirations of internists working in teaching hospital group practices.
This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training.
Aspirations, Psychological↗
The Functional Status Questionnaire: reliability and validity when used in primary care.
A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients' functional status. In this study, the FSQ was administered to 497 regular users of Boston's Beth Israel Hospital's Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.
Activities of Daily Living↗
Selected reflections on quality of medical care evaluation in the 1980s.
Quality assessment of medical care in the 1980s will face several challenges. Most important is the current move toward cost containment. Issues such as making cost-benefit tradeoffs and defining the focus of medical care will be difficult to resolve. With the help of patients and nonhealth professionals, decisions and tradeoffs can be made and a viable equilibrium between cost containment and quality of health care may be achieved.
Cost-Benefit Analysis↗
Quality of life of epilepsy surgery patients as compared with outpatients with hypertension, diabetes, heart disease, and/or depressive symptoms.
Health-related quality of life (HRQOL) of 166 adults who had previously undergone surgical treatment for intractable epilepsy was compared with that of outpatients with hypertension, diabetes, heart disease, and/or depressive symptoms. Eight self-reported HRQOL domains were evaluated and compared by the RAND 36-Item Health Survey 1.0: emotional well-being, social function, role limitations due to emotional problems, energy/fatigue, pain, role limitations due to physical problems, physical function, and general health perceptions. A pictorial item on overall QOL was also administered, for a total of 9 HRQOL domains. With adjustment made for age, gender, education, and comorbid conditions, 55 completely seizure-free patients scored higher (i.e., better health) than patients with hypertension in 6 of 9 domains, higher than diabetic patients in 8 of 9, higher than those with heart disease in all 9, and higher than those with depressive symptoms in all 9 (all p < 0.05). Sixty-seven patients still having seizures with impaired consciousness scored worse than hypertensive patients in 5 domains, worse than diabetic patients in 3, and worse than heart disease patients in 2; for all 3 conditions, these domains included emotional well-being and overall QOL (p < 0.05). These 67 patients, however, scored better than patients with depressive symptoms in all 9 domains, better than those with heart disease in 2, and better than those with diabetes in 1 (all p < 0.05). Forty-four other patients had only simple partial seizures (SPS); their scores were comparable to those of diabetic and heart disease patients on mental and social health scales but were higher ("better") than those of these patients on physical health scales. HRQOL among patients who have undergone "curative" epilepsy surgery is better than that of patients who have hypertension, diabetes, heart disease, or depressive symptoms. Patients who have continued seizures with altered consciousness are worse off in terms of emotional well-being and overall QOL than all other patients, except for those with depressive symptoms.
Ambulatory Care↗
Keeping quality on the policy agenda.
Quality of care in the United States and elsewhere consistently fails to meet established standards. These failures subject patients to premature death and needless suffering. Yet, unlike the experience with other threats to life (tire failures or airplane rudders), public and private policymakers have been unable to maintain sufficient interest in identifying and solving problems with quality to change the way in which care is delivered. We discuss why it is hard to keep quality on the policy agenda and suggest short-term steps that are necessary if quality is to improve here and in the rest of the world.
Delivery of Health Care↗
Quality measurement and assurance.
Explore the source record for details and available documents.
Ambulatory Care↗
Regional differences in appropriateness of cholecystectomy in a prepaid health insurance system.
BACKGROUND: Previous studies have reported variation in the population-based use rate of diagnostic and therapeutic procedures. Cholecystectomy is one of the most common surgical procedures, and we conducted this study to assess whether in Israel the use of this procedure varied by region and whether differences in use can be related to differences in appropriateness of use. In Israel, there is a pre-paid health insurance system and all surgeons are salaried. METHODS: Age-adjusted rates of cholecystectomy in four hospitals, each serving a defined population in Israel, were calculated. Two hundred and sixty-six potential clinical indications for performing cholecystectomy were rated as to their appropriateness by a panel of 9 expert physicians. A trained team abstracted the medical records of all patients who underwent the operation in the four Israeli hospitals in 1986 (n = 702) and recorded the clinical indication for the surgery. RESULTS: The population-based age-adjusted rates of cholecystectomy varied over threefold among the four hospitals. 29% of the cholecystectomies were performed for less than appropriate reasons, and this figure varied by hospital from 36% to 17% (p = 0.002). However, appropriateness did not vary systematically with the population-based use rate. CONCLUSION: Cholecystectomy was performed frequently for inappropriate or equivocal reasons, even in a country in which resources are limited, and physicians are salaried. Efforts to improve surgical decision making should be undertaken.
Adult↗
The appropriateness of performing coronary artery bypass surgery.
Information about how appropriately procedures are performed is vital to the understanding of the impact of technology and to the success of efforts to channel its use appropriately. While the efficacy of coronary artery bypass surgery has been addressed in several large-scale, randomized trials, there is little information about how appropriately the procedure is actually being used in the community. We determined the appropriateness of coronary artery bypass surgeries performed in three randomly chosen hospitals in a western state. We determined appropriateness by comparing data obtained from a detailed medical record review with a list of 488 indications. This list, developed by a national panel of physicians, covered all possible reasons for performing the procedure. Three hundred eighty-six cases from the years 1979, 1980, and 1982 were examined. Fifty-six percent of the surgeries were performed for appropriate reasons, 30% for equivocal reasons, and 14% for inappropriate reasons. The percentage of appropriate surgeries varied by hospital, from 37% to 78%, but did not vary by patient age. Eliminating the performance of inappropriate procedures may lead to reductions in health care expenditures or to improved patient outcomes.
Age Factors↗
Interpreting hospital mortality data. How can we proceed?
Explore the source record for details and available documents.
Data Collection↗
Research opportunities in primary care.
Explore the source record for details and available documents.
Primary Health Care↗
Validity of criteria used for detecting underuse of coronary revascularization.
OBJECTIVE: To assess criteria used for detecting underuse of coronary artery revascularization procedures in terms of patient outcomes. DESIGN: Retrospective cohort study using medical records supplemented by a telephone survey and review of county death records. SETTING: Four public hospitals and two academically affiliated private hospitals in Los Angeles County, California. PARTICIPANTS: A total of 671 patients who had coronary angiography between June 1, 1990 and September 30, 1991, and who met explicit clinical criteria for the necessity of coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA). MAIN OUTCOME MEASURES: For all patients (n = 671), we estimated the association between receipt of necessary revascularization and mortality (median follow-up after angiography, 797 days) after adjusting for potential confounders. For the patients completing the telephone interview (n = 374), we examined the relationship between receipt of necessary revascularization and frequency of chest pain. RESULTS: Patients who received necessary revascularization within 1 year of angiography had lower mortality than those who did not (8.7% vs 15.8%, P = .01), and this association persisted after adjustment for extent of coronary artery disease, clinical symptom complex, ejection fraction, and cardiac surgical risk index (adjusted odds ratio = 0.49; 95% confidence interval, 0.28 to 0.86). The same general results were obtained whether revascularization was received within 1 year or within 30 days of the catheterization, whether panelists' ratings or individual clinical variables were entered as covariates, and whether the statistical procedure used was logistic regression or Cox proportional hazards analysis. In addition, among patients responding to the telephone survey, those receiving necessary revascularization had less chest pain at follow-up (P = .03). CONCLUSIONS: Among patients meeting criteria for the necessity of revascularization, those receiving a revascularization procedure within 1 year had lower mortality than those treated medically. These results support the validity of the RAND/UCLA criteria for detecting underuse of these procedures, but more research is needed to confirm the findings and to determine the validity of guidelines for other procedures.
Aged↗
Coronary angiography and revascularization: defining procedural indications through formal group processes. The Canadian Revascularization Panel, the Canadian Coronary Angiography Panel.
OBJECTIVES: To summarize the process and extent of interphysician agreement within two panels convened to derive indications for the appropriate use of coronary angiography and for coronary revascularization procedures. PARTICIPANTS: Two panels, each with nine practitioners. METHODS: Panelists rated the appropriateness of intervention for a comprehensive set of indications for each procedure. Indications were brief profiles created by combining and permuting clinical characteristics pertinent to case selection for intervention. Ratings were first made at home, with a second round at the panel meeting following open discussion. Final rankings of indications as 'appropriate', 'uncertain' or 'inappropriate' were based on the pattern of panelists' responses on a nine-point scale, including the median rating and extent of agreement among panelists. Agreement was defined as at least seven panelists' ratings within the three-point region containing the median rating. Panelists were later mailed a much-reduced list of indications for which there was agreement on appropriateness. These were re-rated on a necessity scale. A procedure was rated 'necessary' only if a physician was ethically obligated to recommend it as the preferred treatment option. RESULTS: For appropriateness of angiography, agreement occurred in 38.2% of indications in round 1 and 64.4% in round 2 (P < 0.0001). For coronary artery bypass graft (CABG) versus medical therapy, the corresponding increase was from 43.5 to 54.0% (P < 0.0001). Agreement on necessity of angiography occurred for 44.3% of scenarios. For indications where CABG alone was appropriate, agreement on necessity was 56%. However, for indications where percutaneous transluminal coronary angioplasty (PTCA) could be regarded as the first-line intervention, agreement on necessity was only 5%. CONCLUSIONS: A two-step panel process permitted considerable convergence of panelists' ratings, highlighting the importance of formal panel methods in setting utilization management criteria. However, the extent of continuing disagreement on ratings underscores the need to avoid a forced consensus; instead, divergent opinions should be taken as indicative of uncertainty about the appropriateness of intervention. Interpanelist agreement on necessity ratings was modest, but may help in setting benchmarks to assess possible underprovision of invasive cardiac services in Canada.
Angioplasty, Balloon, Coronary↗
Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department.
OBJECTIVE: To determine the regular source of care and the relationship between usual provider and use of medical services among ambulatory emergency department patients. DESIGN: Cross-sectional survey. SETTING: A public hospital in Los Angeles County, California. PATIENTS: A total of 1190 stable, ambulatory adults presenting to the emergency department during a 2-week period. MAIN OUTCOME MEASURES: Self-reported regular source of care, usual health status, and recent physician visits. RESULTS: A total of 16% of the patients identified an emergency department as their regular source of care. One fourth of this group reported fair or poor health. African Americans and Latinos were more likely than whites to identify an emergency department as their regular source of care. Patients who identified an emergency department as their regular source of care had 25% fewer physician visits and were less likely to have seen a physician during the preceding 3 months than patients who were usually seen in an office or clinic (relative risk, 0.45; 95% confidence interval, 0.28 to 0.70). Of all patients, 56% identified a regular source of care other than an emergency department, but 24% to 36% of all their recent physician visits still occurred in an emergency department. CONCLUSION: Our patients rely heavily on emergency departments for ambulatory physician visits, regardless of their reported regular source of care. However, patients who identify an emergency department as their regular source of ambulatory care used physician services less frequently than patients with access to providers in other settings. These issues require further evaluation with population-based surveys.
Adult↗
Primary care physicians' satisfaction with quality of care in California capitated medical groups.
CONTEXT: Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. OBJECTIVE: To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. DESIGN: Cross-sectional questionnaire. SETTING: A total of 89 California physician groups with capitated contracts. PARTICIPANTS: A total of 910 primary care physicians (80% response rate). MAIN OUTCOME MEASURE: Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. RESULTS: Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). CONCLUSION: These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.
Attitude of Health Personnel↗