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PubMed1981

San Francisco General Hospital nurse-midwifery practice: the first thousand births.

Since its inception in 1975, the staff of the Nurse-Midwifery Service at San Francisco General Hospital has attended the deliveries of over 1,000 women. A description of the service and the outcome statistics are presented. The population of women served is a mixed risk group. It includes all women designated as nurse-midwifery patients, including those at risk who were transferred to tertiary care. Outcome statistics are comparable to those of the obstetrics department in general. Use of alternative labor and delivery practices contributes to good perinatal outcome.

Adolescent↗
PubMed2000

The cost of work-related physical assaults in Minnesota.

OBJECTIVE: To describe the long-term productivity costs of occupational assaults. DATA SOURCES/STUDY SETTING: All incidents of physical assaults that resulted in indemnity payments, identified from the Minnesota Department of Labor and Industry (DLI) Workers' Compensation system in 1992. Medical expenditures were obtained from insurers, and data on lost wages, legal fees, and permanency ratings were collected from DLI records. Insurance administrative expenses were estimated. Lost fringe benefits and household production losses were imputed. STUDY DESIGN: The human capital approach was used to describe the long-term costs of occupational assaults. Economic software was used to apply a modified version of Rice, MacKenzie, and Associates' (1989) model for estimating the present value of past losses from 1992 through 1995 for all cases, and the future losses for cases open in 1996. PRINCIPAL FINDINGS: The total costs for 344 nonfatal work-related assaults were estimated at $5,885,448 (1996 dollars). Calculation of injury incidence and average costs per case and per employee identified populations with an elevated risk of assault. An analysis by industry revealed an elevated risk for workers employed in justice and safety (incidence: 198/100,000; $19,251 per case; $38 per employee), social service (incidence: 127/100,000; $24,210 per case; $31 per employee), and health care (incidence: 76/100,000; $13,197 per case; $10 per employee). CONCLUSIONS: Identified subgroups warrant attention for risk factor identification and prevention efforts. Cost estimates can serve as the basis for business calculations on the potential value of risk management interventions.

Adult↗
PubMed2001

Lay therapy intervention with families at risk for parenting difficulties: The Kempe Community Caring Program.

OBJECTIVE: To determine which areas of family functioning lay therapy intervention can improve in a home visitation program for first time mothers at high risk for parenting difficulties, including the potential for child abuse and neglect. METHODS: Families were assessed for risk of parenting difficulties using the Parent Readiness and Risk Assessment Checklists. Lay therapists completed the Scale of Family Functioning pre- and postintervention with 108 high risk families for whom they provided support, education, and referrals. RESULTS: Paired t tests were done to determine whether the eight categories of the Scale of Family Functioning improved from baseline to termination of the service. Four categories showed statistically significant improvement: social support (p = .001), self-esteem (p < .001), confidence as a parent (p < .001), and affective relationships (p = .003). CONCLUSIONS: Statistically significant improvement occurred in four of the eight categories on the Scale of Family Functioning indicating that home intervention programs can improve some categories of family functioning. Longer intervention and an increased focus on improving parent/infant interactions may be able to increase parental sensitivity and expectations. In this study, the categories of family conflict and stability/meeting basic needs were not amenable to change with lay therapy intervention.

Adult↗
PubMed2000

An evaluation of the implementation of a liaison service in an A&E department.

This paper describes the results of an evaluation of a multidisciplinary liaison service based in an A&E department of a district general hospital in South Wales. The aims of the services were to increase the rate of referral for psychosocial assessment of individuals who presented at the department following acts of deliberate self-harm and to increase the number of such assessments completed within 24 h. The paper describes the context in which such a service was developed and outlines how this preliminary evaluation was completed. Data were collected from hospital records, over two corresponding five-month time-periods, in the year before the implementation of the service and the year following implementation of the service. The results show that the implementation of the service led to a statistically significant increase in the rate of referral for assessment by accident and emergency staff. Amongst other positive outcomes, the rate of repeat presentations was reduced for the period of one year following initial presentation. The implications of these results are discussed in relation to other research in the area and the suggestion is made that nursing staff may be more clinically and cost effective in completing psychosocial assessments in A&E departments than medical staff.

Adolescent↗
PubMed1975

Consumer perceptions of health care services: implications for academic medicine.

The factor analytic development of various measures of consumer perceptions regarding characteristics of doctors and health care services is described. Index scores meeting factor analytic and reliability criteria were used to study the importance of consumer perceptions in relation to behavioral outcomes. Numerous dimensions of consumer perceptions were identified and described, including beliefs about doctor conduct in terms of quality of care and humaneness of health care delivery as well as satisfaction with such enabling components as the continuity of care, availability and convenience of services, and various access mechanisms (cost, payment mechanisms, and ease of emergency care facilities). Measures of these perceptions were shown to be related to differences in several estimates of health services utilization. The use of the index scores which have met empirical criteria is in contrast to the common practice of using individual questionnaire items as the unit of analysis in health care research. Findings are discussed in relation to program planning and evaluation in medical education, and suggestions for future research are noted.

Attitude to Health↗
PubMed1998

Predictors of psychiatric hospitalization: a multivariate analysis.

Inpatient treatment continues to be the most expensive form of mental health service. This study sought to improve the methodological weaknesses, e.g., poor statistical controls, in the literature by using multivariate statistics to predict hospitalization. Results revealed that aftercare, i.e., outpatient treatment, is an important factor in reducing the utilization of inpatient resources, even when controlling for demographic and psychiatric history variables. Further, background characteristics, while easily measured, are not important predictors of hospitalization.

Adult↗
PubMed2003

Differences in use of health services between White and African American children enrolled in Medicaid in North Carolina.

OBJECTIVES: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. METHODS: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for North Carolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect of race, controlling for other variables such as low birth weight, WIC participation, and mother's age, education, and marital status. Since all children enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled. RESULTS: African American children had consistently lower Medicaid expenditures and lower use of health services than did White children, after statistically controlling for other maternal and infant characteristics that affect health service use, including child WIC participation. For example, total annual Medicaid expenditures were 207-303 dollars less for African American children than for White children, controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. CONCLUSIONS: African American children enrolled in Medicaid use health services much less than White children, even when controlling for socioeconomic status and other factors that affect service use. Linking state administrative databases can be a cost-effective way of addressing important issues such as racial disparities in health service use.

Black or African American↗
PubMed2001

Defining the "urban" in urbanization and health: a factor analysis approach.

Urban environments have been linked to a range of human health issues, and as the pace of urbanization accelerates, new challenges arise to characterize these environments, and to understand their positive and negative implications for health. We seek to contribute to future studies of urbanization and health by exploring multiple definitions of urbanicity in the Philippines, using data from an ongoing, longitudinal study. We use factor analysis to identify meaningful clusters of household- and community-level variables, and to generate factor scores that summarize each household's position with respect to access to infrastructure and health services, and level of affluence. Factor scores are considered for 1983 and 1994 to assess the type and pace of change that has occurred in the Philippines, and scores are compared across urban and rural areas, and across six different settlement types, to explore household- and community-level markers of urbanicity. This analysis demonstrates the heterogeneity of environments within urban and rural areas, and emphasizes the need for a finer level of investigation in future studies of urbanization and health.

Cluster Analysis↗
PubMed1999

The effects of managed care on physician and clinical integration in hospitals.

OBJECTIVE: To empirically estimate the effects that managed care has had on physician and clinical integration in urban hospitals. DATA SOURCES: The 1993 Hospital-Physician Relationship Survey conducted for the Prospective Payment Assessment Commission, augmented with data from a variety of secondary sources. The entire 1,495 responding hospitals were used to construct measures of integration; 591 responding hospitals in urban areas were used for the managed care analysis. STUDY DESIGN: Factor analysis was used to reduce 23 integration variables into 5 physician and 3 clinical integration factors. Two-stage least-squares regression techniques were used to estimate the effects of endogenous managed care. Models were estimated for all urban hospitals and for hospital subsets based upon ownership, multi-hospital system status, and teaching. PRINCIPAL FINDINGS: Other things equal, physician involvement in hospital management and governance increased with managed care involvement; to a lesser degree, the use of physician organization arrangements and other joint ventures also increased. Practice management and support services were lower in hospitals with high managed care activity. Larger hospitals, investor owned, system, and non-teaching hospitals had larger managed care revenues. Managed care revenues were lower in more concentrated hospital markets. CONCLUSIONS: The relationship between managed care and physician and clinical integration is relatively modest. Much of the realignment under managed care has been limited to certain types of efforts. Those efforts can best be described as foundation-building rather than comprehensive or fundamental.

Data Collection↗
PubMed1995

The community social and health care system in Finland.

The greatest challenge to the national social and health policy in Finland since 1992 has been the task of finding a correct cost/quality ratio of required services. The local authorities have the responsibility to arrange the services to the citizens and may purchase the service from a municipal or a private sector provider. The State supervises the field and contributes to the finding, but the local authorities are responsible for organizing the health services. The central bodies are the Ministry of Social Affairs and Health, and the National Research and Development Centre for Welfare and Health which operates under supervision of the Ministry. Introduction into practice of the population responsibility principle has been started. A patient applies first to his local health centre or private practitioner for examination and treatment. If he cannot be treated there, he is referred to the outpatient department of a hospital. The aim is to ensure continuity in staff-patient contacts. Health care and social care is a natural right of every citizen. The national plan for social and health services is based on statistical data. The entire population is covered by sickness insurance, which includes compensation for lost earnings and treatment costs. Sickness insurance is run by the Social Insurance Institution, directly subordinate to the Parliament and also administering the flat-rate pensions. The Institution has its own network of district and local offices. The Act on the Status and the Rights of a Patient is a comprehensive Act covering the fields of admission, treatments, patient's autonomy, access to information, report on patients, and confidentiality.(ABSTRACT TRUNCATED AT 250 WORDS)

Delivery of Health Care↗
PubMed1995

Estimating the hospital-wide cost differentials warranted for teaching hospitals. An alternative to regression approaches.

Under Medicare's Prospective Payment System, teaching hospitals receive additional reimbursements, vis-à-vis nonteaching hospitals, for both "direct" teaching expenses and for "indirect" expenses. They totaled $3.1 billion in fiscal year 1989. The authors propose and illustrate a non-regression-based, nonparametric method for viewing the total hospital-wide reimbursement differential warranted for teaching hospitals, a method utilizing a peer grouping of like hospitals to estimate two different "best practices" cost frontiers. The hospital's efficiently delivered cost to meet all of the hospital's actual service outputs, including its teaching mission, and delivered level of quality of care, is compared to the corresponding cost when only the teaching mission is excluded. The difference in these costs for a particular hospital can be used to estimate a suggested lump sum Medicare reimbursement add-on, in recognition of the hospital's teaching mission. The approach is illustrated using a subset of the Health Care Financing Administration's 1988 hospital data set, with comparisons of actual and suggested reimbursements provided.

Cost Allocation↗
PubMed1988

On taking chances with the law of large numbers.

An increasing number of major purchasers of health services now consider capitation to be the preferred method of payment for individual physicians and small group practices. This paper is a primer on capitation payment plans for small risk pools. It describes some of the basic economic issues that purchasers and providers face when negotiating small-panel capitation contracts, including sources of risk, techniques of risk reduction and risk sharing. An empirical section analyses the experience of a plan that took a chance with the law (law of large numbers) and lost.

Capitation Fee↗
PubMed2005

A strategic assessment of cervical cancer prevention and treatment services in 3 districts of Uttar Pradesh, India.

BACKGROUND: Despite being a preventable disease, cervical cancer claims the lives of almost half a million women worldwide each year. India bears one-fifth of the global burden of the disease, with approximately 130,000 new cases a year. In an effort to assess the need and potential for improving the quality of cervical cancer prevention and treatment services in Uttar Pradesh, a strategic assessment was conducted in three of the state's districts: Agra, Lucknow, and Saharanpur. METHODS: Using an adaptation of stage one of the World Health Organization's Strategic Approach to Improving Reproductive Health Policies and Programmes, an assessment of the quality of cervical cancer services was carried out by a multidisciplinary team of stakeholders. The assessment included a review of the available literature, observations of services, collection of hospital statistics and the conduct of qualitative research (in-depth interviews and focus group discussions) to assess the perspectives of women, providers, policy makers and community members. RESULTS: There were gaps in provider knowledge and practices, potentially attributable to limited provider training and professional development opportunities. In the absence of a state policy on cervical cancer, screening of asymptomatic women was practically absent, except in the military sector. Cytology-based cancer screening tests (i.e. pap smears) were often used to help diagnose women with symptoms of reproductive tract infections but not routinely screen asymptomatic women. Access to appropriate treatment of precancerous lesions was limited and often inappropriately managed by hysterectomy in many urban centers. Cancer treatment facilities were well equipped but mostly inaccessible for women in need. Finally, policy makers, community members and clients were mostly unaware about cervical cancer and its preventable nature, although with information, expressed a strong interest in having services available to women in their communities. CONCLUSION: To address gaps in services and unmet needs, state policies and integrated interventions have the potential to improve the quality of services for prevention of cervical cancer in Uttar Pradesh.

Journal Article↗
PubMed1980

[Early detection and determination of the incidence of side effects in the hospital by intensive (comprehensive) drug monitoring].

In the "Comprehensive Hospital Drug Monitoring Berne" (CHDMB) the frequency of adverse drug reactions can be either determined by counting individual patients with probable or proven reactions to a drug or by mathematic-statistical analysis of exposed and nonexposed patients with and without the reaction. These two methods are used to show the frequency of a maculopapular rash in connection with three antiinfectious drugs. The mathematic-statistical frequency of a maculopapular rash was 11.0% for aminopenicillins, 3.7% for other penicillins, and 3.4% for co-trimoxazole and sulfonamides compared to 1.2% in patients treated with other than the especially mentioned drug groups. Two new adverse reactions were detected by this system: arterial hypotension due to novaminesulfon-dipyrone (Novalgin) and drug fever to the antidepressive drug nomifensin (Alival). Also the frequency of some other, not unusual adverse reactions is demonstrated.

Anti-Infective Agents↗
PubMed1999

Multi-method assessment of access to primary medical care in rural Colorado.

The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Colorado↗
PubMed2004

Antibiotic sales and the prevalence of symptoms of asthma, rhinitis, and eczema: The International Study of Asthma and Allergies in Childhood (ISAAC).

BACKGROUND: It has been hypothesized that antibiotic use early in life may increase the subsequent risk of asthma. We have conducted an ecologic analysis of the relationship between antibiotics sales and the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema in 99 centres from 28 countries. METHODS: Data for antibiotics sales for 28 countries were obtained from the Institute for Medical Statistics (IMS), Health Global Services, UK and converted to defined daily doses (DDD). Data on the prevalence of symptoms of asthma, rhinitis, and eczema in 13-14 year olds were based on the responses to the written and video questionnaires from the International Study of Asthma and Allergies in Childhood (ISAAC). The analysis was adjusted for gross national product (GNP) as an estimate of the level of affluence. RESULTS: In general, there was a positive association between per capita antibiotics sales and the prevalence of symptoms for asthma, rhinitis, and eczema, but the associations generally became negative once the analyses had been adjusted for GNP. In particular, there were non-significant negative associations between total antibiotics sales and the prevalence of wheeze ever, wheeze in the last 12 months, nose problems with itchy-watery eyes, itchy rash in the last 12 months, and eczema ever. On the other hand there were weak non-significant positive associations for asthma ever, nose problems ever, nose problems in the last 12 months, and itchy rash ever. There was a statistically significant positive association with wheeze at rest as measured by the asthma video questionnaire; however, even this association was weak and would not account for more than a 1% difference in asthma prevalence between countries. CONCLUSIONS: These findings are generally not consistent with the hypothesis that antibiotic use increases the risk of asthma, rhinitis, or eczema. If there is a causal association of antibiotic use with asthma risk, it does not appear to explain the international differences in asthma prevalence.

Adolescent↗
PubMed1998

[Patients with acute coronary syndrome: therapeutic approach (management patterns) and 1-year prognosis in a tertiary general hospital].

BACKGROUND: To assess the determinants of short-term and one-year prognosis of all patients with suspected acute coronary syndrome seen by the cardiologist on duty in the Emergency Service of a tertiary hospital during a six month period. PATIENTS AND METHODS: 153 consecutive patients with a diagnosis of acute myocardial infarction, 225 with a diagnosis of unstable angina and 89 with a diagnosis of atypical chest pain were identified and their in-hospital characteristics and one-year prognosis were prospectively assessed. RESULTS: Age was higher than 65 years in 53% of acute myocardial infarction and in 54% of unstable angina patients. Only 3 patients were lost to follow-up. 35% of acute myocardial infarction patients had died or had reinfarction after one year and 16% of unstable angina patients had died or had suffered acute myocardial infarction. Baseline features, management patterns and prognosis of patients admitted with acute myocardial infarction to the Cardiology Service, to other hospital areas or to other hospitals were markedly different, and admission in areas other than the Cardiology Service was an independent mortality predictor. In unstable angina, complications happened in patients older than 75 years, those with previous revascularization procedures, those undergoing revascularization or those with lesions not deemed revascularizeable. CONCLUSIONS: a) In the study population there was a predominance of elderly patients; the proportion of patients with poor prognosis was considerably high; b) a sizeable proportion of patients with severe complications was scarcely represented in the major clinical trials; c) the possibility arises of a distribution of care resources tending to concentrate the greater therapeutic efforts in the patients with good prognosis.

Acute Disease↗
PubMed1999

The case for combining qualitative and quantitative approaches in health services research.

A judicious combination of qualitative and quantitative methods can play a valuable role in health services research. This paper reviews the main reasons for combining methods: for different stages in a project; to compensate for the shortcomings of individual methods; and for the purpose of 'triangulation'. It examines the potential for qualitative approaches to contribute to quantitative work--by providing insights into the process of data construction, identifying relevant variables to be studied, furnishing explanations for unexpected or anomalous findings, and generating hypotheses or research questions for further investigation. Similarly, qualitative work can be enhanced by using quantitative techniques--albeit often in a modified form--in analysing data, developing sampling strategies, and amalgamating findings from separate qualitative studies. Although there is potential to develop multi-method approaches, there remains an important role for rigorous studies employing either qualitative or quantitative methods.

Data Interpretation, Statistical↗