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Short Form 36 (SF-36) Health Survey questionnaire: which normative data should be used? Comparisons between the norms provided by the Omnibus Survey in Britain, the Health Survey for England and the Oxford Healthy Life Survey.

BACKGROUND: Population norms for the attributes included in measurement scales are required to provide a standard with which scores from other study populations can be compared. This study aimed to obtain population norms for the Short Form 36 (SF-36) Health Survey Questionnaire, derived from a random sample of the population in Britain who were interviewed at home, and to make comparisons with other commonly used norms. METHODS: The method was a face-to-face interview survey of a random sample of 2056 adults living at home in Britain (response rate 78 per cent). Comparisons of the SF-36 scores derived from this sample were made with the Health Survey for England and the Oxford Healthy Life Survey. RESULTS: Controlling for age and sex, many of mean scores on the SF-36 dimensions differed between the three datasets. The British interview sample had better total means for Physical Functioning, Social Functioning, Mental Health, Energy/Vitality, and General Health Perceptions. The Health (interview) Survey for England had the lowest (worst) total mean scores for Physical Functioning, Social Functioning, Role Limitations (physical), Bodily Pain, and Health Perceptions. The postal sample in central England had the lowest (worst) total mean scores for Role Limitations (emotional), Mental Health and Energy/Vitality. CONCLUSION: Responses obtained from interview methods may suffer more from social desirability bias (resulting in inflated SF-36 scores) than postal surveys. Differences in SF-36 means between surveys are also likely to reflect question order and contextual effects of the questionnaires. This indicates the importance of providing mode-specific population norms for the various methods of questionnaire administration.

Adolescent↗

Choosing a national survey to investigate smoking behaviour: making comparisons between the General Household Survey, the British Household Panel Survey and the Health Survey for England.

BACKGROUND: Smoking behaviour is of central concern to enhanced population health and there is a recognized need for detailed information concerning many different aspects of this behaviour. This paper assesses the utility of three large-scale national surveys according to their ability to provide such information. These are the General Household Survey (GHS), the British Household Panel Survey (BHPS) and the Health Survey for England (HSE). METHODS: A number of important data items are identified and a comparative content analysis of the surveys is undertaken to indicate whether these items are present or absent in each source. RESULTS: Although current smoking status and consumption are covered in all three data sets, the GHS and the HSE provide information on many other aspects of the behaviour. Information on the major contextual variables can be found in each of the surveys. All sources can be used within a repeated cross-sectional analytical framework, and limited population-based longitudinal analyses can be undertaken with the GHS and the HSE. The BHPS theoretically opens up potential for a true longitudinal analysis of the cohort dynamics of individual smoking behaviour. Issues of place are best explored using the HSE, where the geographical information is most detailed. CONCLUSIONS: The paper highlights the importance of all three data sets as statistical modelling resources for investigating patterns of smoking prevalence. Although the advantages of the panel approach are noted for cohort-based longitudinal studies, there still remain some problems in undertaking these analyses because of the small number of BHPS waves carried out to date.

Adolescent↗

The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The Medicines Evaluation Group Centre for Health Economics University of York.

BACKGROUND: The EUROHEART programme is a rolling programme of cardiovascular surveys among the member nations of the European Society of Cardiology (ESC). These surveys will provide information on the nature of cardiovascular disease and its management. This manuscript describes a survey into the nature and management of heart failure. AIMS: The EuroHeart Failure survey aims to describe the quality of hospital care, diagnostic and therapeutic, for patients with suspected or confirmed heart failure in ESC member countries. Patients will be interviewed subsequent to hospital discharge to assess their understanding of their condition, side effects from and their compliance with therapy and their satisfaction with the management for heart failure. The quality of management will be judged against the recommendations contained in the ESC guidelines on diagnosis and treatment of heart failure. Outcome will be further assessed by repeat interviews in 6-12 months time. A further survey of heart failure in 2001/2002 is also planned. METHODS: A prospective survey of all deaths and discharges from medical (cardiology, internal medicine and geriatric medicine) and cardiac surgical wards to identify patients with heart failure, suspected or confirmed. Approximately 70 hospital clusters, comprising two to six hospitals in each cluster, in 24 member countries of the ESC are conducting the study. At the time of writing, approximately 30000 deaths and discharges have been screened and approximately 4000 patients have been enrolled. CONCLUSIONS: The EuroHeart Survey will allow actual practice to be compared to ESC guidelines on the diagnosis and treatment of heart failure. The surveys and guidelines should prove mutually informative. The main EuroHeart Failure project will be completed by late 2000. However, new centres volunteering to participate in the study (contact corresponding author) may be accepted providing they have the necessary research personnel and provided funding can be agreed for statistical support and administration.

Angiotensin-Converting Enzyme Inhibitors↗

Canadian heart health surveys: a profile of cardiovascular risk. Survey methods and data analysis. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To describe the methods used in nine provincial surveys carried out as part of the Canadian Heart Health Initiative. DESIGN: Population-based cross-sectional surveys, following a core standardized protocol, implemented by provincial departments of health in collaboration with Health and Welfare Canada. Data were obtained through a home interview and a clinic visit. A standard manual of field operations and standardized training procedures were used in all provinces. SETTING: Nine Canadian provinces during the period 1986 to 1990. PARTICIPANTS: A probability sample of 26,293 men and women aged 18 to 74 years was selected from the health insurance registries in each province. Over 30% of the participants had post-secondary education. About 50% were 18 to 34 years old. OUTCOME MEASURES: Data on sociodemographic characteristics, hypertensive and diabetic status, knowledge and awareness of the causes and consequences of cardiovascular disease and two blood pressure measurements were obtained in a home interview. During a clinic visit, data were collected on height, weight (waist and hip circumferences in four provinces), two blood pressure measures and a blood sample. Total plasma cholesterol, triglycerides and high- and low-density lipoprotein cholesterol were measured in the Lipid Research Laboratory, University of Toronto and St. Michael's Hospital. MAIN RESULTS: Of the subjects invited to participate in the survey, 78% were interviewed, 69% attended the clinic and 64% provided a fasting specimen (8 hours or more). The response rates were slightly lower for men aged 18 to 34, for women aged 65 to 74 and for those with fewer years of education. Data from the provincial surveys (Ontario will complete the survey in 1992) are being compiled in the Canadian Heart Health Database. CONCLUSION: The process followed in the implementation of the provincial heart health surveys is a model of how provincial departments of health may carry out epidemiologic investigations in support of their mandate. The approach illustrates how a country-wide database can be built through partnerships among different levels of government. The use of community health nurses was instrumental in the efficient implementation of the surveys and in the realization of the relatively high rates of response attained.

Adult↗

The stability of survey-assigned assay values when surveyed control materials are used in a daily interlaboratory quality control program. The College of American Pathologists Chemistry Survey--Quality Assurance Service shared pool experience.

Two pools of lyophilized human control serum, distributed as challenges for the 1990 and 1991 College of American Pathologists Comprehensive Chemistry Surveys were employed consecutively as two-level, daily, quality control materials in College of American Pathologists Quality Assurance Service Regional Quality Control programs. Because the Chemistry Survey and Quality Assurance Service use identical method codes and the materials are essentially stable, the variation of differences among Chemistry Survey and Regional Quality Control assay values is a sensitive measure of both the variation of accuracy among calibrator-assigned values and of the matrix response among calibrator/reagent lots following the time of initial Chemistry Survey assay. In the two cycles of data comparison, the Regional Quality Control means for the assay values of 15 stable routine chemistry analytes showed no statistically significant differences from the initial Chemistry Survey for 295 of 361 analyte-method combinations studied 16 months later. Statistically significant changes between Chemistry Survey assay values and Regional Quality Control means most often occurred with closed rather than with open analytic systems and were predominantly in the same direction at both concentration levels. The magnitude of bias difference was usually less than the average within-laboratory standard deviation for the same analyte concentration. Of 64 analyte-pool combinations studied, a single instance of probable analyte instability was noted, ie, decreasing level I glucose during the first cycle. Our findings strongly support the usefulness of Chemistry Survey-assigned target values to help strengthen the intralaboratory accuracy base. They also point out the need for and the utility of Regional Quality Control-recalculated interlaboratory means to supplement assay values assigned at the time a control pool was put into use.

Chemistry, Clinical↗

[Frequency of medical consultation as reflected in 2 representative surveys: DHP-Survey and EVaS-Study (German Cardiovascular Disease Prevention and Survey of Ambulatory Care)].

The frequency of patient-doctor contacts in outpatient care is determined via two representative inquiries supplying complementary perspectives. They concern, on the one hand, a sample of contacts in the consultation room, and, on the other hand, contacts as stated in a population-based survey. In the 25-69 years age bracket, both surveys yielded a contact incidence of 2 to more than 5 contacts per person and quarter of a year. The figure is higher in women than in men. Both surveys agree very well if the consultation-room survey is limited to personal contacts between the doctor and the patient. The distribution of contacts over specialties is similar in both surveys. Compared to other countries, the frequency of outpatient consultations is high in the Federal Republic of Germany. Periodic surveys help to get insight into frequency and structure of medical services.

Adult↗

Sampling procedures and survey methodologies for the 1996 survey with comparisons to earlier national roadside surveys.

This article describes the multistage sampling system employed in the 1996 national roadside survey and compares it to the sampling methods employed in the two prior surveys in 1973 and 1986. Also described are the data collection procedures at the selected sites, the breath-test devices used to collect blood alcohol concentration (BAC) data, and the methods used to impute BAC values where breath-test measures were not obtained. Overall, almost twice as many (6,298 in 1996 compared to 3,698 in 1973 and 3,043 in 1986) drivers were interviewed in the most recent national survey as in the previous efforts. The procedures implemented in the three surveys are sufficiently similar to permit comparison of these surveys conducted at 10-year intervals.

Alcohol Drinking↗

Retirement Confidence Survey 2000 including results from the RCS Minority Survey and the Small Employer Retirement Survey.

The year 2000 represents the 10th anniversary of the Retirement Confidence Survey (RCS), and the third year for the Minority RCS and Small Employer Retirement Survey (SERS). Key RCS findings over the past 10 years include: The fraction of workers saving for retirement has trended upward, and today 80 percent of households report that they have begun to save. The fraction of workers who have attempted to calculate how much they need to save for retirement has risen noticeably over the past several years. Today, 56 percent of households report that they have attempted the calculation. One-half of workers who have attempted such a calculation report that it has changed their behavior, such as saving more and/or changing where they invest their retirement savings. Workers who have done the calculation appear to be in better shape regarding their retirement finances. Worker confidence in the ability of Social Security to maintain benefit levels bottomed out in 1994 and 1995. Workers today are just as confident as they were in 1992, although the majority remain not confident in Social Security. Regarding overall retirement confidence, Hispanic-Americans tend to be the least confident among the surveyed minority groups that they will have enough money to live comfortably throughout their retirement years. Key SERS findings include: While cost and administrative issues do matter to small employers, they are not the primary reasons for low plan sponsorship rates. Employee-related reasons are most often cited as the most important factor for not offering a retirement plan. Business-related reasons, such as profitability, are also a main decision-driver. It is important to note what small employers without plans do not know about plan sponsorship. Small employers that do sponsor a retirement plan report that offering a plan has a positive impact on both their ability to attract and retain quality employees and the attitude and performance of their employees. The survey results indicate that many small company nonsponsors may not be aware of such potential business benefits from plan sponsorship. In addition, many nonsponsors are unaware of the plan options available to them, in particular the ones created specifically for small employers, such as SIMPLE and SEP retirement plans. Therefore, some small employers may be making a premature decision not to sponsor a plan based on incomplete information.

Aged↗

The development and implementation of the National Comorbidity Survey Replication, the National Survey of American Life, and the National Latino and Asian American Survey.

This paper provides an overview of the development and implementation of the Collaborative Psychiatric Epidemiology Surveys (CPES): the National Comorbidity Survey Replication (NCS-R), the National Survey of American Life (NSAL), and the National Latino and Asian American Study (NLAAS). It describes the instrument development and testing phases, the development of training and other project materials, interviewer recruitment and training activities, and data collection procedures and outcomes. The last section offers recommendations for other researchers who undertake similar studies and who might benefit from the experiences learned in the development and operation of NCS-R, NSAL and NLAAS.

Adult↗

A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS).

AIMS: To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. METHODS AND RESULTS: We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. CONCLUSIONS: This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region.

Acute Disease↗

Explaining discrepancies in reproductive health indicators from population-based surveys and exit surveys: a case from Rwanda.

OBJECTIVES: Reproductive health programmes often need exit surveys and population-based surveys for monitoring and evaluation. This study investigates why such studies produce discrepant estimates of condom use, sexual behaviour and condom brand knowledge, and discusses the implications for future use of exit surveys for programme monitoring. METHODS: Logistic regression is used to explain differences between a household survey of 1295 persons and an exit survey among a random sample of 2550 consumers at retail outlets in RWANDA: RESULTS: Discrepancies in ever use of condoms and risky sexual behaviours are due to differences in socioeconomic status of the two samples. After controls, exit surveys at most outlet types have the same results as the household survey. Only exit surveys at bars, nightclubs and hotels yield significantly different estimates. However, the above-average knowledge of Prudence Plus condoms in the exit interviews is not attributable to socioeconomic or demographic variables, most likely because respondents have seen the product at the outlets. CONCLUSIONS: Information about condom use and sexual behaviour obtained from exit surveys appears as accurate as that obtained through household surveys. Nevertheless, exit surveys must be used cautiously. Because exit surveys may include wealthier and better-educated respondents, they are not representative of the general population. The composition of exit survey samples should be validated through existing household surveys. Comparisons across survey types are generally unadvisable, unless they control for sample differences. When generalizing to the population at large is not needed (e.g. for studies aimed at identifying the characteristics and behaviour of users of particular products or services), exit surveys can provide an appropriate alternative to household surveys.

Adolescent↗

Changes of multiple metal accumulation (MMA) in New Orleans soil: preliminary evaluation of differences between survey I (1992) and survey II (2000).

Soil metal surveys were conducted in Baltimore, MD (1976-1979), Minnesota (1981-1988) and most recently, New Orleans, LA (1989-present). The unique characteristic of New Orleans is that it has two surveys; Survey I was completed in 1992 and Survey II was completed in 2000. This paper seeks to determine if there is a perceptible change in the amount of metals during less than a decade that separated these surveys. The Survey I collection was 4,026 samples stratified by 283 census tracts. All samples were collected in residential neighborhoods at least one block from a busy street. The Survey II collection was 5,467 samples stratified by 286 census tracts (plus City Park). The Survey II collection included busy streets as a category of samples. For comparison, the busy street category of 1,078 samples was excluded from Survey II for a total of 4,388 samples. The extraction methods of the two surveys used the same protocol for strength of acid (1 M HNO3), shaker-time (2 hours), and room temperature (approximately 22 degrees C). However, Survey II differed in amount of sample used in extraction. For Surveys I and II, 4.0g and 0.4g were used respectively. The same ICP-AES was used to measure 8 metals in both surveys. To evaluate the analytical results of the two methods, reference soi 1 samples (n=36) from the Wageningen Evaluating Programs for Analytical Laboratories, International Soil-analytical Exchange (WEPAL; ISE) were used. The relationship between the 4.0 and 0.4 g results were linear and the Survey I results were adjusted for sample:acid ratio. Further evaluation was done by creating interpolated Multiple Metal Accumulation (MMA) maps based on the median MMA for each census tract. A new map was created by dividing Survey II MMA by Survey I MMA. The ratio indicates increases of soil metals in the inner city and decreases of soil metals in the outlying areas of Metropolitan New Orleans. Comparing fresh parent alluvium from the Mississippi River with urban soil metal quantities demonstrates that the soils of New Orleans have undergone a massive accumulation of metals. The preliminary results provide ideas about methods needed to further evaluate the changes between these surveys.

Cities↗

A national survey of U.S. pharmacists in 2000: assessing nonresponse bias of a survey methodology.

The first objective of this study was to assess the existence of nonresponse bias to a national survey of licensed pharmacists conducted in 2000. Three methods were used to assess nonresponse bias. The second objective of the study was to examine reasons why sampled licensed pharmacists did not respond to the national survey of licensed pharmacists. We used data from 2204 respondents to a national survey of pharmacists and from 521 respondents to a survey of nonrespondents to the national survey. We made comparisons between respondents for 5 variables: employment status, gender, age, highest academic degree, and year of initial licensure. Chi-square tests were used to examine differences in the 5 variables between respondents to the first mailing and second mailing of the survey, early and late respondents to the survey, and respondents to the survey and respondents to the nonrespondent survey. There were no significant differences between first mailing and second mailing respondents, but there were differences in each variable except year of licensure between early and late respondents. These differences likely were due to regional bias possibly related to differences in mailing times. There were differences between respondents and nonrespondents in terms of employment status and year of licensure. The main reasons for not responding to the survey were that it was too long or that it was too intrusive. Overall, the survey methodology resulted in a valid sample of licensed pharmacists. Nonresponse bias should be assessed by surveying nonrespondents. Future surveys of pharmacists should consider the length of the survey and the address where it is sent.

Adult↗

Comparisons of the costs and quality of norms for the SF-36 health survey collected by mail versus telephone interview: results from a national survey.

Many health status surveys have been designed for mail, telephone, or in-person administration. However, with rare exception, investigators have not studied the effect the survey mode of administration has on the way respondents assess their health and other important parameters (such as response rates, nonresponse bias, and data quality), which can affect the generalizability of results. Using a national sampling frame of noninstitutionalized adults from the General Social Survey, we randomly assigned adults to a mail survey (80%) or a computer-assisted telephone survey (20%). The surveys were designed to provide national norms for the SF-36 Health Survey. Total data collection costs per case for the telephone survey ($47.86) were 77% higher than that for the mail survey ($27.07). A significantly higher response rate was achieved among respondents randomly assigned to the mail (79.2%) than telephone survey (68.9%). Nonresponse bias was evident in both modes but, with the exception of age, was not differential between modes. The rate of missing responses was higher for mail than telephone respondents (1.59 vs. 0.49 missing items). Health ratings based on the SF-36 scales were less favorable, and reports of chronic conditions were more frequent, for mail than telephone respondents. Results are discussed in light of the trade-offs involved in choosing a survey methodology for health status assessment applications. Norms for mail and telephone versions of the SF-36 survey are provided for use in interpreting individual and group scores.

Adult↗

DADOS-Survey: an open-source application for CHERRIES-compliant Web surveys.

BACKGROUND: The Internet has been increasingly utilized in biomedical research. From online searching for literature to data sharing, the Internet has emerged as a primary means of research for many physicians and scientists. As a result, Web-based surveys have been employed as an alternative to traditional, paper-based surveys. We describe DADOS-Survey, an open-source Web-survey application developed at our institution that, to the best of our knowledge, is the first to be compliant with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). DADOS-Survey was designed with usability as a priority, allowing investigators to design and execute their own studies with minimal technical difficulties in doing so. RESULTS: To date, DADOS-Survey has been successfully implemented in five Institutional Review Board-approved studies conducted by various departments within our academic center. Each of these studies employed a Web-survey design as their primary methodology. Our initial experience indicates that DADOS-Survey has been used with relative ease by each of the investigators and survey recipients. This has been further demonstrated through formal and field usability testing, during which time suggestions for improvement were incorporated into the software design. CONCLUSION: DADOS-Survey has the potential to have an important role in the future direction of Web-survey administration in biomedical research. This CHERRIES-compliant application is tailored to the emerging requirements of quality data collection in medicine.

Academic Medical Centers↗

Estimates from two survey designs: national hospital discharge survey.

The methodology for the National Hospital Discharge Survey (NHDS) has been revised in several ways. These revisions, which were implemented for the 1988 NHDS, included adoption of a different hospital sampling frame, changes in the sampling design (in particular the implementation of a three-stage design), increased use of data purchased from abstracting service organizations, and adjustments to the estimation procedures used to derive the national estimates. To investigate the effects of these revisions on the estimates of hospital use from the NHDS, data were collected from January through March of 1988 using both the old and the new survey methods. This study compared estimates based on the old and the new survey methods for a variety of hospital and patient characteristics. Although few estimates were identical across survey methodologies, most of the variations could be attributed to sampling error. Estimates from two different samples of the same population would be expected to vary by chance even if precisely the same methods were used to collect and process the data. Because probability samples were used for the old and new survey methodologies, sampling error could be measured. Approximate relative standard errors were calculated for the estimates using the old and new survey methods. Taking these errors into account, less than 10 percent of the estimates were found to differ across survey methodologies at the 0.05 level of significance. Because a large number of comparisons were made, 5 percent of the estimates could have been found to be significantly different by chance alone. When there were statistically significant differences in nonmedical data, the new methods appeared to produce more accurate estimates than the old methods did. Race was more likely to be reported using the new methods. "New" estimates for hospitals in the West Region and government-owned hospitals were more similar than the corresponding "old" estimates to data from the census of hospitals conducted by the American Hospital Association. The numerous significant differences in estimates for bed size categories between the two survey methodologies reflected the change in the universe and definition of beds for the new survey. Few statistically significant differences were found in the medical data using the old and the new survey methods. Two main differences, in estimates for cataract and alcohol dependence syndrome, may have resulted from problems with the new survey. A measurement error, reporting outpatients to the NHDS, is one possible explanation of the higher estimates for diagnosis of cataract using the new survey methods.(ABSTRACT TRUNCATED AT 400 WORDS)

Bias↗

Measuring patient satisfaction: a post-visit survey vs a general membership survey.

OBJECTIVE: To explore the implications of alternative survey approaches for measuring patient satisfaction among members of an HMO. DESIGN: Comparisons of findings on patient satisfaction from two different mail surveys conducted in 1994 of HMO members: a post-visit survey and a general membership survey. SETTING: Kaiser Permanente, Northwest Region (KPNW). PARTICIPANTS: Two random samples of KPNW members: 7680 members surveyed shortly after an HMO office visit; 2142 members from the general KPNW membership roster. MAIN OUTCOME MEASURES: Patient or member ratings of satisfaction with various aspects of services received from physicians, other clinicians, and non-clinician staff, as well as the overall level of satisfaction with the care and service provided by KPNW. RESULTS: Satisfaction is greater for all aspects of care when patients are reporting on specific visits than when members are generalizing about the care they receive from KPNW. But the pattern of satisfaction is highly consistent across the two surveys. Among the sociodemographic characteristics of patients and members, age is the best predictor of satisfaction. CONCLUSIONS: Both surveys have value for managing, monitoring, and evaluating HMOs. The member survey probably reflects something of the reputation of the HMO while the patient survey mirrors more its current functional status. The member survey is probably more useful for managing and monitoring the health care system (which in turn will create its future reputation), but the visit survey provides valuable information for those purchasers and individuals making choices among contemporary health care options.

Demography↗