Impact of patient socioeconomic status on physician profiles: a comparison of census-derived and individual measures

BACKGROUND

Patient education has been shown to affect physician performance profiles. It is not known whether census-derived measures of patient socioeconomic status (SES) show comparable effects.

OBJECTIVE

The objective of this study was to compare the effects on physician profiles for patient satisfaction and physical and mental health of adjustment for patient SES derived from patient addresses geocoded to the census block group level, zip codes, and patient education.

DESIGN

This was a cross-sectional survey of patients in physician practices.

SETTING

Subjects came from adult primary care practices in western New York.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician participated in the study.

MEASUREMENTS

Independent variables were census-derived (block group and zip code) patient SES and patient-reported education. The outcomes were physician ranks for patient satisfaction (Patient Satisfaction Questionnaire) and physical and mental health status (SF-12). RESULTS. In empirical Bayes models that adjusted for patient age, age squared, gender, insurance, and case mix, both the census-derived measures (block group and zip code) of SES and education had similar effects on each of the physician profiles. CONCLUSIONS. The results suggest that SES derived from either patient addresses geocoded to the census block group level or zip codes may offer a convenient alternative to individually collected SES when adjusting physician profiles for the socioeconomic characteristics of physicians' practices. The relative ease of using zip codes compared with geocoded addresses and loss of information associated with incomplete matching during geocoding suggest that zip code-derived SES may be preferable.

Racial and ethnic disparities in perceptions of physician style and trust

CONTEXT

While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly.

OBJECTIVE

To assess whether a person's race or ethnicity is associated with low trust in the physician.

DESIGN, SETTING, AND PARTICIPANTS

Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32,929).

MAIN OUTCOME MEASURE

Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules.

RESULTS

After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites.

CONCLUSIONS

Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed. Arch Fam Med. 2000;9:1156-1163

Physician referral rates: style without much substance?

BACKGROUND

Primary care physicians (PCPs) exhibit widely varying referral rates, resulting in dramatic differences in the exposure of their patients to specialists. The relationships between this physician behavior and costs and patient outcomes are unknown.

OBJECTIVES

To examine the relationships between PCP referral rates and costs, risk of avoidable hospitalization, health status, and satisfaction.

DESIGN

Cross-sectional analyses of claims and patient survey data.

SETTING AND SUBJECTS

Independent practice association (IPA)-style managed care organization in the Rochester, NY, metropolitan area. The 1995 claims data included 457 PCPs in the IPA and 217,606 adult patients assigned to their panels. Approximately 50 consecutive patients of each of a random sample of 100 PCPs completed a patient survey in 1997-1998.

MEASURES

From the claims data, total expenditures per panel member, the risk of avoidable hospitalization, and physician referral rate were measured. Measures derived from the survey included SF-12 scores, satisfaction, and physician referral rate.

RESULTS

The relationship between physician referral rate and per-panel-member costs was not statistically significant after case-mix adjustment of the referral rate. There was no relationship between the case-mix-adjusted referral rate and risk of avoidable hospitalization. In the survey data, there was no adjusted relationship between the physicians' referral rate and their patients' self-rated physical or mental health. There was a modest direct relationship between patient satisfaction and survey-derived referral rate.

CONCLUSIONS

Despite stable, wide variations in PCP referral rates, there are few discemible relationships between this physician behavior and costs and patient outcomes. Efforts to constrain PCP referrals to specialists may be misguided.

Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care

Socioeconomic and racial/ethnic disparities in health care quality have been extensively documented. Recently, the elimination of disparities in health care has become the focus of a national initiative. Yet, there is little effort to monitor and address disparities in health care through organizational quality improvement. After reviewing literature on disparities in health care, we discuss the limitations in existing quality assessment for identifying and addressing these disparities. We propose 5 principles to address these disparities through modifications in quality performance measures: disparities represent a significant quality problem; current data collection efforts are inadequate to identify and address disparities; clinical performance measures should be stratified by race/ethnicity and socioeconomic position for public reporting; population-wide monitoring should incorporate adjustment for race/ethnicity and socioeconomic position; and strategies to adjust payment for race/ethnicity and socioeconomic position should be considered to reflect the known effects of both on morbidity. JAMA. 2000;283:2579-2584

Individual income, income inequality, health, and mortality: what are the relationships?

OBJECTIVE

To examine the pathways between income inequality, self-rated health, and mortality in the United States.

DATA SOURCE

The first National Health and Nutrition Examination Survey and Epidemiologic Follow-up Study.

DESIGN

This was a longitudinal, multilevel study.

DATA COLLECTION

Baseline data were collected on county income inequality, individual income, age, sex, self-rated health, level of depressive symptoms, and severity of biomedical morbidity from physical examination. Follow-up data included self-rated health assessed in 1982 through 1984 and mortality through 1987.

PRINCIPAL FINDINGS

After adjustment for age and sex, income inequality had a modest independent effect on the level of depressive symptoms, and on baseline and follow-up self-rated health, but no independent effect on biomedical morbidity or subsequent mortality. Individual income had a larger effect on severity of biomedical morbidity, level of depressive symptoms, baseline and follow-up self-rated health, and mortality.

CONCLUSION

Income inequality appears to have a small effect on self-rated health but not mortality; the effect is mediated in part by psychological, but not biomedical pathways. Individual income has a much larger effect on all of the health pathways.

Do physicians who diagnose more mental health disorders generate lower health care costs?

BACKGROUND

Underrecognition and undertreatment of mental health disorders in primary care have been associated with poor health outcomes and increased health care costs, but little is known about the impact of the diagnoses of mental health disorders on health care expenditures or outcomes. Our goal was to examine the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of avoidable hospitalizations.

METHODS

We used cross-sectional analyses of claims data from an independent practice association-style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.

RESULTS

After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5% - 13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.

CONCLUSIONS

Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.

Why do physicians vary so widely in their referral rates?

OBJECTIVE

To determine which physician practice and psychological factors contribute to observed variation in primary care physicians' referral rates.

DESIGN

Cross-sectional questionnaire-based survey and analysis of claims database.

SETTING

A large managed care organization in the Rochester, NY, metropolitan area.

PARTICIPANTS

Internists and family physicians.

MEASUREMENTS AND MAIN RESULTS

Patient referral status (referred or not) was derived from the 1995 claims database of the managed care organization. The claims data were also used to generate a predicted risk of referral based on patient age, gender, and case mix. A physician survey completed by a sample of 182 of the physicians (66% of those eligible) included items on their practice and validated psychological scales on anxiety from uncertainty, risk aversiveness, fear of malpractice, satisfaction with practice, autonomous and controlled motivation for referrals and test ordering, and psycho-social beliefs. The relation between the risk of referral and the physician practice and psychological factors was examined using logistic regression. After adjustment for predicted risk of referral (case mix), patients were more likely to be referred if their physician was female, had more years in practice, was an internist, and used a narrower range of diagnoses (a higher Herfindahl index, also derived from the claims data). Of the psychological factors, only greater psychosocial orientation and malpractice fear was associated with greater likelihood of referral. When the physician practice factors were excluded from the analysis, risk aversion was positively associated with referral likelihood.

CONCLUSIONS

Most of the explainable variation in referral likelihood was accounted for by patient and physician practice factors like case mix, physician gender, years in practice, specialty, and the Herfindahl index. Relatively little variation was explained by any of the examined physician psychological factors.

Supplemental insurance and mortality in elderly Americans. Findings from a national cohort

CONTEXT

As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing.

OBJECTIVE

To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance.

DESIGN

Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures.

SETTING

The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index.

PARTICIPANTS

A total of 3751 persons aged 65 years and older.

MAIN OUTCOMES MEASURES

Five-year mortality rate.

RESULTS

After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9).

CONCLUSIONS

Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.

Influence of patient education on profiles of physician practices

BACKGROUND

Few data are available about the effect of patient socioeconomic status on profiles of physician practices.

OBJECTIVE

To determine the ways in which adjustment for patients' level of education (as a measure of socioeconomic status) changes profiles of physician practices.

DESIGN

Cross-sectional survey of patients in physician practices.

SETTING

Managed care organization in western New York State.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician.

MEASUREMENTS

Ranks of physicians for patient physical and mental health (Short Form 12-Item Health Survey) and satisfaction (Patient Satisfaction Questionnaire), adjusted for patient age, sex, morbidity, and education.

RESULTS

Physicians whose patients had a lower mean level of education had significantly better ranks for patient physical and mental health status after adjustment for patients' level of education level than they did before adjustment (P < 0.001); this result was not seen for patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 (95% CI, 6.6 to 9.6) for patient physical health status and by 4.9 (CI, 3.9 to 5.9) for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients.

CONCLUSIONS

Profiles of physician practices that base ratings of physician performance on patients' physical and mental health status are substantially affected by patients' level of education. However, these results do not suggest that physicians who care for less educated patients provide worse care. Physician profiling should account for differences in patients' level of education.

Telephone ownership and deaf people: implications for telephone surveys

OBJECTIVES

This study was done to determine the prevalence of telephone ownership in different deaf populations and to explore its implications for telephone-based surveys.

METHODS

Multivariate analyses, with adjustments for sociodemographics and health status, were done of National Health Interview Survey (NHIS) data from 1990 and 1991, the years in which the NHIS Hearing Supplement was administered.

RESULTS

Prelingually deafened adults were less likely than members of the general population to own a telephone (adjusted odds ratio [AOR] = 0.35; 95% confidence interval [CI] = 0.15, 0.82), whereas postlingually deafened adults were as likely as members of the general population to own one (AOR = 1.00; 95% CI = 0.78, 1.28).

CONCLUSIONS

Telephone surveys risk marginalizing prelingually deafened adults because of low telephone ownership and language barriers between the deaf and hearing communities.

Is family care associated with reduced health care expenditures?

BACKGROUND

Specific components of family medicine associated with reduced health care costs are not well understood. We examined whether people who received "family care," the sharing of a personal physician across familial generations, had lower health care expenditures than those who received "individual care" that lacked generational continuity.

METHODS

We studied 1728 children and 2543 adults using a data subset of the 1987 National Medical Expenditure Survey, a representative sample of the civilian noninstitutionalized US population, to examine the relationship between care category and total health care expenditures, adjusting for potential confounders and effect modifiers. Survey respondents from households with either a married or a single woman aged 18 to 55 years as head of household and at least 1 child younger than 18 years were included. Only individuals reporting a family physician (FP) or general practitioner (GP) as their personal doctor were examined, since intergenerational family care is provided almost exclusively by FPs and GPs.

RESULTS

Family care provided by an FP or GP was associated with 14% lower expenditures for adults ($51), after adjustment for covariates (P = .04), compared with individual care provided by a family or general practitioner. Although not statistically significant, for children family care was associated with 9% lower expenditures ($19).

CONCLUSIONS

These findings suggest that family care provided by FPs or GPs is associated with lower health care costs. Policies promoting family care may reduce health care costs.

Does skepticism towards medical care predict mortality?

OBJECTIVES

Attitudes towards medical care have a strong effect on utilization and outcomes. However, there has been little attention to the impact on outcomes of doubts about the value of medical care. This study examines the impact of skepticism toward medical care on mortality using data from the 1987 National Medical Expenditure Survey (NMES).

METHODS

A nationally representative sample from the United States comprising 18,240 persons (> or = 25 years) were surveyed. Skepticism was measured through an 8-item scale. Mortality at 5-year follow-up was ascertained through the National Death Index.

RESULTS

In a proportional hazards survival analysis of 5-year mortality that controlled for age, sex, race, education, income, marital status, morbidity, and health status, skepticism toward medical care independently predicted subsequent mortality. That risk was attenuated after adjustment for health behaviors but not after adjustment for health insurance status.

CONCLUSION

Medical skepticism may be a risk factor for early death. That effect may be mediated through higher rates of unhealthy behavior among the medically skeptical. Further studies using more reliable measures are needed.

The adequacy of Papanicolaou smears as performed by family physicians and obstetrician-gynecologists

BACKGROUND

Little is known about the quality of Papanicolaou (Pap) smears performed by family physicians and obstetrician-gynecologists.

METHODS

Using hospital archival records of Pap smears performed from 1995 to 1997, we compared the quality of Pap smear sampling and the rate of detection of significant cytologic abnormalities by family physicians and obstetrician-gynecologists. Using hierarchic logistic regression, we examined the relationship between physician specialty and Pap smear reports, controlling for patient age and socioeconomic position, multiple Pap smears performed by the same clinician, and physician attending status.

RESULTS

A total of 34,916 Pap smears performed by 130 family physicians and 88 obstetrician-gynecologist residents and attending physicians were included in the analysis. There were no statistically significant differences by specialty in the rates of unsatisfactory reports (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI], 0.48 - 1.38), satisfactory but limited reports (AOR = 1.16; 95% CI, 0.93 - 1.48), or detection rates of significant cytologic abnormalities (AOR = 0.83; 95% CI, 0.66 - 1.04). However, family physicians submitted more Pap smears with an absent endocervical component (AOR = 1.50; 95% CI, 1.07 - 2.11).

CONCLUSIONS

These findings show no significant differences by specialty in Pap smear quality as measured by rates of unsatisfactory and satisfactory but limited reports, or detection of cytologic abnormalities. The finding of higher rates of absent endocervical cells, if replicated by further study, may suggest the need for improved training of family physicians in sampling the endocervix.

Variations in primary care physician referral rates

OBJECTIVE

To examine primary care physician referral rate variations, including their extent and their stability over time and across diagnostic categories.

DATA SOURCES

1995/1996 claims data for adult patients from a large Independent Practitioner Association (IPA) model managed care organization (MCO) in the Rochester, NY metropolitan area. The IPA includes over 95 percent of area primary care physicians (PCPs), and the MCO includes over 50 percent area residents.

STUDY DESIGN

Referral rates (patients referred to and seen by specialists one or more times/patients seen by PCP/year) were developed for the PCPs (457 general practitioners, family physicians, and internists) in the MCO, including observed referral rates, expected referral rates based on case-mix adjustment across the whole sample, physician-specific case mix-adjusted referral rates (empirical Bayes estimates), and diagnostic category-specific case mix-adjusted referral rates.

PRINCIPAL FINDINGS

Wide variations in observed referral rates (0.01-0.69 patients referred/patients seen/year) were attenuated relatively little by case-mix adjustment and persisted in case mix-adjusted empirical Bayes estimates (0.02-0.65). The year-to-year case mix-adjusted referral rate correlation was .90. Correlations of case mix adjusted-referral rates across diagnostic categories were moderate (r=.46-.67).

CONCLUSIONS

PCP referral rates exhibit wide variations that are independent of case mix, remain stable over time, and are generalizable across diagnostic categories. Understanding this physician practice variation and its relationship to costs and outcomes is critical to evaluating the effect of current efforts to reduce PCP referral rates.

Smoking and deaf adults: associations with age at onset of deafness

Smoking is a major health problem whose prevalence in different populations is thought to be influenced by sociocultural and linguistic factors. Although smoking and hearing loss are positively correlated, little is known about the smoking habits of deaf populations. Using national survey data, this study determined the smoking prevalence in two socioculturally distinct deaf populations, based on age at onset of deafness. The smoking prevalence in each deaf population was compared to the smoking prevalence in the hearing population in multivariate analyses that adjusted for sociodemographics and health status. The smoking prevalence among postlingually deafened adults was not significantly different from that among hearing adults. Prelingually deafened adults were found to be less likely to smoke than hearing adults, even though they have less education and lower income, factors both associated with higher smoking prevalence in other populations. The lower smoking prevalence among prelingually deafened adults may be due to cultural differences or to limited access to English-language tobacco advertising.

Low-dose mifepristone 200 mg and vaginal misoprostol for abortion

The objectives of this study were to determine the effectiveness, side effects, and acceptability of one-third the standard 600 mg dose of mifepristone (200 mg) to induce abortion. A prospective trial at seven sites enrolled women > or = 18 years, up to 8 weeks pregnant, and wanting an abortion. The women received 200 mg mifepristone orally, self-administered 800 micrograms misoprostol vaginally at home 48 h later, and returned 1-4 days later for ultrasound evaluation. Surgical intervention was indicated for continuing pregnancy, excessive bleeding, persistent products of conception 5 weeks later, or other serious medical conditions. Of the 933 subjects, 906 (97%) had complete medical abortions, 22 had surgical intervention, two were protocol failures, and three were lost to follow up. Of the 746 subjects who had no or minimal bleeding before misoprostol, 80% bled within 4 h and 98% within 24 h of using misoprostol. By day 7, 95% of women had a complete abortion. Side effects were aceptable in 85% of subjects, and 94% found the procedure acceptable. Low-dose mifepristone followed by vaginal misoprostol was highly effective as an abortifacient.

Deafness and mortality: analyses of linked data from the National Health Interview Survey and National Death Index

OBJECTIVE

To examine the association between age at onset of deafness and mortality.

METHODS

The authors analyzed National Health Interview Survey data from 1990 and 1991--the years the Hearing Supplement was administered--linked with National Death Index data for 1990-1995. Adjusting for sociodemographic variables and health status, the authors compared the mortality of three groups of adults ages > or = 19 years: those with prelingual onset of deafness (< or = age 3 years), those with postlingual onset of deafness (> age 3 years), and a representative sample of the general population.

RESULTS

Multivariate analyses adjusted for sociodemographics and stratified by age found that adults with postlingual onset of deafness were more likely to die in the given time frames than non-deaf adults. However, when analyses were also adjusted for health status, there was no difference between adults with postlingual onset of deafness and a control group of non-deaf adults. No differences in mortality were found between adults with prelingual onset of deafness and non-deaf adults.

CONCLUSIONS

Adults with postlingual onset of deafness appear to have higher mortality than non-deaf adults, which may be attributable to their lower self-reported health status.

The risk of low birth weight associated with vaginal douching

OBJECTIVE

To examine the association between vaginal douching and low birth weight (LBW) after accounting for known risk factors.

METHODS

We used cross-sectional interview data from the 1988 National Survey of Family Growth, a nationally representative sample of 4665 women of child-bearing age and 11,553 singleton live births. We compared the risk of LBW among women who reported they douched regularly with the risk among women who did not douche, after controlling for potential confounders including maternal age, race, household income, marital status, total number of pregnancies, smoking, alcohol use, drug use during the pregnancy, year of birth of each infant, geographic region, and self-reported history of pelvic inflammatory disease.

RESULTS

In multivariate analysis, regular douching was associated with an increased risk of LBW (adjusted odds ratio [OR], 1.29; 95% confidence interval [CI] 1.06, 1.57). Frequency of douching and LBW exhibited a dose-response. The adjusted OR for the association between daily douching and LBW was 2.49 (95% CI 1.23, 5.01) compared with an adjusted OR of 1.13 (95% CI 0.83, 1.55) for the association between monthly douching and LBW. There was no racial difference in the risk of LBW associated with douching.

CONCLUSION

These preliminary data suggest an association between douching and LBW risk. If these findings are replicated in future studies, douching may represent a major preventable risk factor for LBW.

Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience

BACKGROUND

The advent of managed care has resulted in considerable debate regarding the relative effects of specialist and primary care on patient outcomes and costs. Studies on these subjects have been limited to a disease-focused orientation rather than a patient-focused orientation inherent in primary care management. We examined whether persons using a primary care physician have lower expenditures and mortality than those using a specialist as their personal physician.

METHODS

Using data on a nationally representative sample of 13,270 adult respondents tot he 1987 National Medical Expenditure Survey reporting as their personal physician either a primary care physician (general practitioner, family physician, internist, or obstetrician-gynecologist) or a specialist, we examined total annual health care expenditures and 5-year mortality experience.

RESULTS

Respondents with a primary care physician, rather than a specialist, as a personal physician were more likely to be women, white, live in rural areas, report fewer medical diagnoses and higher health perceptions and have lower annual healthcare expenditures (mean: $2029 vs $3100) and lower mortality (hazard ratio = 0.76, 95% confidence interval [CI], 0.64-0.90). After adjustment for demographics, health insurance status, reported diagnoses, health perceptions, and smoking status, respondents reporting using a primary care physician compared with those using a specialist had 33% lower annual adjusted health care expenditures and lower adjusted mortality (hazard ratio = 0.81; 95% CI, 0.66-0.98).

CONCLUSIONS

These findings provide evidence for the cost-effective role of primary care physicians in the health care system. More research is needed on how to optimally integrate primary and specialty care.

Toward consistency in cost-utility analyses: using national measures to create condition-specific values

OBJECTIVES

The authors developed an "off-the-shelf" source of health-related quality of life (HRQL) scores for cost-effectiveness analysts unable to collect primary data.

METHODS

The authors derived and conducted preliminary validation on a set of health-related quality of life scores for chronic conditions using nationally representative data from the National Health Interview Survey (NHIS) and the Healthy People 2000 Years of Healthy Life measure developed to monitor the health (longevity and health-related quality of life) of Americans during this decade. The measure comprises two domains, role function and self-rated health, and is scaled from 0 (death) to 1 (best health state). Health-related quality of life scores for chronic conditions were calculated using the Years of Healthy Life scores associated with chronic conditions reported in the 1987-1992 National Health Interview Survey. Preliminary validation was examined by comparing the health-related quality of life scores with those obtained in two other studies.

RESULTS

Tables provide health-related quality of life scores for persons with and without conditions. The scores had reasonable face validity, ranging from 0.87 for allergic rhinitis to 0.27 for hemiplegia. Correlations of the health-related quality of life condition weight scores with those from two other studies were 0.78 and 0.86.

CONCLUSIONS

These condition weights may prove useful to investigators conducting cost-effectiveness analyses using secondary data, where community ratings of health-related quality of life for chronic conditions are required. Use of a standard set of health-related quality of life weights gathered from a national sample can enhance the comparability of cost-effectiveness analyses. Improvements in national data collection techniques, with empirical gathering of preferences, will further strengthen this measure.

Skepticism toward medical care and health care utilization

OBJECTIVES

As health care moves toward systems that assume accountability for defined populations, there has been increasing emphasis on developing performance measures for those systems and their providers, with little attention given to patient demand or attitudinal factors. The impact of skepticism toward health care providers on health behavior and health care utilization was assessed using a cross-sectional analysis of data from the 1987 National Medical Expenditure Survey (NMES).

METHODS

A nationally representative sample from the United States comprising 18,240 persons 25 years and older was surveyed. Skepticism, defined as doubts about the ability of conventional medical care to appreciably alter one's health status, was assessed through a 4-item scale. Outcome measures included health behavior, access (health care insurance, having a regular source of care, and physician type), utilization (annual number of physician or emergency department visits and hospitalizations), total annual health care expenditures, and preventive health care behavior (having had a Pap smear within 3 years or ever having had a mammogram).

RESULTS

In multivariate analyses, skepticism was associated with younger age, white race, lower income, less education, and higher health perceptions. After adjusting for these variables, skepticism was associated with less healthy behavior, with not having health insurance, not having one's own physician, choice of a physician, fewer physician and emergency department visits, less frequent hospitalizations, lower annual health care expenditures, and less prevention compliance.

CONCLUSIONS

Medical skepticism represents a relevant patient demand factor that demonstrates significant associations with a variety of health care access and utilization measures with important policy implications.

Does psychological distress contribute to racial and socioeconomic disparities in mortality?

Being black or poor are powerful predictors of mortality. Although psychological distress has been proposed as mediating the effects of race and socioeconomic status on mortality, this hypothesis has not been previously directly tested. We used data from the National Health and Nutrition Examination I (NHANES I), a nationally representative sample from the U.S, and the NHANES I Epidemiological Follow-up Survey (NHEFS) of subsequent mortality to test this hypothesis. Both black race and lower family income were associated with significantly higher psychological distress as measured at the time of the initial survey by reports of hopelessness, depression, and life dissatisfaction. Black race and low income in addition to each of the measures of psychological distress were associated with higher mortality at follow-up. In a series of Cox proportional hazards models that controlled for the effects of age and gender, additional adjustment for hopelessness, depression, or life dissatisfaction had little effect on the relationship between either African American race or family income and subsequent all-cause mortality. We conclude that the effects of both race and income on mortality are largely independent of psychological distress. These findings do not support the hypothesis that psychological distress is a significant mediator of the effects of race or class on health.

Utilization of specialty and primary care: the impact of HMO insurance and patient-related factors

BACKGROUND

Appropriate utilization of primary and specialty care has stimulated substantial debate, but the portion of the discussion focused on policies that restrict or discourage direct access to specialists has been largely uninformed by empirical analysis. Using data from the National Ambulatory Care Survey (1985 to 1992 surveys), we examined the associations of patient and physician demographics and health maintenance organization (HMO) insurance status with the utilization of primary compared with specialty care.

METHODS

Office visits for adult patients seen by primary care physicians and specialists were analyzed for: (1) patient-initiated utilization of specialists (patient self-referral) compared with that of primary care physicians; and (2) utilization of specialists compared with that of primary care physicians, stratified by HMO insurance status.

RESULTS

After multivariate adjustment, patient self-referral was less likely among black patients (adjusted odds ratio [AOR] = 0.67; 95% confidence interval [CI] = 0.59 to 0.76), self-pay (AOR = 0.81; 95% CI = 0.74 to 0.88), or patients with Medicaid (AOR = 0.51; 95% CI = 0.43 to 0.61). The proportion of non-HMO patients seeing specialists remained stable (44.9%). For HMO patients, the proportion of total visits made to specialists increased from 27.6% in 1985 to 41.3% in 1991, then dropped to 33.2% in 1992. Disparities in utilization of specialists by women, blacks, and patients with Medicaid observed among non-HMO patients were not found in the HMO population. Specialists were more likely to see HMO patients for follow-up of a known problem, whereas non-HMO patients were more likely to have specialist follow-up visits for new problems.

CONCLUSIONS

The results suggest greater utilization of specialists by male, white, and privately insured patients. The findings may partially account for disparities in specialty procedure use, and suggest that HMO insurance may reduce some of these disparities. The less frequent and more selective use of specialists among HMO patients suggests an evolving role for specialists in managed care.