Hospital inpatient mortality. Is it a predictor of quality?

Various potential measures of quality of care are being used to differentiate hospitals. Last year, on the basis of diagnostic and demographic data, the Health Care Financing Administration identified hospitals in which the actual death rate differed from the predicted rate. We have developed a similar model. To understand why there are high-outlier hospitals (in which the actual death rate is above the predicted one) and low-outlier hospitals (in which the actual death rate is below the predicted one), we reviewed 378 medical records from 12 outlier hospitals treating patients with one of three conditions: cerebrovascular accident, myocardial infarction, and pneumonia. After adjustment for the severity of illness, the death rate in the high outliers exceeded that predicted from the severity of illness alone by 3 to 10 percent, and in the low outliers, the actual death rate fell short of the severity-adjusted predictions by 10 to 15 percent (P less than 0.01). Reviews of the process of care using 125 criteria revealed no differences between the high and low outliers. However, detailed reviews by physicians of the records of patients who died during hospitalization revealed a higher rate of preventable deaths in the high outliers than in the low outliers. For the three conditions studied, we project that 5.7 percent of a standard cohort of patients admitted to the high-outlier hospitals would have preventable deaths, as compared with 3.2 percent of patients admitted to the low-outlier hospitals (P less than 0.05). A meaningful comparison of hospital death rates requires adjustment for severity of illness. Our findings indicate that high-outlier hospitals care for sicker patients. However, these same hospitals or their medical staffs may also provide poorer care. Our results need confirmation before death-rate models can be used to screen hospitals.

Effects of the National Institutes of Health Consensus Development Program on physician practice

The effects of the National Institutes of Health Consensus Development Program on physician behavior were investigated. The medical records of 2770 patients treated in ten hospitals throughout the state of Washington were reviewed to determine if quality of care improved with respect to 12 recommendations put forth by four consensus panels concerning surgical management of primary breast cancer, the use of steroid receptors in breast cancer, cesarean childbirth, and coronary artery bypass surgery. Care was studied during 24 months before and 13 to 24 months after each consensus conference. Results showed that the conferences mostly failed to stimulate change in physician practice, despite moderate success in reaching the appropriate target audience. It was concluded that the consensus development conference is an important educational tool whose effects might be enhanced by focusing on areas of practice that need improvement and by encouraging follow-up programs at the state and local level.

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures

We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significantly levels of inappropriate use: 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

How coronary angiography is used. Clinical determinants of appropriateness

Using ratings of appropriateness derived from an expert physician panel, we measured how appropriately physicians in 1981 performed coronary angiography in a randomly selected, community-based sample of cases in the Medicare population. We studied large geographic areas (three sites) in three states, representing regions of high and low use. The high-use site had fewer procedures classified as appropriate (72%) than either low-use site (77% and 81%, respectively). Over all sites, 17% of procedures were classified as inappropriate. Patients in the high-use site were older, had less severe angina, and were less intensively medically treated than patients in either of the low-use sites. Patients without angina who had not undergone exercise testing constituted the most common subgroup of inappropriate cases. Although overall differences in appropriateness were not large, practice differences do exist. This analysis of practice differences among study sites provides the clinical basis for understanding the small, but significant, differences in the appropriateness of use of coronary angiography. The finding of 17% inappropriate use may be cause for concern.

Obtaining clinical data on the appropriateness of medical care in community practice

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.

Sufficiency of clinical literature on the appropriate uses of six medical and surgical procedures

We reviewed the English-language clinical literature on carotid endarterectomy, cholecystectomy, upper gastrointestinal endoscopy, colonoscopy, coronary angiography and coronary artery bypass graft procedure to identify the appropriateness of using these procedures in 1981. Most of the 803 relevant articles and textbooks were published after 1975; about 10% of the 571 research studies were randomized, controlled trials, while two thirds were retrospective studies. Incomplete or contradictory information was available on the indications for and efficacy of using the procedures; almost no data were available on costs and use; data on complications failed to specify patients' symptoms or the relationship between complications and reasons for doing the procedure.

The association between hypertension treatment, control, and functional status

The authors examined the relationship between hypertension treatment, control, and functional status among 356 "uncomplicated" hypertensive patients receiving care in 16 teaching hospital group practices. Antihypertensive drug therapy and blood pressure control were determined from a medical record review. Functional status (health perceptions, mental health, role, and physical functioning) was assessed with a questionnaire. After adjustment for potential confounders, hypertensive patients without drug therapy were less likely to have impairment in mental health functioning, compared with patients receiving one or more than one antihypertensive medication (9% versus 25% and 20% respectively, p less than 0.05). However, uncontrolled hypertensive patients were more likely to have role limitations than patients controlled only at the end or throughout the record review period (51% versus 39% and 36%, respectively, p less than 0.05). Patients controlled throughout the review period had the least impairment for each measure of functional status. These preliminary findings suggest that pharmacologic therapy may have a negative influence on the mental health of "uncomplicated" hypertensive patients, but that the dual goals of blood pressure control and positive functional status are not incompatible.

Assuring the quality of health care for older persons. An expert panel's priorities

To select topics for quality assurance activities focusing on older patients, we convened a 14-member panel of physicians and experts in quality assurance. In two rounds of ratings, panelists rated 42 medical conditions (eg, pneumonia) in terms of their effects on patient outcomes, the availability of beneficial interventions, and the health benefits from improving current quality. They rated 27 health services (eg, adult day-care) on similar dimensions. The feasibility of doing quality assurance work on each condition and service also was rated. Using the ratings, the conditions selected for quality assurance work were congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression. Health care services selected were hospital discharge planning, acute inpatient care for the frail elderly, long-term-care facilities (intermediate-care facilities and skilled nursing facilities), home health care services, and case management.

Adjusted hospital death rates: a potential screen for quality of medical care

Increased economic pressure on hospitals has accelerated the need to develop a screening tool for identifying hospitals that potentially provide poor quality care. Based upon data from 93 hospitals and 205,000 admissions, we used a multiple regression model to adjust the hospitals crude death rate. The adjustment process used age, origin of patient from the emergency department or nursing home, and a hospital case mix index based on DRGs (diagnostic related groups). Before adjustment, hospital death rates ranged from 0.3 to 5.8 per 100 admissions. After adjustment, hospital death ratios ranged from 0.36 to 1.36 per 100 (actual death rate divided by predicted death rate). Eleven hospitals (12 per cent) were identified where the actual death rate exceeded the predicted death rate by more than two standard deviations. In nine hospitals (10 per cent), the predicted death rate exceeded the actual death rate by a similar statistical margin. The 11 hospitals with higher than predicted death rates may provide inadequate quality of care or have uniquely ill patient populations. The adjusted death rate model needs to be validated and generalized before it can be used routinely to screen hospitals. However, the remaining large differences in observed versus predicted death rates lead us to believe that important differences in hospital performance may exist.

Providing primary general medical care in university hospitals: efficiency and cost

Data on efficiency, costs, and profits of 15 internal medicine outpatient group practices in university hospitals were collected for 9 months from interviews, a time-motion study, observations, and reviews of bills. Charges for a follow-up visit were about 25% higher than Medicare's allowable charges, but differed threefold across practices. Physicians spent more than half their allocated patient care or supervision time in other activities and 14% of nursing time was used for direct patient care. Visits to second- and third-year residents cost one half of those to faculty. Faculty supervision of second- and third-year residents was limited; it was, on average, 2 minutes per follow-up visit. Despite these inefficiencies, bad debts, and educational costs, practices appeared to break even financially. We conclude it is financially feasible for university hospitals to provide primary care to disadvantaged populations.

Educating physicians and treating patients in the ambulatory setting. Where are we going and how will we know when we arrive?

We evaluated 15 group practices in general internal medicine in university hospitals with regard to access to and quality of care, patients' satisfaction with that care, and quality of residency education provided. We used these data to speculate about potential changes in ambulatory care programs in university teaching hospitals. All 15 practices participated for 4 years. One third of their patient population had no medical insurance. Practice patients had twice as many chronic illnesses as did the general population, and two fifths of patients stayed at least 2 years in the practice. Few faculty members spent more than 14 hours weekly in the practices, and housestaff worked an average of 4 hours per week. Patient waiting times did not meet ideal standards, but patient satisfaction was higher than in a general population. Compliance with quality of care criteria was not exceptional; for example, 10% of eligible patients received an annual influenza vaccination. Housestaff assigned a relatively low ranking to their educational experience in the practices. We recommend the institution of additional experimental programs in ambulatory care and housestaff education to improve the quality of care in the ambulatory setting.

Effects of cost sharing on physiological health, health practices, and worry

In a randomized trial of the effects of medical insurance on spending and the health status of the nonaged, we previously reported that patients with limited cost sharing had approximately one-third less use of medical services, similar general self-assessed health, and worse blood pressure, functional far vision, and dental health than those with free care. Of the 20 additional measures of physiological health studied here on 3,565 adults, people with cost sharing scored better on 12 measures and significantly worse only for functional near vision. People with cost sharing had less worry and pain from physiological conditions on 33 of 44 comparisons. There were no significant differences between plans in nine health practices, but those with cost sharing fared worse on three types of cancer screening and better on weight, exercise, and drinking. Overall, except for patients with hypertension or vision problems, the effects of cost sharing on health were minor.

The appropriateness of using a medical procedure. Is information in the medical record valid?

Understanding the clinical appropriateness of a procedure's use may be critical in explaining geographic variations in its use. Little is known, however, about whether data on appropriateness can be obtained from a medical record. A national panel of physicians formulated a list of 300 mutually exclusive, detailed clinical indications for performing coronary angiography. Using this list, we compared the reasons physicians perform coronary angiography as revealed in medical records with those given in interviews with the physicians who actually did the procedure. Thirty-five of 47 eligible billing entities (74%) from two Los Angeles Professional Standards Review Organization areas participated. These physicians practiced in 14 hospitals and accounted for 81% of all angiographies performed on Medicare patients in the two areas. Sixty-six records (approximately two per physician) were reviewed; physician interviews were conducted by two trained data collectors who were blinded to each other's results. Ninety-one percent agreement was reached on the specific indication for performing coronary angiography when information from the record review and interview was compared. We conclude that medical records yield valid information on why coronary angiography is performed and that they are a suitable source to use in judging the appropriateness of that use.

Derivation of clinical indications for carotid endarterectomy by an expert panel

We used a two-round consensus panel method to derive and rate the appropriateness of comprehensive sets of detailed clinical indications for performing carotid endarterectomy. Before meeting, nine nationally influential physicians rated 675 indications; after review and discussion, they rated 864. The method did not force unanimity; our purposes were not only to encourage agreement but also to uncover areas of disagreement concerning the procedure's appropriate use. The panelists agreed on the level of appropriateness for 54 per cent of the final 864 indications and disagreed on 18 per cent. Ratings were reliably reproduced six to eight months after the completion of the process. The physicians' indications and ratings were consistent with those in the literature, and statistical analysis demonstrated that they followed logical clinical rationale. We conclude that consensus methods that do not force agreement can be used with panels of physicians to produce detailed, reliable, and valid indications. They can also identify medically controversial reasons for using a procedure that can serve as a starting point for a research agenda.

Effect of a health maintenance organization on physiologic health. Results from a randomized trial

In a previous comparison of persons between 14 and 62 years of age randomly assigned to receive care through a fee-for-service system (n = 784) or through a health maintenance organization (HMO) (n = 738) in Seattle, Washington, persons in the HMO had much lower hospital expenditures and admissions, more bed days, a higher prevalence of serious symptoms, and less satisfaction with care. We report an examination of 20 additional health status measures. Our results are consistent with a hypothesis of no differences in health status measures between the two systems. In addition, a comparison of nine health practices between the systems also indicated no overall differences. Most physiologic measures and health practices for a typical person were not affected by care received through the fee-for-service system or the HMO. However, we are less certain of this result in specific subgroups, such as persons of lower income initially at elevated risk, because confidence intervals are necessarily wider. We conclude that the cost savings achieved by this HMO through lower hospitalization rates were not reflected in lower levels of health status.

The effect of cost sharing on the use of antibiotics in ambulatory care: results from a population-based randomized controlled trial

Little is known about how generosity of insurance and population characteristics affect quantity or appropriateness of antibiotic use. Using insurance claims for antibiotics from 5765 non-elderly people who lived in six sites in the United States and were randomly assigned to insurance plans varying by level of cost-sharing, we describe how antibiotic use varies by insurance plan, diagnosis and health status, geographic area, and demographic characteristics. People with free medical care used 85% more antibiotics than those required to pay some portion of their medical bills (controlling for all other variables). Antibiotic use was significantly more common among women, the very young, patients with poorer health, and persons with higher income. Use of antibiotics for viral, viral-bacterial, and bacterial conditions did not differ between free and cost-sharing insurance plans, given antibiotics were the treatment of choice. Cost sharing reduced inappropriate and appropriate antibiotic use to a similar degree.

Use of carotid endarterectomy in five California Veterans Administration medical centers

Although carotid endarterectomy is a controversial and frequently performed surgical procedure, little is known about the clinical appropriateness of its use in actual practice. Are the majority of procedures performed for highly accepted clinical reasons? We studied the clinical appropriateness of 107 procedures performed on 95 patients in 1981 in five Veterans Administration teaching medical centers. Standards for judging appropriate use were based on the recommendations of a multidisciplinary panel of nine physicians. Fifty-five percent of the procedures studied were judged clearly appropriate, 32% equivocal, and 13% clearly inappropriate. The rate of serious operative complications was 5.6%. These results suggest that carotid endarterectomy is overutilized within at least some segments of the Veterans Administration population.

Inappropriate use of hospitals in a randomized trial of health insurance plans

We examined geographic variation in the rate of inappropriate hospitalization and the effect of cost sharing on that rate. The medical records of 1132 adults hospitalized in a randomized trial of health insurance plans were reviewed by two physicians who were blinded to the patients' insurance plan. They judged 23 percent of the admissions to be inappropriate and an additional 17 percent to have been avoidable by the use of ambulatory surgery. The percentage of inappropriate admissions varied among six sites (from 10 to 35 percent), but areas with low total admission rates did not necessarily have low proportions of inappropriate admissions. In plans with cost sharing for all services, 22 percent of admissions and 34 percent of hospital days were classified as inappropriate, as compared with 24 percent of admissions and 35 percent of hospital days in the plan under which care was free to the patient (these differences were not statistically significant). Our data show that a substantial fraction of hospitalization is potentially avoidable. Because cost sharing did not selectively reduce inappropriate hospitalization, it is important to develop other mechanisms to do so.

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

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

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

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

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

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

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

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

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

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

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

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

Physician ratings of appropriate indications for six medical and surgical procedures

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

Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care

To determine whether health outcomes in a health maintenance organisation (HMO) differed from those in the fee-for-service (FFS) system, 1673 individuals ages 14 to 61 were randomly assigned to one HMO or to an FFS insurance plan in Seattle, Washington for 3 or 5 years. For non-poor individuals assigned to the HMO who were initially in good health there were no adverse effects. Health outcomes in the two systems of care differed for high and low income individuals who began the experiment with health problems. For the high income initially sick group, the HMO produced significant improvements in cholesterol levels and in general health ratings by comparison with free FFS care. The low income initially sick group assigned to the HMO reported significantly more bed-days per year due to poor health and more serious symptoms than those assigned free FFS care, and a greater risk of dying by comparison with pay FFS plans.

The Functional Status Questionnaire: reliability and validity when used in primary care

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients' functional status. In this study, the FSQ was administered to 497 regular users of Boston's Beth Israel Hospital's Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

Childhood enuresis: prevalence, perceived impact, and prescribed treatments

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

Popular press coverage of eight National Institutes of Health consensus development topics

The quality of medical journalism has been widely criticized. As part of a larger evaluation study, we analyzed popular press coverage of eight topics selected by the National Institutes of Health for consensus development conferences in 1979 and 1980. Using periodical indexes to identify relevant articles, we analyzed the characteristics of 269 topical articles published in newspapers and magazines in the four years surrounding each conference and examined the role that the conference played in subsequent reporting. Most topics received widespread press interest that culminated around the time of each conference. Consensus findings were widely cited in articles that appeared after the conferences. Articles were mostly factual and balanced, relied on experts, and emphasized major themes covered by the conference. We conclude that the popular press can make an important contribution to the dissemination of new medical information.

Work satisfaction and career aspirations of internists working in teaching hospital group practices

This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training.

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

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

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

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

Medicare capitation and quality of care for the frail elderly

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

A method for the detailed assessment of the appropriateness of medical technologies

The standard way to assess medical technologies is to conduct a randomized clinical trial. Patients are randomly assigned to groups receiving alternative treatments, and outcomes are monitored over a long period of time. For example, some victims of left main coronary artery disease may undergo coronary artery bypass surgery, and others may receive medical treatment with nitroglycerine and beta blockers. Comparison of five-year mortality and morbidity in the two groups helps to determine the relative appropriateness of the two procedures. In addition, information about quality of life and cost can also be collected and compared.

Career orientations of medical and pediatric residents

Educators have expressed concern about the declining percentage of graduating residents who choose an academic career. This study identifies characteristics of postgraduate physicians that are associated with intentions to pursue an academic career or a full-time private practice. Data were obtained from 299 residents in pediatrics and internal medicine at five academic medical centers in Southern California, using self-report questionnaires. Preference for an academic career was strongest among residents who were most satisfied with their work, were frequently sponsored by faculty, had published, or who either lived alone or were married to another professional. The likelihood of full-time private practice was strongest among residents who were less frequently sponsored by faculty, had not published, lived with others, were from certain medical schools, or were females. Training programs may wish to consider some of these factors in the selection of residents and in program development.

How free care reduced hypertension in the health insurance experiment

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

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

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

The impact of cost sharing on emergency department use

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

Consequences of cost-sharing for children's health

Do children whose families bear a percentage of their health care costs reduce their use of ambulatory care compared with those families who receive free care? If so, does the reduction affect their health? To answer these questions, 1,844 children aged 0 to 13 years were randomly assigned (for a period of 3 or 5 years) to one of 14 insurance plans. The plans differed in the percentage of their medical bills that families paid. One plan provided free care. The others required up to 95% coinsurance subject to a +1,000 maximum. Children whose families paid a percentage of costs reduced use by up to one third. For the typical child in the study, this reduction caused no significant difference in either parental perceptions of their child's health or in physiologic measures of health. Confidence intervals are sufficiently narrow for most measures to rule out the possibility that large true differences went undetected. Nor were statistically significant differences observed for children at risk of disease. Wider confidence intervals for these comparisons, however, mean that clinically meaningful differences, if present, could have been undetected in certain subgroups.