From physician to consumer: the effectiveness of strategies to manage health care utilization

Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits

INTRODUCTION

Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics.

METHODS

Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects.

RESULTS

The analytic sample included 53,489 patient visits with reproductive-age (15-49 years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p = .02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p = .00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services.

CONCLUSIONS

Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.

Disruptions to the patient-provider relationship and patient utilization and outcomes: Evidence from medicaid managed care

The patient-provider relationship is considered a cornerstone to delivering high-value healthcare. However, in Medicaid managed care settings, disruptions to this relationship are disproportionately common. In this paper, I evaluate the impact of a primary provider's exit from a Medicaid managed care plan on adult beneficiary healthcare utilization and outcomes. Using an event study approach, I estimate a 5% decrease in the number of beneficiaries with primary care visits in the year following the exit, with slightly larger effects in terms of percentage points for patients with chronic conditions. Additionally, I observe a nearly 50% increase in the number of beneficiaries with a chronic condition who are hospitalized following a disruption.

The effect of medication cost transparency alerts on prescriber behavior

OBJECTIVE

The purpose of this study was to determine if medication cost transparency alerts provided at time of prescribing led ambulatory prescribers to reduce their use of low-value medications.

MATERIALS AND METHODS

Provider-level alerts were deployed to ambulatory practices of a single health system from February 2018 through April 2018. Practice sites included 58 primary care and 152 specialty care clinics totaling 1896 attending physicians, residents, and advanced practice nurses throughout western Washington. Prescribers in the randomly assigned intervention arm received a computerized alert whenever they ordered a medication among 4 high-cost medication classes. For each class, a lower cost, equally effective, and safe alternative was available. The primary outcome was the change in prescribing volume for each of the 4 selected medication classes during the 12-week intervention period relative to a prior 24-week baseline.

RESULTS

A total of 15 456 prescriptions for high-cost medications were written during the baseline period including 7223 in the intervention arm and 8233 in the control arm. During the intervention period, a decrease in daily prescribing volume was noted for all high-cost medications including 33% for clobetasol propionate (p < .0001), 59% for doxycycline hyclate (p < .0001), 43% for fluoxetine tablets (p < .0001), and a non-significant 3% decrease for high-cost triptans (p = .65). Prescribing volume for the high-cost medications overall decreased by 32% (p < .0001).

CONCLUSION

Medication cost transparency alerts in an ambulatory setting lead to more cost-conscious prescribing. Future work is needed to predict which alerts will be most effective.

GENETIC DUTIES

Most of our genetic information does not change, yet the results of our genetic tests might. Labs reclassify genetic variants in response to advances in genetic science. As a result, a person who took a test in 2010 could take the same test with the same lab in 2020 and get a different result. However, no legal duty requires labs or physicians to inform patients when a lab reclassifies a variant, even if the reclassification communicates clinically actionable information. This Article considers the need for such duties and their potential challenges. In so doing, it offers much-needed guidance to physicians and labs, who may face liability, and to courts, which will hear these cases.

Long-term care coverage and its relationship with hospital care: Lessons from Italy on coordination among care-settings

Long-term care for the elderly is one among the most important challenges for welfare and health care system across the world. Demographic and epidemiological trends are signalling that demand for long-term care will continue increasing in the next future, while public systems investments and efforts to cope with this issue are not enough. One possible strategy could be to reinforce integration between different care settings so to have positive spill over effects. The paper is focussed on Italian long-term care system analysing and assessing its performance at the regional level both in terms of answering citizens' long-term care needs and integrating with hospital care. The study is based on National health care records and regional data concerning long-term care to assess the state of the arts of in-kind services, and on qualitative focus groups with care providers and policy makers to provide interpretation about the Italian long-term care system performance and weaknesses. Results show that, due to a widespread and important lack of supply and inability to answer to citizens' needs, integration between long-term care and hospitals is not working, and substitution effect following investment in long-term care settings is not present. The paper introduces different interpretations of the causes of this phenomenon, suggesting to policy makers and managers the possible solutions to be implemented.

Fixed effects analysis of the incidence of cardiovascular outcomes under managed care following the managed care backlash

To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.

The effects of gatekeeping on the quality of primary care in Guangdong Province, China: a cross-sectional study using primary care assessment tool-adult edition

Background

Developed countries have widely implemented a gatekeeping system as a core policy of primary care, also known as the system of first visit in the community. As gatekeepers, general practitioners are responsible for the diagnosis and treatment of residents in the community health centres, and referring patients to specialists as appropriate. After several years of healthcare reform, gatekeeping policy has achieved remarkable success in China. Shenzhen and Dongguan were the first batch of pilot cities that implemented the policy of gatekeeping. This study aims to examine the effects of gatekeeping on the quality of primary care between the gatekeeping and non-gatekeeping groups in these two pilot cities.

Methods

A cross-sectional survey was conducted in five community health centres in Shenzhen and Dongguan cities, both located within Guangdong Province, China, using a validated Chinese version of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) and carrying out face-to-face interviews with patients 18 years and older. Analyses were grouped according to whether or not patients had gatekeepers. Propensity Score Matching was used to control for confounding factors. A chi-square test was used to compare the factors mentioned above and an independent t-test was performed to compare the eight domains of the core functions of primary care between the two groups of patients.

Results

In total, 765 valid questionnaires were collected for analysis, after matching the sample size were 238 pairs. All the confounding factors observed between the gatekeeping and non-gatekeeping groups were balanced. The PCAT-AE scores for first-contact utilisation (3.29 > 2.66, p < 0.001) and coordination (2.06 > 1.95, p < 0.05) were higher in the gatekeeping group after matching, but the domains of accessibility (1.59 < 1.67, p < 0.05) and continuity (2.26 < 2.40, p < 0.05) were lower. The PCAT-AE mean score was slightly higher in gatekeeping group (1.98 > 1.93, p > 0.05) but without statistical significance.

Conclusion

This study demonstrated that gatekeeping has helped to improve first-contact utilisation and coordination of primary care, but that other goals such as continuity and comprehensiveness have been harmed. To establish a sustainable gatekeeping system and to strengthen the core functions of the community comprehensively, the current gatekeeping system needs refinement.

Network Optimization And The Continuity Of Physicians In Medicaid Managed Care

Health plans use selective physician networks to control costs while improving quality. However, narrow (limited) networks raise concerns about reduced access to and continuity of care. In the period 2010-15, the proportion of Medicaid managed care plans in fourteen states with narrow primary care physician networks-that is, the plans that employed 30 percent or less of those physicians in their market-declined from a peak of 42 percent in 2011 to 27 percent in 2015. On average, plans experienced a 12 percent annual turnover rate, with 34 percent of primary care physicians exiting within five years. Turnover was 3 percentage points higher in plans with narrow networks after one year, and 20 percentage points higher after five years, compared to turnover in plans with non-narrow networks. These findings suggest that efforts to maintain adequate physician networks must monitor not only the breadth of the networks, but also the continuity within them.

Evaluating the Effectiveness of Concurrent Review: Does It Improve Stroke Measure Results?

BACKGROUND

Concurrent review is a quality improvement strategy in which patients are tracked from admission to discharge, and messages are communicated to the responsible physician when quality stroke measures have not been met. There is little research regarding interventions that might influence clinical practice patterns and improvement in compliance with core quality measures. This study sought to evaluate whether concurrent review implementation was associated with change in performance on stroke measure outcome data.

METHODS

Randomly selected charts from 2 hospitals (A and B) during 3 time periods were reviewed. In period 1, neither hospital had a process for concurrent review. In period 2, hospital A, where concurrent review was implemented, was compared with hospital B without this process. In period 3, both hospitals had the process of concurrent review. Information on baseline demographics, insurance status, and length of stay was collected, as well as stroke performance measures.

RESULTS

A total of 620 medical records were reviewed during the 3 time periods. Although the number of beds and annual stroke volume were higher at hospital B, patient characteristics were similar. During period 2, when hospital A implemented concurrent review and hospital B had not, a statistically significant higher compliance with performance in 7 stroke measures occurred in hospital A than in hospital B. In period 3, when both hospitals utilized concurrent review, no statistical significant differences occurred in 7 of the 10 stroke measures.

CONCLUSION

Concurrent review is a quality improvement intervention that increases performance with stroke performance measures.

Managing Febrile Infants

The authors hypothesized that sepsis workup recommendations are associated with practice recommendations published during the physician’s residency. The first published recommendations suggesting sepsis workups for nontoxic, young, febrile infants appeared in pediatric journals from 1975-1980 and in family practice journals from 1981-1987. Data are from the Community Tracking Study (3,272 pediatricians and 2,432 family physicians). “Percentage of sepsis workups recommended” was defined by response to a vignette about the percentage of well-appearing 6-week-old children with a fever of 101°F for whom the physician would recommend a sepsis workup. Multivariable regression with piecewise linear functions evaluated workup recommendations by timing of literature recommendations during residency. Pediatricians recommended sepsis workups 81.6% of the time and family physicians 67.7% (p < .001). Increased recommendations occurred among pediatricians who completed residency from 1975-1980 (p < .05) and among family physicians who completed residency from 1981-1987 (p < .005), when specialty-specific journals published recommendations for sepsis workups for febrile infants. The association between publication of sepsis workup recommendations during a physician’s residency and increased sepsis workup recommendations suggests an unrecognized and enduring impact of such publications.

Overutilization, overutilized

Overutilization is commonly blamed for escalating costs, compromising quality, and limiting access to the US health care system. Recent estimates suggest that nearly one-third of health care spending in the United States is a result of unnecessary care. Despite the surge of exposés that purport to uncover this "new" problem, narratives about overutilization have been circulating in health policy debates since the beginnings of the health insurance industry. This article traces how the term overutilization has spread in popularity from a relatively small community of mid-twentieth-century insurance experts to economists, physicians, epidemiologists, and eventually the news media of the early twenty-first century. A quick glimpse at the history of the term reveals that there has been constant disagreement and debate over the meaning and impact of overutilization. Moreover, the term has been put to very different uses, from keeping socialism at bay to preserving the fiscal integrity of Medicare to protecting the health of patients. The overutilization narrative, seductive in its promise of cutting costs without sacrificing access to quality care, too often drowns out other difficult conversations about social welfare, health equity, prices, and universal coverage.

Physician organization care management capabilities associated with effective inpatient utilization management: a fuzzy set qualitative comparative analysis

Background

We studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand.

Methods

We used fuzzy-set qualitative comparative analysis (fsQCA) to conduct an exploratory comparative case series study. Data about PO capabilities were collected using structured interviews with medical directors at fourteen California POs that are delegated to provide inpatient utilization management (UM) for HMO members of a California health plan. Health plan acute hospital claims from 2011 were extracted from a reporting data warehouse and used to calculate inpatient utilization statistics. Supplementary analyses were conducted using Fisher’s Exact Test and Student’s T-test.

Results

POs with low inpatient bed-days per thousand minimized length of stay and surgical admissions by actively engaging in concurrent review, discharge planning, and surgical prior authorization, and by contracting directly with hospitalists to provide UM-related services. Disease and case management were associated with lower medical admissions and readmissions, respectively, but not lower bed-days per thousand.

Conclusions

Care management methods focused on managing length of stay and elective surgical admissions are associated with low bed-days per thousand in high-risk California POs delegated for inpatient UM. Reducing medical admissions alone is insufficient to achieve low bed-days per thousand. California POs with high bed-days per thousand are not applying care management best practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0582-5) contains supplementary material, which is available to authorized users.

A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

The role of Medicaid managed care interventions in Chlamydia screening by physicians

BACKGROUND

Chlamydia trachomatis (CT) guidelines call for annual screening of all sexually active young females. In previous studies, Medicaid health maintenance organizations (HMOs) did not consistently recommend CT and other sexually transmitted disease guidelines, but physicians with HMO practices were more likely to comply with guidelines than those without HMO practices. This study examines the relationship between HMO interventions and physician adherence to annual (CT) screening guidelines for sexually active young (ages 15-25) females.

METHODS

Medicaid HMOs (N = 17) of California were surveyed regarding their interventions to increase physician adherence with national CT screening guidelines in 2002. Primary care physicians (N = 941) who contracted with these HMOs were also surveyed on their frequency (always/usually) of CT screening. Data were analyzed using logistic regression models.

RESULTS

HMO-reported recommendations for CT screening and other interventions were associated with significantly higher odds of frequent CT screening by contracted physicians in unadjusted models. HMO recommendations to screen young females increased the odds of frequent CT screening, but other interventions were no longer significantly associated after controlling for physician characteristics. Physicians also had higher odds of reporting frequent CT screening if they had received training in the past, had received feedback from their contracted HMOs, or reported having access to national CT screening guidelines. Physician gender, specialty, years of clinical experience, and other factors were also significantly associated with the odds of frequency of CT screening.

DISCUSSION

Improving physician adherence with CT screening guidelines requires a refinement of current approaches with targeted interventions that are tailored to the characteristics of physicians. In addition, interventions are more likely to be effective if provided in formats that are perceived and acknowledged by physicians.

Association between elder self-neglect and hospice utilization in a community population

Elder self-neglect is associated with substantial 1-year mortality. However, hospice utilization among those with self-neglect remain unclear. The objective of this study is to quantify the prospective relation between self-neglect and risk for hospice utilization in a community population of older adults. Prospective population-based study in a geographically defined community in Chicago of older adults who participated in the Chicago Health and Aging Project. Of the 8669 participants in the Chicago Health and Aging Project, a subset of 1438 participants was reported to social services agency for suspected elder self-neglect. Outcome of interest was the hospice utilization obtained from the Center for Medicare and Medicaid System. Cox proportional hazard models were used to assess independent association of self-neglect with risk of hospice utilization using time-varying covariate analyses. After adjusting for potential confounding factors, elders who self-neglect was associated with increased risk for hospice utilization (HR, 2.43, 95% CI, 2.10-2.81). Greater self-neglect severity (mild: (HR, 2.12 (1.61-2.79); moderate: (HR, 2.36 (1.95-2.84); severe: (HR, 4.66 (2.98-7.30)) were associated with increased risk for hospice utilization. Interaction term analyses suggest that the significant relationship between self-neglect and hospice utilization was not mediated through medical conditions, cognitive impairment and physical disability. Moreover, self-neglect was associated with shorter length of stay in hospice (PE, -0.27, SE, 0.12, p<0.02) and shorter time from hospice admission to death (PE, -0.32, SE, 0.13, p<0.01). Elder self-neglect was associated with increased risk of hospice use in this community population. Elder self-neglect is associated with shorter length of stay in hospice care and shorter time from hospice admission to death.

Discourses of influence and autonomy in physicians' accounts of treatment decision making for depression

Models of patient-physician decision making are typically framed on a continuum of discourses and practices ranging from patient autonomy to physician paternalism, with the middle ground being occupied by terms such as shared decision making. Critiques of these models center on the gulf between these idealized models and actual practice and on how context influences decision-making practices. In this article I focus on how 11 Canadian family physicians talked about patient-physician decision making in interviews about their diagnostic and treatment practices for depression. I adopt a discursive approach to analyzing extracts from these interviews, and show how these physicians constructed themselves as engaging in acts of professional judgment and persuasion, and patients as having the final say in decision making about treatment for depression. I argue that whether the intertwining of discourses of physician influence and patient autonomy is understood as a balance of power between physicians and patients is an open question.

Contemporary quality of life issues affecting gynecologic cancer survivors

Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential gynecologic cancer clinical trials.

Managing care? Medicare managed care and patient use of cardiologists

OBJECTIVE

To examine the impact of Medicare managed care (MMC) versus Medicare fee for service (MFFS) on stent patients' use of physicians with lower resource use and better outcomes.

DATA SOURCES/STUDY SETTING

Retrospective secondary data from 2003 through 2006 for 67,476 patients without acute myocardial infarction, staying 2 or more days in hospital, and treated by 486 physicians in Florida performing 10 or more cases per quarter.

STUDY DESIGN

Analysis was at the patient level. Multivariate logistic models estimated the probability of an MMC patient using a physician with a particular risk-adjusted profile rank with respect to hospital peers.

PRINCIPAL FINDINGS

No differences were found in usage of physicians with shorter admissions. Compared with MFFS, MMC patients were significantly less likely to use physicians whose average mortality was the lowest/lowest quartiles/below median among facility peers, and more likely to use a physician ranked below median on live discharges directly home (not needing home health care, skilled nursing care, or a subacute hospital convalescence). Similar results were found with emergency admissions, and where physicians both attended and treated.

CONCLUSIONS

Florida percutaneous coronary interventions patients insured by MMC used physicians with worse outcome profiles than those of MFFS patients. Results were not consistent with hospital care differences, physician-patient, or payor-physician selection, but they were consistent with selection of unobservably sicker members into MMC and concentration of MMC among physicians.

[Scientific evidence and the cost of innovations in the health-care system]

When depicting the relationship between evidence and the cost of an innovation in the health-care system, the overall risks of assessment, the redistribution of risks in a regulated market, and the ethical consequences must first be taken into account. There are also evidence-based criteria and economic considerations which are relevant when calculating the cost of an innovation. These topics can indicate, but not exhaustively deal with the complicated relationship between scientific evidence and calculating the cost of an innovation in the health-care system. The following three statements summarize the current considerations in the continuing discussion of this topic: *Scientific evidence undoubtedly exists which should be taken into consideration when calculating the cost of an innovation in the health-care system. *The existing scientific evidence is, however, not sufficient to reach such a decision. Additional information about the benefit perceived by the patient is required. *No standardized method exists to measure this additional information. Therefore, a definition problem also exists in the health-care system when setting a price according to scientific evidence.

Physician Perceptions of Access to Quality Care in California's Workers' Compensation System

OBJECTIVE

We measured the association of physician perceptions of access to quality care with intentions to change workers' compensation (WC) participation levels, barriers to delivery of quality care, levels of payment, and type of provider after the implementation of California WC reforms in 2004.

METHODS

Bivariate and logistic regression models were employed using a representative survey of WC providers.

RESULTS

The analyses revealed that intentions to quit or decrease the volume of WC patients, reporting utilization review as a barrier to quality care, and being a chiropractor or acupuncturist were significantly associated with perceptions of decline in access or quality since 2004 and the belief that injured workers do not have access to quality care.

CONCLUSIONS

The results indicate specific aspects of WC reform that lead to negative perceptions among providers and require further scrutiny and improvement.

Work system design for patient safety: the SEIPS model

Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.

Overprescribing of lipid lowering agents

BACKGROUND

Undertreatment of hyperlipidemia has received considerable attention. However, little is known about trends in overprescribing of lipid lowering agents. We examined these trends and their associations with physician, practice, and organisational factors.

METHODS

2034 physicians were surveyed twice: baseline (1996-7) and follow up (1998-9). On each occasion they were asked: "For what percentage of 50 year old men without other cardiac risk factors would you recommend an oral agent for total cholesterol of 240, LDL 150, and HDL 50 after 6 months on a low cholesterol diet?" During the survey period the National Cholesterol Education Program guidelines did not recommend prescribing for these patients. Binomial and multinomial logistic regressions assessed baseline overprescribing and longitudinal changes in overprescribing, accounting for complex sampling.

RESULTS

39% of physicians recommended prescribing at baseline (round 1), increasing at follow up (round 2) to 51% (p < 0.001). Physicians who were more likely to overprescribe at baseline were less likely to be board certified (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.38 to 0.63; p < 0.001), were in solo or two-physician practices (OR 1.88, 95% CI 1.46 to 2.41; p < 0.001), had more revenue from Medicare (OR 1.10, 95% CI 1.03 to 1.17; p = 0.004) or Medicaid (OR 1.09, 95% CI 1.01 to 1.18; p = 0.03), or were family physicians (OR 1.87, 95% CI 1.35 to 2.58; p < 0.001). Physicians with large increases in overprescibing were more likely than those with small increases in overprescribing to be international medical graduates (OR 2.09, 95% CI 1.20 to 3.64; p = 0.011) and to spend more hours in patient care (OR 1.14, 95% CI 1.03 to 1.26; p = 0.016).

CONCLUSIONS

Overprescribing of lipid lowering agents is commonplace and increased. At baseline and longitudinally, overprescribing was primarily associated with physician and practice characteristics and not with organisational factors.

Randomized pilot study to disseminate caries-control services in dentist offices

BACKGROUND

To determine whether education and financial incentives increased dentists' delivery of fluoride varnish and sealants to at risk children covered by capitation dental insurance in Washington state (U.S.).

METHODS

In 1999, 53 dental offices in Washington Dental Service's capitation dental plan were invited to participate in the study, and consenting offices were randomized to intervention (n = 9) and control (n = 10) groups. Offices recruited 689 capitation children aged 6-14 and at risk for caries, who were followed for 2 years. Intervention offices received provider education and fee-for-service reimbursement for delivering fluoride varnish and sealants. Insurance records were used to calculate office service rates for fluoride, sealants, and restorations. Parents completed mail surveys after follow-up to measure their children's dental utilization, dental satisfaction, dental fear and oral health status. Regression models estimated differences in service rates between intervention and control offices, and compared survey measures between groups.

RESULTS

Nineteen offices (34%) consented to participate in the study. Fluoride and sealant rates were greater in the intervention offices than the control offices, but the differences were not statistically significant. Restoration rates were lower in the intervention offices than the control offices. Parents in the intervention group reported their children had less dental fear than control group parents.

CONCLUSION

Due to low dentist participation the study lacked power to detect an intervention effect on dentists' delivery of caries-control services. The intervention may have reduced children's dental fear.

Changes in Usual Source of Care and Perceptions of Health Care Access, Quality, and Use

OBJECTIVE

We sought to evaluate the extent of changes in usual source of care and associations with perceived health care access, quality, and use.

RESEARCH DESIGN

We collected cross-sectional data on adults from the 1998 to 1999 Community Tracking Household Survey (n = 48,720). Linear and logistic regressions accounted for survey design and possible confounders.

RESULTS

Eleven percent of respondents reported a change in usual source of care in the last 12 months; 14% reported no usual source. After adjustment, respondents with a change in usual source reported more unmet needs than those with no usual source or a continuous usual source (13%, 10%, and 7%, respectively), whereas respondents with a change in usual source or no usual source reported lower satisfaction with health care than respondents with a continuous usual source (52%, 51%, and 68%, respectively). However, respondents with a change in usual source were more likely to see a physician in the last 12 months than those with no usual source or a continuous usual source (91%, 46%, and 83%, respectively).

CONCLUSIONS

Persons who experience a change in usual source of care more closely resemble persons who have no usual source in perceptions of access and quality but resemble persons who have a continuous usual source in use. Although we cannot determine whether the change in usual source caused these variations in perceived access, quality, and use, these data suggest that there are important and unrecognized differences in interactions with the health system among individuals who report a usual source of care at a single point in time.