Estimating physician requirements for neurology: a needs-based approach.

Applying the adjusted needs-based model developed by the Graduate Medical Education National Advisory Committee (GMENAC), physician requirements in neurology were estimated for the year 1990. A Delphi panel of physician experts estimated appropriate patterns of treatment for 56 neurologic conditions. Their median estimates implied a need for 14,500 neurologists in 1990, suggesting a shortage relative to the projected supply. An advisory panel of former GMENAC members reviewed those estimates and recommended certain adjustments to ensure internal consistency and compatibility with those for other specialties. Adoption of these adjustments significantly reduces requirements, implying a total need for 8,400 neurologists--a figure in near balance with the projected supply of 8,650. The difference between the Delphi and Advisory Panel estimates reflects divergent views, apparent as well among the Delphi panelists, of the appropriate role of neurologists--consultants versus principal care providers.

Data analysis and sample size issues in evaluations of community-based health promotion and disease prevention programs: a mixed-model analysis of variance approach.

The growing interest in community-based approaches to health promotion and disease prevention (HP/DP) has been accompanied by a growing need to evaluate the effectiveness of such programs. Special issues that arise in these evaluation studies include (1) entire communities are assigned to intervention and control groups, (2) only a small number of communities can usually be studied, (3) the time course of changes in behavior and other outcomes is often of interest, and (4) surveys to measure such changes over time can be conducted with either repeated cross-sectional samples or with longitudinal samples. This paper shows how these issues can be addressed under a mixed-model analysis of variance approach. This approach serves to unify several ideas in the literature on evaluation of community studies, including use of time-series regression and the question of whether the individual or the community should be the unit of analysis. We also describe how the method can be used to estimate sample size requirements, statistical power, or minimum detectable program effect.

Biological and lifestyle factors, and lipid and lipoprotein levels among Japanese Americans in Seattle and Japanese men in Japan.

BACKGROUND: It has been previously shown that Japanese Americans in Seattle have significantly higher cholesterol levels than native Japanese. The present study examines the association of biological and lifestyle factors with plasma lipid and lipoprotein levels among Japanese Americans (JA) and native Japanese (NJ) to determine if these associations are consistent between these high and low cholesterol populations. METHODS: Study samples consisted of 710 JA male and 728 JA female volunteers living in the Seattle area and a random sample of 3833 NJ male urban workers who participated in parallel cardiovascular disease screening and lifestyle surveys for 1989-1994. Multiple regression analysis was conducted to examine the association of lifestyle and biological factors with lipid and lipoprotein levels. RESULTS: Alcohol consumption was positively and linearly associated with high density lipoprotein cholesterol (HDL-C) levels and negatively associated with both low density lipoprotein cholesterol (LDL-C) levels and the ratio of total cholesterol (TC)/HDL-C (P < 0.05 to P < 0.001) among JA males and JA females and NJ males. Current smoking habit was observed to be negatively associated with HDL-C levels and positively with TC/HDL-C ratio and log TG levels (logarithmic transformation of triglyceride values) (P < 0.05 to P < 0.001) among all three groups. Body mass index (BMI) was negatively associated with HDL-C levels and positively associated with log TG and TC/HDL-C ratio among all three groups (P < 0.05 to P < 0.001). Moderate alcohol consumption was negatively associated with log TG levels among JA males and females (P < 0.05), whereas heavy alcohol consumption was positively associated with log TG levels in NJ males (P < 0.001). Smoking was positively associated with TC and LDL-C levels (P < 0.05) among JA males, whereas a negative association (P < 0.05) was observed in NJ males. CONCLUSION: Overall, the fitted models were consistent between JA males and females and NJ males with the exception of smoking on TC and LDL-C. The results suggest that moderate alcohol consumption favourably influences lipid profiles in both high and low cholesterol populations. The results also indicate that light alcohol consumption is associated with decreased triglyceride levels, whereas heavy alcohol consumption is associated with increased triglyceride levels.

Evaluating quality-of-life and health status instruments: development of scientific review criteria.

The Medical Outcomes Trust is a depository and distributor of high-quality, standardized, health outcomes measurement instruments to national and international health communities. Every instrument in the Trust library is reviewed by the Scientific Advisory Committee against a rigorous set of eight attributes. These attributes consist of the following: (1) conceptual and measurement model; (2) reliability; (3) validity; (4) responsiveness; (5) interpretability; (6) respondent and administrative burden; (7) alternative forms; and (8) cultural and language adaptations. In addition to a full description of each attribute, we discuss uses of these criteria beyond evaluation of existing instruments and lessons learned in the first few rounds of instrument review against these criteria.

The Kaiser Family Foundation Community Health Promotion Grants Program: findings from an outcome evaluation.

OBJECTIVES: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities. METHODS: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities. RESULTS: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse. CONCLUSIONS: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.

Effect of compensation method on the behavior of primary care physicians in managed care organizations: evidence from interviews with physicians and medical leaders in Washington State.

The perceived relationship between primary care physician compensation and utilization of medical services in medical groups affiliated with one or more among six managed care organizations in the state of Washington was examined. Representatives from 67 medical group practices completed a survey designed to determine the organizational arrangements and norms that influence primary care practice and to provide information on how groups translate the payments they receive from health plans into individual physician compensation. Semistructured interviews with 72 individual key informants from 31 of the 67 groups were conducted to ascertain how compensation method affects physician practice. A team of raters read the transcripts and identified key themes that emerged from the interviews. The themes generated from the key informant interviews fell into three broad categories. The first was self-selection and satisfaction. Compensation method was a key factor for physicians in deciding where to practice. Physicians' satisfaction with compensation method was high in part because they chose compensation methods that fit with their practice styles and lifestyles. Second, compensation drives production. Physician production, particularly the number of patients seen, was believed to be strongly influenced by compensation method, whereas utilization of ancillary services, patient outcomes, and satisfaction are seen as much less likely to be influenced. The third theme involved future changes in compensation methods. Medical leaders, administrators, and primary care physicians in several groups indicated that they expected changes in the current compensation methods in the near future in the direction of incentive-based methods. The responses revealed in interviews with physicians and administrative leaders underscored the critical role compensation arrangements play in driving physician satisfaction and behavior.

Randomized trial of a patient-centered hospital unit.

Patient-centered hospital units have grown out of the national trend to greater consumerism, but few of these units have been evaluated rigorously. We used a randomized controlled trial to compare patient outcomes on the Planetree Model Hospital Unit with other medical-surgical units in the hospital. Planetree patients were significantly more satisfied than controls with their hospital stay, the unit's environment and nursing care, but did not differ in ratings of physician care. Planetree patients reported more involvement in their care while hospitalized and higher satisfaction with the education they received. There were few differences between Planetree and controls in health behaviors. While Planetree patients reported better mental health status and role functioning after discharge, their health status was similar to controls after 3 to 6 months. There were no differences in length of stay and charges for the index hospitalization, readmissions or outpatient care during the following year.

Community-based surveillance of acute ischemic heart disease: are one-time mailed questionnaires to physicians useful?

A 12-month data collection from medical records in Seattle/King County for acute ischemic heart disease among patients with diabetes mellitus was augmented with mailed questionnaires to personal physicians. The responsible Human Subjects Committee restricted the study to a one-time questionnaire mailing. Only 380 of 1,235 patients required physician contact when information was missing from primary data sources. Questionnaires were highly personalized, and most were limited to one page. Seventy-seven per cent of 330 physicians returned at least one questionnaire, and 62% of all questionnaires were returned with usable data. We conclude that useful data may be collected from physicians by way of mailed questionnaires if researchers use a brief and personal format.

The effect of matching on the power of randomized community intervention studies.

Currently, there is considerable interest in studies that use the community as the experimental unit. Health promotion programmes are one example. Because such activities are expensive, the number of experimental units (communities) is usually very small. Investigators often match communities on demographic variables in order to improve the power of their studies. Matching is known to improve power in certain circumstances. However, we show here that if the number of communities is small, the matched design will probably have less power than the unmatched design. This is due primarily to the loss of degrees of freedom in the matched design, which outweighs the benefits of matching on any but the strongest correlates of changes in behaviour. In the community intervention situation, even small differences in sample size between the matched and unmatched analyses can have expensive consequences.

Establishment of total and intraservice work by chiropractic physicians in providing spinal manipulative therapy and evaluation and management services.

OBJECTIVE: To develop and test a self-report survey instrument that measures the work performed by chiropractors in the delivery of evaluation and management (E/M) services and spinal manipulative therapy (SMT). Work is one leg of a triad used to develop Resource-Based Relative Values Scales (RBRVS) for physician reimbursement. DESIGN: Reliability study modeled after a tool designed and tested by economists at Harvard University School of Public Health in the development of relative values scales for physician reimbursement. The survey instrument uses magnitude estimation as a means of obtaining reliable and valid measures of the subjective assessments of the dimensions of a physicians work. SAMPLE: A random national sample was drawn from all members of the American Chiropractic Association. RESULTS: Estimates of the work performed by chiropractors in providing E/M and SMT services were established. The reliability of work ratings indicated that chiropractors agree closely on their ratings for work. The validity of the results indicated a high degree of consistency in rating work, which implies that the results are realistic. A review of demographics suggested that the survey population was representative of the general population of chiropractors. CONCLUSIONS: This study generated valid and reliable estimates of the work performed by chiropractors in providing E/M and SMT services. Work is one of three components used in the development of RBRVS, the method of physician reimbursement that is currently the industry standard. By quantifying the work required in providing services, chiropractors can now develop RBRVS. Additionally, the evidence-based data on work collected here can be used for a comparison with the work of similar services provided by other specialists. This can facilitate the use or modification of service description codes for use by chiropractic physicians.

Long-term effect of vasectomy on coronary heart disease.

We investigated the association between coronary heart disease (CHD) and vasectomy in a population of 10,632 men who were under surveillance for multiple CHD risk factors during participation in a university-based exercise testing program. We conducted a mail survey with telephone follow-up to determine the vasectomy status of individuals in the population. Responses were obtained from 6,159 individuals. The 4.944 males on whom information was complete enough to be included in the multivariate analysis comprised the study population. Among the 1,383 (28 per cent) vasectomized males in the study populations, the interval from vasectomy to the time of the survey ranged from less than one year to 37 years with a mean duration of 15 years. Although increased relative risks for CHD were found to be associated with family history of CHD, high blood pressure and smoking in this population, the relative risk of CHD associated with vasectomy was not increased in general, nor was it increased when the vasectomized males were classified by time since vasectomy. Likewise, serum antisperm-antibody titers were not predictive of CHD among vasectomized men. These studies support the findings from previous investigations of populations with shorter average post-vasectomy experience in which vasectomy has been shown to be unassociated with altered risk of CHD in humans.

Measuring the quality of medical care. A clinical method.

We outline the implementation of a new method of measuring the quality of medical care that counts cases of unnecessary disease and disability and unnecessary untimely deaths. First of all, conditions are listed in which the occurrence of a single case of disease or disability or a single untimely death would justify asking, "Why did it happen?" Secondly, we have selected conditions in which critical increases in rates of disease, disability, or untimely death could serve as indexes of the quality of care. Finally, broad categories of illness are noted in which redefinition and intensive study might reveal characteristics that could serve as indexes of health. We describe how these inth of the general population and the effects of economic, political, and other environmental factors upon it, and to evaluate the quality of medical care provided both within and without the hospital to maintain health and to prevent and treat disease.

Interspecialty variation in office-based care.

Analysis of national survey data on physician-patient encounters raises questions about physician education and manpower policy. Data compiled by the University of Southern California Medical Activities and Manpower Projects and the United States Bureau of Health Professionals reveal differences among internists, cardiologists, family practitioners, and pediatricians in procedures used for diagnosing and treating several frequently encountered conditions. Differences are observed in expenditure of time and use of a broad range of diagnostic and therapeutic techniques. These differences remain significant even after several important characteristics of individual physicians, patients, and the practice environment have been controlled. Findings from this study underscore the necessity of reviewing the content of medical education and policies that encourage a broad range of specialists to provide primary care. The findings also emphasize the need to address the physician's knowledge base in promoting changes in practice patterns.

Sampling elderly in the community: a comparison of commercial telemarketing lists and random digit dialing techniques for assessing health behaviors and health status.

A study of health behaviors in four communities in the western United States in 1988 provided the opportunity to compare two methods of sampling elderly respondents for a telephone interview. The Polk telemarketing lists were used to identify 1,407 respondents aged 65 years and older in four communities, where 253 respondents in the same age group were also identified by the method of random digit dialing. Individuals identified from the Polk lists received a letter prior to the initial telephone contact. The overall response rate was 49.3% for random digit dialing and 57.3% for the Polk lists. On the average, the identification of one elderly respondent using the Polk lists required about 20-25% as much interviewer time per subject identified as was required by the random digit dialing method. The elderly identified by the Polk lists were significantly older than those identified by random digit dialing, and the proportions of the Polk sample who were married, white, or had an income of greater than $10,000 were slightly higher than those of the random digit dialing sample. Among 40 variables measuring various health behaviors, indicators of health status, and participation in health-related programs and classes, only three differed significantly between the two samples. The authors conclude that sampling from commercial telemarketing lists was an efficient method of identifying elderly respondents and that in these four communities, the estimates of health behaviors and health status were comparable with those obtained by random digit dialing techniques.

The cost and efficacy of home care for patients with chronic lung disease.

A randomized controlled trial was conducted to assess efficacy and cost of sustained home nursing care for patients with chronic lung disease. Three hundred one patients were randomly assigned to a respiratory home care group (RHC) that received care from respiratory home care nurses, a standard home care group (SHC) that received care from regular home care nurses, or an office care group (OC) that received whatever care they needed except for home care. Patients were followed for 1 year. At the end of the study year, there was no difference in survival, pulmonary function, or everyday functioning among the three groups. Average annual cost of care for all study patients was $7,647 (1981-82 dollars). The average annual health care costs for patients in the RHC group was $9,768; for those in the SHC group, $8,058; and for those in the OC group, $5,051 (F = 6.45, df = 2/298, P = 0.02). These results suggest that the current policy of limited coverage of home nursing services by Medicare and other third-party payers may be appropriate.

Race- and ethnicity-specific characteristics of participants lost to follow-up in a telephone cohort.

The purpose of this study was to describe race- and ethnicity-specific characteristics of subjects lost to follow-up. For a study of community-based health interventions, adult subjects from 11 US communities were initially recruited by random digit dialing and interviewed by telephone in 1988; 2 years later, they were recontacted, and the same survey was administered a second time. Associations with loss to follow-up were assessed in separate models for whites, African Americans, Hispanic Americans, and Asian Americans. After 2 years, 40.8% of the 5,851 participants were lost to follow-up; cohort attrition was highest among African Americans (51.3%) and lowest among whites (37.5%). Age, aspects of employment, education, marital status, and income were significant independent predictors of loss to follow-up for one or more of the four racial and ethnic groups. Characteristics of subjects lost to follow-up in this telephone cohort differed among various racial and ethnic groups. After adjustment for demographic, socioeconomic, and health status variables, the important behavioral predictors of loss to follow-up were current smoking for whites (p < 0.05), having a high fat diet for African Americans (p < 0.10), consuming one or more alcoholic drinks per day for Hispanic Americans (p < 0.10), and high levels of physical activity for Asian Americans (p < 0.05).

Implementation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grant Program: a process evaluation.

The Community Health Promotion Grants Program, sponsored by the Henry J. Kaiser Family Foundation, represents a major health initiative that established 11 community health promotion projects. Successful implementation was characterized by several critical factors: (1) intervention activities; (2) community activation; (3) success in obtaining external funding; and (4) institutionalization. Analysis of the program was based on data from several sources: program reports, key informant surveys, and a community coalition survey. Results indicate that school-based programs focusing on adolescent health problems were the most successful in reaching the populations they were targeting. The majority of the programs were able to attract external funding, thereby adding to their initial resource base. The programs were less successful in generating health promotion activities and in achieving meaningful institutionalization in their communities.