Diagnostic Accuracy of the Primary Care Screener for Affective Disorder (PC-SAD) in Primary Care.

BACKGROUND: Depression goes often unrecognised and untreated in non-psychiatric medical settings. Screening has recently gained acceptance as a first step towards improving depression recognition and management. The Primary Care Screener for Affective Disorders (PC-SAD) is a self-administered questionnaire to screen for Major Depressive Disorder (MDD) and Dysthymic Disorder (Dys) which has a sophisticated scoring algorithm that confers several advantages. This study tested its performance against a 'gold standard' diagnostic interview in primary care. METHODS: A total of 416 adults attending 13 urban general internal medicine primary care practices completed the PC-SAD. Of 409 who returned a valid PC-SAD, all those scoring positive (N=151) and a random sample (N=106) of those scoring negative were selected for a 3-month telephone follow-up assessment including the administration of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) by a psychiatrist who was masked to PC-SAD results. RESULTS: Most selected patients (N=212) took part in the follow-up assessment. After adjustment for partial verification bias the sensitivity, specificity, positive and negative predictive value for MDD were 90%, 83%, 51%, and 98%. For Dys, the corresponding figures were 78%, 79%, 8%, and 88%. CONCLUSIONS: While some study limitations suggest caution in interpreting our results, this study corroborated the diagnostic validity of the PC-SAD, although the low PPV may limit its usefulness with regard to Dys. Given its good psychometric properties and the short average administration time, the PC-SAD might be the screening instrument of choice in settings where the technology for computer automated scoring is available.

Development and preliminary validation of the PC-SAD5, a screener-derived short depression severity measure.

BACKGROUND: The prevalence of depressive disorders is high among patients with skin disease. The PC-SAD is a 37-item self-administered depression screening questionnaire that has been validated in dermatological patients. OBJECTIVE: The aim of this study was to develop and validate a brief depression severity instrument derived from the PC-SAD that can be used to assess severity and monitor ongoing clinical course. METHODS: Two patient samples participated in the study: 72 adult dermatological inpatients and 73 adults attending six primary care practices. Psychiatric assessment included the Structured Clinical Interview for DSM-IV and an 18-item version of the PC-SAD; moreover, dermatological patients completed the Patient Health Questionnaire depression scale (PHQ-9), while primary care patients were administered the Montgomery-Asberg Depression Rating Scale (MADRS). A subset of five PC-SAD items showing the best psychometric properties were selected, and the reliability and validity of the resulting instrument (PC-SAD5) were examined. RESULTS: The PC-SAD5 showed satisfactory internal consistency in both samples. There was a high correlation between PC-SAD5 and PHQ-9 and MADRS scores. Multiple regression analysis revealed a gradient of PC-SAD5 scores from patients with no mental disorder, those with milder forms of depression, to those with Major Depressive Disorder. Similar results were observed for the 18-item version of the PC-SAD. CONCLUSION: The availability of valid and reliable continuous measures of depression severity derived from the PC-SAD extends its field of application from depression screening to use as a follow-up measure of depression severity in routine clinical practice. A validated very short instrument such as the PC-SAD5 may have substantial clinical value.

Outcomes for adult outpatients with depression under prepaid or fee-for-service financing.

OBJECTIVE: To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties. METHOD: Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States. RESULTS: Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall. CONCLUSION: Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

Quality of care for depressed elderly patients hospitalized in the specialty psychiatric units or general medical wards.

BACKGROUND: Studies to assess quality of care have become increasingly important for research and policy purposes. OBJECTIVE: To evaluate the difference in quality of care between elderly depressed patients hospitalized in specialty psychiatric units and those hospitalized in general medical wards. METHODS: We reviewed retrospectively the medical charts of 2746 patients with depression hospitalized in 297 general medical hospitals in five different states. Quality of care was assessed by clinical review of explicit and implicit information contained in the medical records of patients in specialty psychiatric units (n = 1295) and general medical wards (n = 1451). We also used other secondary data sources to determine postdischarge outcomes. RESULTS: We found that (1) a higher percentage of admissions on the psychiatric units were considered appropriate, (2) overall psychological assessment was better on the psychiatric unit, (3) patients were more likely to receive psychological services on the psychiatric wards but more likely to receive traditional general medical services on medical wards, (4) there were more inpatient general medical complications on the psychiatric wards, and (5) implicit measures of clinical status at discharge were better for those on the psychiatric unit. CONCLUSIONS: Although limited by reliance on medical record abstraction and a retrospective study design, our data indicate that the quality of care for the psychological aspects of the treatment of depression may be better on psychiatric units, while the quality of general medical components of care may be better on general medical wards.

Recall of recommendations and adherence to advice among patients with chronic medical conditions.

BACKGROUND: Patient adherence to treatment regimens may be a critical mediator between physician recommendations and patient outcomes, but levels of adherence have not been compared across disease groups, and patient self-reports have not been well validated. METHODS: To determine recall of and adherence to physicians' recommendations among patients with chronic medical conditions and to measure the correspondence between self-reported adherence and disease activity, we analyzed data from the Medical Outcomes Study. A total of 1751 patients with diabetes mellitus, hypertension, and heart disease were identified among 20,223 patients visiting family physicians, general internists, cardiologists, and endocrinologists in 1986. Main outcome measures included recall of 15 disease-specific recommendations, self-reported general and specific adherence, and correlations between adherence and clinical measures of disease activity and control. RESULTS: Among patients in all three disease groups, the proportion recalling recommendations to take prescribed medications (> or = 90%) exceeded the fraction recalling recommendations to follow a restricted diet, exercise regularly, and perform various self-care activities (22% to 84%). Adherence to recalled recommendations was similar across conditions but varied markedly according to the nature of the recommendations; for example, 91% of diabetics took prescribed medications but 69% followed a diabetics diet and 19% engaged in regular exercise. Adherence to recommendations was correlated with reduced serum glucose (r = -.33) and glycohemoglobin (r = -.25) levels among insulin-dependent diabetics and with reduced diastolic blood pressure among patients with hypertension (r = -.15). CONCLUSIONS: The majority of chronically ill patients failed to recall elements of potentially important medical advice and did not always adhere to advice that was recalled. Self-reported adherence was correlated with clinical measures of disease activity and control. Additional research is needed not only to improve adherence to medical advice in patients with chronic illnesses but also to determine which life-style changes are truly beneficial for these patients.

Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment.

BACKGROUND: The relationship of do-not-resuscitate (DNR) orders to patient and hospital characteristics has not been well characterized. METHODS: This observational study of a nationally representative sample of 14,008 Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture evaluated the relationship of DNR orders to patient sickness at admission, functional impairment, age, disease, race, gender, preadmission residence, insurance status, and hospital characteristics. RESULTS: Of the 14,008 patients, DNR orders were assigned to 11.6%. Patients with greater sickness at admission and functional impairment received more DNR orders (P < .001) but even among patients in the sickest quartile (with a 65% chance of death within 180 days), only 31% received DNR orders. The DNR orders were assigned more often to older patients after adjustment for sickness at admission and functional impairment (P < .001), and DNR order rates differed by diagnosis (P < .001). After adjustment for patient and hospital characteristics, DNR orders were assigned more often to women and patients with dementia or incontinence and were assigned less often to black patients, patients with Medicaid insurance, and patients in rural hospitals. CONCLUSIONS: Do-not-resuscitate orders are assigned more often to sicker patients but may be underused even among the most sick. Sickness at admission and functional impairment do not explain the increase in DNR orders with age or the disparity across diagnosis. Further evaluation is needed into whether variation in DNR order rates with age, diagnosis, race, gender, insurance status, and rural location represents differences in patient preferences or care compromising patient autonomy.

Organizational and financial characteristics of health plans: are they related to primary care performance?

BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

Quality of care for hospitalized depressed elderly patients before and after implementation of the Medicare Prospective Payment System.

OBJECTIVE: The authors evaluated the impact of Medicare's Prospective Payment System on aspects of quality of care and outcomes for depressed elderly inpatients in acute-care general medical hospitals. METHOD: The depressed elderly inpatients (N = 2,746) were hospitalized in 297 acute-care general medical hospitals. The authors used a retrospective before-and-after design, controlling for differences over time in sickness at admission. Quality of care and outcomes were assessed through clinical review of explicit and implicit information in the medical records; secondary data sources provided information on postdischarge outcomes. RESULTS: After implementation of the prospective payment system 1) a higher percentage of patients had clinically appropriate acute-care admissions; 2) the initial assessment of psychological status by the treating provider was more complete; 3) the quality of psychotropic medication management, as rated by the study psychiatrists, improved; 4) the rates of any inpatient medical or psychiatric complication, of discharge to another hospital or a nursing home, and of inpatient readmission declined; and 5) there was no marked change in the percentage of patients rated by study clinicians as having acceptable overall clinical status at discharge or the rate of mortality 1 year after admission. CONCLUSIONS: After the implementation of the Medicare Prospective Payment System, the quality of care for depressed elderly inpatients improved and there was no marked increase in adverse clinical outcomes. Despite these gains, after implementation the quality of care was moderate at best and over one-third of the patients had unacceptable clinical status at discharge.

Prepaid group practice effects on the utilization of medical services and health outcomes for children: results from a controlled trial.

A total of 693 children between the ages of 0 and 13 years were randomly assigned to either a staff model HMO or to one of several fee-for-service insurance plans in Seattle to evaluate differences in medical expenditures and health outcomes. Although the fee-for-service plans varied the amount of cost sharing (0% to 95%), all children were covered for the same medical services, for either 3 or 5 years. No differences in imputed total expenditures were observed for children assigned to the HMO or any of the fee-for-service plans. Children with cost-sharing fee-for-service plans, however, had fewer medical contacts and received fewer preventive services than those assigned to the HMO. Nonetheless, children with the cost-sharing fee-for-service plans were perceived (by their mothers) to be in better health overall than those assigned to the HMO. No significant differences regarding physiological outcomes (eg, visual acuity, hemoglobin level) were observed between the two groups. The results of this experiment neither strongly support nor indict fee-for-service or prepaid care for children.

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.

Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the Medical Outcomes Study.

This study was carried out to determine whether levels of physical activity of patients with various chronic diseases are associated with subsequent functioning and well-being. It was an observational 2-year longitudinal design. The setting was offices of medical and mental health practices within health maintenance organizations, large multispecialty groups, and solo practices or small single-specialty group practices in three U.S. cities. Included in the study were 1758 adult patients with one or more of the following: diabetes, hypertension, congestive heart failure, recent myocardial infarction, depressive symptoms, or current depressive disorder. Outcome measures included physical, role, and functioning; energy/fatigue; pain intensity; sleep problems; depressed affect, anxiety, positive affect, and overall psychological distress/well-being; health distress; and current health perceptions. Cross-sectional (base-line), 2-year endpoint, and change score relationships were evaluated between baseline levels of physical activity and each outcome, controlling for chronic conditions, comorbidity, smoking, alcohol use, overweight, self-reported adherence, and other patient and study characteristics. Higher baseline levels of exercise were uniquely associated with better functioning and well-being at baseline and 2 years later for some measures. The magnitude of the differences varied by disease group, but tended to be between 0.17 and 0.39 of the baseline SD. Greater levels of exercise are associated with feeling and functioning better for patients with chronic conditions over a 2-year period, suggesting that this is a fruitful area for further study using controlled interventions.

Influences of gender and social class on adolescents' perceptions of health.

OBJECTIVE: To explore how gender and social class affect perceptions of health status among 16-year-old adolescents. DESIGN: Cross-sectional survey. SETTING: University psychology laboratory. PARTICIPANS: Fifty upper-middle-class and 48 working-class adolescents stratified by gender. MAIN OUTCOME MEASURES: The general health perceptions (GHP) scale of the Medical Outcomes Survey 36-Item Short Form Health Survey (SF-36). The other self-reported health status domains and 3 measures of different aspects of psychological well-being were included as covariates in analysis of variance models. RESULTS: Upper-middle-class females reported the lowest and upper-middle-class males the highest GHP (76.7 vs 88.4, P=.003). A multivariate regression model (adjusted R2=0.08) revealed significant gender (P=.03) differences in GHP, but not a social class effect, and an interaction effect between gender and class (P=.01). With addition of psychological well-being covariates (P<.001), gender remained significant (P=.04) and a significant portion of the interaction effect (P=.13) was explained. When the self-reported physical health status scales (P<.001) were added to the model (adjusted R2=0.51), gender remained significant (P=.03) and the interaction effect was partially explained (P=.07). CONCLUSIONS: Gender is a crucial factor in understanding the complex relationships between sociostructural inequalities and health differentials. These data suggest that psychological well-being and self-reported physical health status mediate the effects of gender and the gender and social class interaction in explaining variation in GHP. Contrary to the social class gradient hypothesis, upper-middle-class females reported the lowest GHP. These results suggest that the paradigms applicable to early childhood and adulthood may not be appropriate to understand the complex dynamics of adolescence.

Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study.

The influence of physicians' attributes and practice style on patients' adherence to treatment was examined in a 2-year longitudinal study of 186 physicians and their diabetes, hypertension, and heart disease patients. A physician-level analysis was conducted, controlling for baseline patient adherence rates and for patient characteristics predictive of adherence in previous analyses. General adherence and adherence to medication, exercise, and diet recommendations were examined. Baseline adherence rates were associated with adherence rates 2 years later. Other predictors were physician job satisfaction (general adherence), number of patients seen per week (medication), scheduling a follow-up appointment (medication), tendency to answer patients' questions (exercise), number of tests ordered (diet), seriousness of illness (diet), physician specialty (medication, diet), and patient health distress (medication, exercise).

Do depressed patients in different treatment settings have different levels of well-being and functioning?

Differences in the functioning and well-being of adult patients with current or past depressive disorder who visited clinicians of different specialties in health maintenance organizations, solo practices, or large multispecialty group practices were examined. For patients in different systems, there were no significant differences in functioning and well-being across 12 domains tested. Patients of mental health specialists had worse mental health and more limitations in social activities, whereas patients of medical clinicians had worse physical functioning, more pain, more physical/psychophysiologic symptoms, and worse health perceptions. Thus, each system of care had depressed patients with a similar functioning and well-being "burden" but specialty sectors had patients with slightly different functioning and well-being profiles, probably reflecting patient selection of type of provider.

Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the Medical Outcomes Study.

OBJECTIVE: We compare mental health utilization in prepaid and fee-for-service plans and analyze selection biases. DATA SOURCE: Primary data were collected every six months over a two-year interval for a panel of depressed patients participating in the Medical Outcomes Study, an observational study of adults in competing systems of care in three urban areas (Boston, Chicago, and Los Angeles). STUDY DESIGN: Patients visiting a participating clinician at baseline were screened for depression, followed by a telephone interview, which included the depression section of the NIMH Diagnostic Interview Schedule. Patients with current or past lifetime depressive disorder and those with depressed mood and three other lifetime symptoms were eligible for this analysis. We analyze mental health utilization based on periodic patient self-report. ANALYTIC METHODS: We use two-part models because of the presence of both nonuse and skewness of use. Standard errors are corrected nonparametrically for correlations across observations due to clustered sampling within participating physicians and repeated observations on the same individual. PRINCIPAL FINDINGS: The average number of mental health visits was 35-40 percent lower in the prepaid system, adjusted and unadjusted for observed differences in patient characteristics, including health status. Utilization differences were concentrated among patients of psychiatrists, with only minor differences among patients of general medical providers. Analyzing the effect of switches that patients make between payment systems over time, we found some evidence of adverse selection into fee-for-service plans based on baseline utilization, but not based on utilization at the end of the study. In particular, after adjusting for observed patient characteristics and health status, patients switching out of prepaid plans had higher baseline use than predicted, whereas patients switching out of fee-for-service had lower use than predicted. Switching itself appears to be related to an immediate decline in utilization and was not followed by an increase or "catch-up" effect. CONCLUSIONS: The absence of the commonly found "catch-up" effect following switching and the significant decrease in utilization during the switching period suggests an interruption in care that does not occur for patients staying within a payment system. This finding emphasizes the need for integrating new patients quickly into a system, an issue that should not be neglected in the current policy discussion.

A longitudinal study of hospitalization rates for patients with chronic disease: results from the Medical Outcomes Study.

OBJECTIVE: To prospectively compare inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for patients with chronic disease. DATA SOURCE/STUDY SETTING: Data from the Medical Outcomes Study, a longitudinal observational study of chronic disease patients conducted in Boston, Chicago, and Los Angeles. STUDY DESIGN: A four-year prospective study of resource utilization among 1,681 patients under treatment for hypertension, diabetes, myocardial infarction, or congestive heart failure in the practices of 367 clinicians. DATA COLLECTION/EXTRACTION METHODS: Insurance payment system (PPD or FFS), hospitalizations, and office visits were obtained from patient reports. Disease and severity indicators, sociodemographics, and self-reported functional status were used to adjust for patient mix and to compute expected utilization rates. PRINCIPAL FINDINGS: Compared to FFS, PPD patients had 31 percent fewer observed hospitalizations before adjustment for patient differences (p = .005) and 15 percent fewer hospitalizations than expected after adjustment (p = .078). The observed rate of FFS hospitalizations exceeded the expected rate by 9 percent. These results are not explained by system differences in patient mix or trends in hospital use over four years. Half of the PPD/FFS difference in hospitalization rate is due to intrinsic characteristics of the payment system itself. CONCLUSIONS: PPD patients with chronic medical conditions followed prospectively over four years, after extensive patient-mix adjustment, had 15 percent fewer hospitalizations than their FFS counterparts owing to differences intrinsic to the insurance reimbursement system.

Do patient assessments of primary care differ by patient ethnicity?

OBJECTIVE: To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity. DATA SOURCES/STUDY DESIGN: A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design. PRINCIPAL FINDINGS: Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites. CONCLUSIONS: We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

Gender differences in medical treatment: the case of physician-prescribed activity restrictions.

A growing scientific literature highlights concern about the influence of social bias in medical care. Differential treatment of male and female patients has been among the documented concerns. Yet, little is known about the extent to which differential treatment of male and female patients reflects the influence of social bias or of more acceptable factors, such as different patient preferences or different anticipated outcomes of care. This paper attempts to ascertain the underlying basis for an observed differential in physicians' tendency to advice activity restrictions for male and female patients. We explore the extent to which the gender-based treatment differential is attributable to: (1) patients' health profile, (2) patients' role responsibilities, (3) patients' illness behaviors, and (4) physician characteristics. These four categories of variables correspond to four prominent social science hypotheses concerning gender differences in health and health care utilization (i.e, biological basis hypothesis, fixed role hypothesis, socialization hypothesis, physician bias hypothesis). Data are drawn from the Medical Outcomes Study (MOS), a longitudinal observational study of 1546 patients of 349 physicians practicing in three U.S. cities. Multivariate logistic regression is used to evaluate the likelihood of physician-prescribed activity restrictions for male and female patients, and to explore the absolute and relative influence of patient and physician factors on the observed treatment differential. Results reveal that the odds of prescribed activity restrictions are 3.6 times higher for female patients than for males with equivalent characteristics. The observed differential is not explained by differences in male and female patients' health or role responsibilities. Gender differences in illness behavior and physician gender biases both appear to contribute to the observed differential. Female patients exhibit more illness behavior than males, and these behaviors increase physicians' tendency to prescribe activity restrictions. After accounting for illness behavior differences and all other factors, the odds of prescribed activity restrictions among female patients of male physicians is four times that of equivalent male patients of those physicians. Medical practice, education, and research must strive to identify and remove the likely unconscious role of social bias in medical decision making.

Information content and clarity of radiologists' reports for chest radiography.

RATIONALE AND OBJECTIVES: We systematically characterized the information provided by chest radiography reports on a nationally representative sample of 822 elderly patients hospitalized in 297 acute-care hospitals in five states who had an admission diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. METHODS: We studied the content of radiography reports, including mention of the type or adequacy of radiography; the presence or absence of a prior radiograph; comments about bones, the aorta, the mediastinum, and pleura and notation of the laterality of findings; and the presence of diagnosis. Two physicians reviewed each patient's report, and a third assigned the final rating when they disagreed. RESULTS: Our analysis found wide variation in content of chest radiography reports, extensive variation in terms used to identify the presence or absence of abnormal findings, and a large degree of uncertainty in what was found. CONCLUSION: With most hospitals introducing new information systems in response to technological advances and the need to generate more formal hospitalwide reports, the time is right to improve the quality of chest radiography reporting.

Adolescents' understanding of social class: a comparison of white upper middle class and working class youth.

PURPOSE: Social class is increasingly being recognized as an important factor in the development of population-based variation in health among teens. However, little consensus exists regarding its measurement or conceptualization. METHODS: This study examined beliefs about social class of 48 working class and 50 upper middle class 16-year-old, white teens. RESULTS: Working class teens were more likely to misclassify themselves with regard to social class position. Significant class differences were present in beliefs regarding social mobility, parents' equity, equality of opportunity within society, and financial status as adults. How this conceptualization of social class translates into population-based variation in health remains an important area for further inquiry.