Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics.

The Ryan White CARE Act supports comprehensive care to persons with HIV infection. With an annual budget of over $1 billion, it is the largest federally funded programme for HIV care in the USA. We analysed data from the HIV Costs and Services Utilization Study, a nationally representative sample of HIV patients. Patient data were collected in 1996-97 and clinic data were collected in 1998-99. We examined whether CARE Act funded clinics differed from other HIV clinics in (1) the characteristics of their patients, and (2) their organization, staffing, and services. We found that patients at CARE Act clinics were younger, less educated, poorer, and more likely to be female, non-white, unemployed, uninsured, and have heterosexual contact as an HIV risk factor, compared to patients at other HIV clinics. CARE Act clinics tended to specialize in HIV care, had more infectious disease specialists, had fewer total patients, and provided more support services (e.g. mental health, nutrition, case management, child care). These results are consistent with findings of other studies that were limited by non-probability samples or restricted geographical areas.

Evidence for reliability, validity and usefulness of the Medical Outcomes Study HIV Health Survey (MOS-HIV).

The Medical Outcomes Study HIV Health Survey (MOS-HIV) is a brief, comprehensive measure of health-related quality of life (HRQoL) used extensively in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). The 35-item questionnaire includes ten dimensions (health perceptions, pain, physical, role, social and cognitive functioning, mental health, energy, health distress and quality of life (QoL) and takes approximately 5 minutes to complete. Subscales are scored on a 0-100 scale (a higher score indicates better health) and physical and mental health summary scores can be generated. The MOS-HIV has been shown to be internally consistent, correlate with concurrent measures of health, discriminate between distinct groups, predict future outcomes and be responsive to changes over time. Limited experience suggests acceptable reliability and validity in women, injecting drug users and African-American and lower socioeconomic status patients. The MOS-HIV is available in 14 languages and has been included as a secondary outcome measure in numerous clinical trials for all stages of disease. In several studies it has detected significant differences between treatments; in some cases concordant with conventional endpoints and, in others, discordant. The interpretation of scores is facilitated by an explanation in terms meaningful to the intended audience. Research is needed to compare the MOS-HIV to other strategies for HRQoL assessment in early HIV disease.

Rural hospital administrators and strategic management activities.

This study examines the association of characteristics of rural hospital administrators and the adoption of seven strategic activities in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Based on the premise that managerial activities can affect organizational change, we test five hypotheses relating head administrator characteristics to strategic adaptation, controlling for environment-market and hospital-related variables. Bivariate analysis of the strategic adoption showed a positive association with administrative turnover and a negative association with head administrator age. Multivariate logistic regression showed that only high levels of turnover were associated with strategic activities, net of control variables. The implications of these findings and the lack of predictive power of other rural hospital administrator characteristics--especially affiliation with the American College of Healthcare Executives--are discussed within the context of a "strategic management policy" for rural hospitals.

Rural hospital-based alcohol and chemical abuse services: availability and adoption, 1983-1988.

Data from a 1983-88 retrospective panel study of 797 rural (non-Metropolitan Statistical Area) U.S. hospitals revealed that less than one in five (18.7%) had any alcohol and chemical abuse (ACA) service. About one-third of both inpatient and outpatient services had been established during the study period, but few hospitals not offering these services planned to offer them in the immediate future. These findings support other studies that the availability of such services may not meet population need or demand, although non-hospital-sponsored services might partially fill the gap. Bivariate analysis showed that hospital locations in counties that were more densely populated, had higher per capita income and had more physicians per 1,000 population were positively associated with ACA services. Hospitals that were in the New England, Mid-Atlantic, East North Central census divisions, and were large according to number of beds, presence of psychiatric services, availability of psychiatrists and other nonphysician personnel, certain organizational arrangements and strategic management activities were positively associated with ACA services. Multivariable logistic regression suggested the presence of psychiatric services as a key correlate of ACA services, and the scarcity of psychiatric personnel in rural areas appears to have been a major reason for the infrequency of rural hospital-sponsored ACA services.

Horizontal and vertical integration-diversification in rural hospitals: a national study of strategic activity, 1983-1988.

This study examines both the magnitude of and factors influencing the adoption of 13 horizontal and vertical integration and diversification strategies in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Using organization theory, hypotheses were posed relating environmental and market factors, geographic location, and hospital characteristics to the adoption of horizontal and vertical integration and diversification. Results indicate that only one of 13 strategies was adopted by more than 50 percent of all rural hospitals during the study period, and that most of the directional hypotheses were not confirmed using Cox's proportional hazards models. In particular, environmental and market factors were unrelated to the strategies studied. Issues of methodology and theory are discussed; however, during an historically turbulent period, both relatively low levels of rural hospital strategic activities and lack of predictive power of the theory suggest caution in relying heavily on a policy for rural hospital survival that is dependent on individual market-oriented strategic behavior.

Medical malpractice claims filed by Medicaid and non-Medicaid recipients in Maryland.

Several databases available in Maryland are used to investigate whether Medicaid recipients are more likely than other persons to engage in medical malpractice litigation. All malpractice claims filed during 1985 and 1986 (N = 1037) were updated for outcomes through 1989 and described with regard to the payer status of claimants. The proportion of claims filed by persons enrolled in Medicaid before and/or during the alleged malpractice incident was lower than the proportion of state residents enrolled in Medicaid. In addition, the proportion of obstetric claims filed by Medicaid recipients was identical to their proportion of hospital discharges for obstetric services during the period in which the incidents occurred.

Diffusion and adoption of CDC guidelines for the prevention and control of nosocomial infections in US hospitals.

Since 1981, the Centers for Disease Control (CDC) has been publishing Guidelines for the Prevention and Control of Nosocomial Infections as a useful reference tool in infection control. The extent to which practices recommended by CDC to reduce hospital-acquired infections have been successfully diffused and adopted were evaluated in a stratified random sample of 445 US hospitals that were sent a questionnaire in 1985. The data suggest that over 84% of infection control practitioner respondents (78% response rate) are aware of each guideline, although small hospitals (less than 50 beds) are least likely to be aware of the guidelines or to have reviewed them thoroughly. Adoption of the recommendations remains far from universal, ranging from 23% to 75% for 16 specific recommendations investigated. Smaller hospitals were significantly less likely than large hospitals to have adopted each suggested policy. Recommendations that carried Category I rankings were more likely to be adopted, as were those procedures that had cost-savings implications.

Underdiagnosis of alcoholism by residents in an ambulatory medical practice.

Alcoholism is a widespread illness which in its early stages can be treated effectively. It is important, therefore, that medical residents be able to diagnose alcoholism prior to end-stage disease and organ damage. To assess the ability of residents to diagnose alcoholism, a survey was conducted of 95 patients from the ambulatory care internal medicine practice of the Johns Hopkins Hospital. The patients' alcohol consumption was measured by a self-report questionnaire, and the patients answered an alcoholism questionnaire, the responses to which have been shown to correlate with alcoholism. The questionnaire contains four questions, one each on cutting down on alcohol consumption, annoyance at criticism of alcohol consumption, guilty feelings about alcohol consumption, and use of alcohol early in the day. The answers to the questionnaire were compared with the residents' diagnoses of alcoholism on the medical record. Alcoholism was diagnosed by the residents in only 11 of the 20 patients (55 percent) who had given three or more yes answers on the alcoholism questionnaire and in only 14 of the 31 patients (45 percent) who had given two or more yes answers. (Yes answers indicate that patients suffer from alcoholism.) The residents' diagnosis of alcoholism correlated with signs of physical damage or dependence. These results demonstrate a moderate underdiagnosis of alcoholism by residents in the ambulatory care setting and suggest that diagnosing alcoholism in early stages of the disease should be made a part of the training curriculum.

Patient understanding and satisfaction as predictors of compliance.

Patients' satisfaction with the communicative aspects of their medical visits and understanding of their prescription drug regimens were measured for a sample of visits to a prepaid medical plan in a mid-Atlantic metropolitan area. The 1367 patients, who visited either the Department of Adult Medicine or the Urgent Care Center during a 2-week period and their physicians completed questionnaires as part of an ongoing quality assessment study. A 50% random sample of these patients was interviewed by telephone a week after their visits. Compliance was found to be positively correlated with understanding of drug instructions but negatively correlated with satisfaction with communication during the visit. Our findings suggest that satisfying doctor-patient interactions do not necessarily reflect effective communication about drug regimens.

Impact of divergent evaluations by physicians and patients of patients' complaints.

Physicians' estimates of patients' anxiety, discomfort or pain, and activity limitation were compared with reports by their patients on the same dimensions. The data were collected as part of a series of quality assessment studies at a prepaid group practice serving 19,000 people in a Mid-Atlantic metropolitan area. Analysis of the data showed that physicians underestimated the three dimensions 35 percent of the time and that activity limitation was the dimension most often underestimated. Patients whose physicians correctly estimated their discomfort or pain were more likely to receive prescriptions than patients whose physicians underestimated their discomfort or pain. Patients whose physicians underestimated their activity limitation were most likely to report dissatisfaction with the treatment given. The results are consistent with a growing body of evidence suggesting that physicians who show concern about their patients and a desire to understand their problems establish better therapeutic relationships.

Do prescriptions adversely affect doctor-patient interactions?

The purpose of this study was to assess the impact of the prescription on the doctor-patient interaction. Data were collected during ongoing quality assessment studies at a prepaid group practice of about 19,000 enrollees. Adult patients and their providers completed forms on all visits to the Department of Medicine and Urgent Care Center during a two-week period. A 50 percent random sample of patients was interviewed by telephone one week after the index visit. Patients who did not receive prescriptions reported more satisfaction with the communicative aspects of their visits to physicians than patients who did receive prescriptions. We suggest that prescriptions may hinder patient satisfaction with the doctor-patient interaction by substituting for other, more "meaningful" communication between patient and provider.

The role of new health practitioners in a prepaid group practice: provider differences in process and outcomes of medical care.

Practice patterns and patient-reported outcomes of care are compared in detail for ten physicians and 12 new health practitioners delivering ambulatory care in two departments of a prepaid group practice, the Columbia Medical Plan (CMP). All providers completed questionnaires for a 50 per cent random sample of patients seen during a two-week period. Patients completed questionnaires prior to receiving care and were interviewed one week and one month after their clinic visits. New health practitioners deliver approximately 75 per cent of well-person care, 56 per cent of problem-oriented care in adult medicine, and 29 per cent of problem care in pediatrics. They have become increasingly involved over time in the treatment of acute conditions and injuries while physicians have retained their predominant role in treating patients with chronic conditions. Thirty-two per cent of visits with new healh providers involved a physician in one or more of the following: decision-making, direct supervision, consultation, or seeing the patient as a second provider of care. Degree of autonomy varied by type of task performed, category of problem treated, and specialty. The following outcomes of care were examined by type of provider: patient-reported change in problem status,including frequency and intensity of pain or discomfort, level of anxiety, and degree of activity limitation; the degree to which physician-specified criteria for the most commonly occurring conditions were met with respect to change in problem status; and patient satisfaction with a number of dimensions of the clinic visit. The analysis suggests that the new health practitioners at the CMP are providing care, within their areas of responsibility, of comparable quality to that delivered by physicians.