Uncompensated care provided by private practice physicians in Florida.

While a great deal of attention has been paid in recent years to establishing the magnitude and characteristics of uncompensated care in hospitals, comparatively little research has been undertaken to study physician uncompensated care. This article reports the results of a prospective patient-specific study of uncompensated care in Florida. Of 4,042 cases examined, 26.2 percent had charges voluntarily reduced below the usual and customary charge at the time of service. However, only 13.5 percent of those reductions were attributed to charity. Overall, 10.4 percent of the total billed amount was left unresolved. When payment source was considered, it was found that self-pay patients accounted for 30.6 percent of the cases but accounted for 52.0 percent of the unresolved amounts. Further analysis indicated that the self-pay patients were 35.5 times more likely to leave an outstanding balance than individuals with some type of insurance coverage. Odds of unresolved balances were also calculated as a function of income, specialty type, practice size, and type of visit.

Impact of a required family medicine clerkship on medical students' attitudes about primary care.

A study of 314 medical students before and after a required third-year clerkship in family medicine explored relationships among exposure to the clerkship and changes in attitudes toward primary care. The survey instrument contained 29 statements distinguishing the philosophy of primary care from that of subspecialty-oriented medicine and asked students' to state their future residency plans. The responses of the primary care and subspecialty-oriented groups were the most disparate, whereas the students who were uncertain about residency plans shifted on several items from an alignment with the specialty group toward an alignment with the primary care group. This study shows that experience in a family medicine clerkship may be associated with changes in attitudes that represent development of a more informed image of primary care.

Morbidity and comorbidity among Great Lakes American Indians: predictors of functional ability.

This article explores patterns of morbidity and comorbidity and their ability to predict functional disability among American Indian elders, using data from a sample of urban, rural off-reservation, and reservation Great Lakes American Indians age 55 and older. Higher rates are reported of a number of chronic illnesses than found in overall samples of U.S. elders. Results of multiple regression analyses predicting Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) show age to be a consistent predictor of functional disabilities: The CMI (Index of Comorbidity) was found to be a more useful predictor of functional disability than was the simple summation of the number of chronic illnesses.

The effect of religious concentration and affiliation on county cancer mortality rates.

Previous research has documented lower cancer mortality rates among religious groups characterized by doctrinal orthodoxy and behavioral conformity. In addition, there is evidence that the general population in an area with a high concentration of religious participants may experience health benefits resulting from diminished exposure to or increased social disapproval of behaviors related to cancer mortality. This research examines the effect of religious concentration and denominational affiliation on county cancer mortality rates. Our findings suggest that religion has a significant impact on mortality rates for all malignancies combined, for digestive cancer, and for respiratory cancer when we control for demographic, environmental, and regional factors known to affect cancer mortality. These results provide new insight into the relationship between religion and health at the macro or community level and suggest that the influence of religion on social structure warrants further attention.

Determinants of primary caregiver stress and burden: area of residence and the caregiving networks of frail elders.

This research examines the association among characteristics of the caregiving network, primary caregiver stress and burden, and area of residence. The purpose is two-fold: to determine whether the structure of the relationship between the caregiving network, and stress and burden is uniform across rural, small city, and urban samples; and, to assess whether stress and burden are explained by a similar set of variables within area of residence categories. The data are drawn from a matched sample of 1,388 impaired elders and their primary caregivers from the 1982 National Long-Term Care Survey and the National Survey of Informal Caregivers. In general, the analysis shows that several characteristics of the care-receiver and the primary caregiver have a differential effect on stress and burden across residential categories, and that, within rural, small city, and urban samples, the determinants of stress and burden are not homogeneous. When the frail elder is able to reciprocate by doing chores, babysitting, or providing some other type of assistance for the primary caregiver, however, both stress and burden are reduced in all three residential categories. Similarly, the increased provision of assistance with instrumental activities of daily living by the primary caregiver uniformly increases stress and burden. These findings suggest that interventions designed to alleviate primary caregiver stress and burden may be able to have some common components, but may also need to be tailored in some ways to specific residential environments.

The effects of on- and off-reservation residence on in-home service use among Great Lakes American Indians.

Community-based, in-home services are a crucial component in the long-term care continuum. Research has shown rural populations to be less likely to use these services. American Indian elders are more likely than their non-American Indian counterparts to reside in non-metropolitan areas, yet little rural research has focused on this subpopulation. The purpose of this article is to explore differences in in-home service use among urban, rural off-reservation, and rural on-reservation older American Indians using data from a statewide needs assessment. The sample includes 206 Great Lakes American Indians aged 55 and older. Predictor variables include the residential classification variable (rural off-reservation, rural on-reservation, and urban) along with sociodemographic, social support, health and functional status, and general knowledge of services. Results of logistic regression analysis indicate that the odds are significantly greater for on-reservation rural American Indian elders use of home services, home health aides, and home visits, than for urban American Indian elders. The off-reservation rural American Indian elder is significantly less likely than the urban American Indian elder to use a home health aid. Health rating, activities of daily living/instrumental activities of daily living (ADL/IADL) impairments, and general knowledge of in-home service availability increase the odds for all groups use of home services and home health aides.

Recruitment and retention of rural physicians: issues for the 1990s.

This paper briefly describes a number of structural and economic changes in the profession of medicine and in the rural medical care delivery system that have occurred since about 1970. Changes in the national physician supply; in the training, work, and practice characteristics of physicians; in the demographic characteristics of physicians; in the medical resources available in rural communities; and in federal and state support for the provision of medical services are noted. Four conceptual models that underlie physician recruitment and retention programs for small towns and rural communities are described. These include affinity models, which attempt to recruit rural persons into training or foster interest in rural practice among trainees; economic incentive models, which address reimbursement or payment mechanisms to increase economic rewards for rural practice; practice characteristics models, which address technical, collegial, referral, and other structural barriers to rural practice; and indenture models, which recruit temporary providers in exchange for scholarship support, loan forgiveness, or licensure. Examples of applications of each model are provided and the effects of changes in the medical care system on the effectiveness of each model are assessed. Finally, it is argued that elements of an optimal model for the recruitment of physicians to rural practice include the promotion of medical careers among rural high school students, the provision of financial and cultural support for their training, the development of technical and collegial support systems, and the limited use of indenture mechanisms to meet the needs of the most impoverished or isolated rural settings.

Decomposing area of residence differences in multiple regression studies: the relative contributions of independent variables and model coefficients.

When rural/urban differences are found in health status or health care use, it is often desirable to identify those factors (such as age, social structure, income, etc.) that influence such differences. To this end, researchers often test rural/urban differences in age, social structure, income, etc., for statistical significance. Also, researchers commonly perform multivariate analyses (such as multiple regressions) to examine rural-urban differences in the influence of various independent variables on the dependent variable of interest. Frequently, researchers discover: (1) statistically significant rural/urban differences in the independent variables (such as age, social structure, income, etc.) and (2) statistically significant rural/urban differences in the effects of these independent variables (i.e., statistically significant rural/urban differences in regression coefficients). The analysis typically stops here, without addressing the relative contributions of (1) and (2) to the rural/urban differences in the dependent variable. This paper argues that the relative contributions of (1) and (2) have important implications for the way policy-makers address rural health problems. This paper presents a method for assessing the relative contributions of differences in the independent variables and differences in regression coefficients to observed differences in the dependent variable, and illustrates the application of the method by analyzing rural/urban differences in the risk of institutionalization.

The health status, health services utilization, and support networks of the rural elderly: a decade review.

Research from the 1980s on several dimensions of health and health care among the rural elderly is reviewed. Following a brief discussion of the demographic patterns and life conditions of the rural elderly, the current state of knowledge regarding health status, health services utilization, and the potential for informal and familial care of the elderly is examined. The review concentrates on studies that include comparisons between rural and urban populations and/or control for additional variables that are known to covary with residence. Such analyses permit the documentation of the effects of residential location on health indicators net of other factors. The review concludes that the rural elderly are relatively disadvantaged in terms of both health status and access to health care services, and have little if any advantage over the urban elderly in their access to informal sources of care. Following the review, an agenda for future research is identified.

Job satisfaction among hospital nurses: facility size and location comparisons.

Despite recent declines in turnover and vacancy rates, maintaining a stable nursing staff continues to be critical to the effective operation of American hospitals. Job satisfaction is a pivotal element in nurse retention, and organizational theory suggests that some of the factors that influence job satisfaction vary by facility size. This is a study of job satisfaction among a sample of 731 nurses providing direct patient care in 22 hospitals. The sample includes approximately equal numbers of nurses employed in very small rural hospitals (1-49 beds), medium sized facilities located in small towns (50-99 beds), and larger metropolitan institutions (> 100 beds). Differences by hospital size were observed in overall job satisfaction and in five sub-dimensions of that concept (i.e., professional status, task requirements, pay, organizational policies, and autonomy). With the exception of pay, the results indicated that nurses employed in the very small rural hospitals were more satisfied with their jobs. Differences by hospital size were also observed in the personal characteristics of the nurses, several specific aspects of their job, and in their perceptions of job mobility. A set of four hierarchically nested ordinary least squares regression models indicated that job-specific characteristics were the most powerful predictors of job satisfaction.

The design of a simulated forcible entry test for fire fighters.

This study investigated the physiological responses and performances for 20 fire fighters when completing simulated forcible entry tests. The purpose was to establish the validity of using a tire striking test and to examine the effects of varying the test parameters. The tests consisted of striking a reinforced structure and a weighted truck tire on a plywood covered table with either a 4.54 or a 5.60 kg sledge hammer. The results indicate that the simulated forcible entry tests are short in duration (range = 8.0-17.6 s), but are also physically demanding in terms of cardiovascular response (range = 86.5-97.2 for a percentage of heart rate reserve). The differences in striking a reinforced structure versus hitting a tire were insignificant according to most of the measures taken. The parameters for the simulated forcible entry test that were determined to be most appropriate were to move the tire 30 cm and use the 4.54 kg sledge hammer.

A multivariate comparison of the involvement of adult sons versus daughters in the care of impaired parents.

The purpose of this research was to explore whether gender differences in parent care (i.e., the greater participation of daughters) persisted after controlling for additional caregiver and care-receiver characteristics known to affect the provision of care. Assistance with activities of daily living (ADLs) was examined separately from assistance with instrumental activities of daily living (IADLs). A multivariate analytical framework was employed to account for the effects of a wide range of variables. Moreover, data on all of the living children (N = 13,172) of a sample of impaired elders (N = 4,371) were used, not just data on those children who were known to be providing help. Net of other caregiver and care-receiver characteristics, daughters were 3.22 times more likely than sons to provide ADL assistance and 2.56 times more likely to provide IADL assistance. Although these results are not substantively different from previous research, the methodological approach taken provides a better empirical base for estimating the effect of gender on the probability of being involved in parent care.

The association of gender, sibling network composition, and patterns of parent care by adult children.

Based on matched data from the 1982 National Long-Term Care Survey and the National Survey of Informal Caregivers, this article explores the degree to which separating adult children (N = 3,742) by the composition of their sibling network (i.e., only children, single-gender networks, and mixed-gender networks) provides insight into the association between gender and patterns of parent-care. Caregiving participation was calculated as a proportion of the availability of all children of a specific gender. The data reveal that, within all sibling network categories, daughters were more likely than sons to be providing care to an impaired parent; however, the repercussions of being a caregiver were not similarly uniform. Specifically, sons and daughters from only-child and single-gender networks reported a similar number of hours per day spent in parent-care and experienced comparable levels of stress and burden. In contrast, daughters from mixed-gender networks reported significantly higher levels of stress and burden and more hours per day spent caregiving than sons. These findings demonstrate that differentiating children by sibling network type does offer some clarity to our understanding of the complex association between gender and patterns of parent-care.

Gender differences in parent care: demographic factors and same-gender preferences.

This study tested the hypothesis that, when aging parents are assisted in the tasks of daily living by their adult children, the gender of the child providing care depends in part upon the gender of the parent requiring care. Data on 4,371 infirm elders and their 13,172 adult children from the National Long-Term Care Survey were analyzed by means of logistic regression. Separate analyses show that adult children are more likely to provide care to a parent of the same gender, and infirm elders are more likely to receive care from a child of the same gender. Because the substantial majority of elderly parents requiring care from children are mothers, this tendency toward gender consistency in the caregiving relationship partially accounts for the fact that daughters are more likely than sons to be involved in parent care.

Area of residence and the risk of institutionalization.

Many of the sociodemographic, health status, and social support characteristics that predict the use of health services by elders vary by area of residence. Yet, little is known about how these factors affect the risk of institutionalization in rural, small city, and urban areas. The purpose of this research was to: (a) determine the rate of institutionalization over a two-year period for impaired community-dwelling elders in rural, small city, and urban areas; (b) test for residence differences in sociodemographic, health status, and social support characteristics likely to influence the risk of institutionalization; and (c) examine their effect on the probability of being institutionalized in each area of residence. Although rural elders are less likely to be placed in a nursing home than their small city or urban counterparts, race and level of impairment affect the risk of institutionalization more in rural than in urban areas.

Medical students and comprehensive patient care: attitudes, perceived competence and demonstrated ability.

The importance of medical training which emphasizes comprehensive, biopsychosocial medical care is increasingly recognized. Research has focused on characteristics affecting attitudes toward psychosocial information, inferring that such attitudes are acceptable surrogates for demonstrated ability. The current study evaluates the accuracy of information elicited during medical interviews conducted by medical students. Information regarding patient compliance, patient income and patient reliance on social support was correlated with student characteristics, attitudes toward psychosocial information and self-perceived competence in eliciting such data. For 36 third-year medical students on a 4-week family medicine rotation, results showed that measures of psychosocial attitudes were not an acceptable substitute for demonstrated ability. Exposing medical students to the importance of psychosocial data is valuable, but additional attention must be given to their eliciting such information accurately and efficiently.

Home-based management of urinary incontinence: a pilot study with both frail and independent elders.

OBJECTIVE: The participation of older rural women and their caregivers in a pilot research study on behavioral management interventions for urinary incontinence is described. DESIGN: A quasiexperimental design was used. SETTING AND SUBJECTS: Women 55 years old and older and living in a rural county in North Florida who had episodes of urinary incontinence twice or more per week were included. Outreach was directed at two groups of elders with incontinence, those who were functioning independently and those who were frail and dependent on caregivers for assistance with activities of daily living. METHODS: Behavioral management of continence comprised three techniques for the management of urinary incontinence: self-monitoring, scheduling regimens and pelvic muscle exercise with biofeedback. MAIN OUTCOME MEASURES: The main outcome measures were episodes of urine loss and amount (In grams) of urine loss with time, determined with a weighed pad test. RESULTS: Behavioral management of continence resulted in significant decrease in urinary incontinence; decreases in frequency and volume of urine loss were found among all study participants when data were analyzed. CONCLUSIONS: Although behavioral management of continence was effective in reducing incontinence among independent, community-dwelling elderly women, there was a marked lack of response to this project by frail elders and their caregivers. The same barriers to implementing time-intensive behavioral management interventions among frail elders in long-term care facilities may operate in the home setting.

A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results.

Patients suffering from neurogenic intermittent claudication secondary to lumbar spinal stenosis have historically been limited to a choice between a decompressive laminectomy with or without fusion or a regimen of non-operative therapies. The X STOP Interspinous Process Distraction System (St. Francis Medical Technologies, Concord, Calif.), a new interspinous implant for patients whose symptoms are exacerbated in extension and relieved in flexion, has been available in Europe since June 2002. This study reports the results from a prospective, randomized trial of the X STOP conducted at nine centers in the U.S. Two hundred patients were enrolled in the study and 191 were treated; 100 received the X STOP and 91 received non-operative therapy (NON OP) as a control. The Zurich Claudication Questionnaire (ZCQ) was the primary outcomes measurement. Validated for lumbar spinal stenosis patients, the ZCQ measures physical function, symptom severity, and patient satisfaction. Patients completed the ZCQ upon enrollment and at follow-up periods of 6 weeks, 6 months, and 1 year. Using the ZCQ criteria, at 6 weeks the success rate was 52% for X STOP patients and 10% for NON OP patients. At 6 months, the success rates were 52 and 9%, respectively, and at 1 year, 59 and 12%. The results of this prospective study indicate that the X STOP offers a significant improvement over non-operative therapies at 1 year with a success rate comparable to published reports for decompressive laminectomy, but with considerably lower morbidity.