Associations of mental, and medical illnesses with against medical advice discharges: the National Hospital Discharge Survey, 1988-2006.

This study examined the association of mental and medical illnesses with the odds for leaving against medical advice (AMA) in a national sample of adult patients who left general hospitals between 1988 and 2006. Leaving AMA was first examined as a function of year and mental illness. Multiple logistic regression analysis was then used to adjust for patient and hospital characteristics when associating mental and major medical diagnoses with AMA discharges. The results indicated that leaving AMA was most strongly associated with mental health problems. However, the impact of mental illness was attenuated after adjusting for medical illnesses, patient and hospital characteristics. The strongest predictors of AMA discharge included being self-pay, having Medicaid insurance, being young and male, and the regional location of the hospital (Northeast). When substance abuse conditions were excluded from the mental illness discharge diagnoses, mental illness had lower odds for leaving AMA. The results may be of value to clinicians, and hospital administrators in helping to profile and target patients at risk for treatment-compliance problems. Prospective primary data collection that would include patient, physician, and hospital variables is recommended.

Patient safety: solutions in managed care organizations?

Despite the growing acknowledgment of the necessity for patient safety initiatives to address medical errors, the role of managed care organizations (MCOs) in these programs has only recently been challenged. Managed care quality improvement programs have mainly focused upon pay-for-performance initiatives, largely ignoring specific patient safety efforts. To effectively reduce medical errors, MCOs must leverage their unique positions to influence and educate both providers and consumers. This article describes MCOs' self-implemented barriers to quality improvement, and early initiatives by MCOs to encourage safe practices, including pay-for-performance. An approach for MCOs to facilitate progress and inspire a culture of patient safety is discussed. Avenues for strengthening the organizational and technological infrastructure of the health care system from a managed care perspective are examined, and strategies for implementing best practices within the constraints of managed care are explored. System-wide solutions that address the critical areas of culture, infrastructure, and best practices are necessary to continue to make significant strides in reducing medical errors and prioritizing patient safety.

The performance of Medicare, Medicaid, and individual commercial products.

Medicare, Medicaid, and individual nongovernmental insurance products are marketed by commercial health insurance companies. We propose that the product offerings be viewed as a group rather than as separate products competing for internal company resources. A study population consisting of 35 Aetna plans in 24 states, 124 Blue Cross Blue Shield plans (BCBS) in 45 states and the District of Columbia, 43 Cigna plans in 28 states, and 23 UnitedHealth plans in 22 states was examined on 29 variables, including financial, marketing, and medical management data. The findings revealed that Medicaid and individual nongovernmental products were terminated more often than other products across all ownership types. When BCBS plans were analyzed across for-profit, nonprofit, and mutual ownership types, the companies had distinct preferences for product offerings. The study provided evidence that health plans will limit their exposure to Medicare, Medicaid, and individual nongovernmental products in preference to comprehensive/group products.

Current issues in health care informatics.

Health care informatics has emerged as a diverse and important new field of study. The field can be very broadly defined as the science that addresses how best to use information to improve health care. The field includes the four areas of bioinformatics, medical informatics, public health informatics, and consumer health informatics. Health care informatics applications can be used to improve the quality of patient care, to increase productivity, and to provide access to knowledge. After providing an overview of the field, the 10 articles contained in this special issue are briefly discussed. The first six articles address a diverse set of topics such as the use of health care informatics to conduct research, clinical information systems used by the U.S. Air Force, electronic medical records and physician satisfaction in Oman, and a point of care documentation system used by hospice care providers. The last four articles discuss the complex issues raised by the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Comparing GIS-based methods of measuring spatial accessibility to health services.

The inequitable geographic distribution of health care resources has long been recognized as a problem in the United States. Traditional measures, such as a simple ratio of supply to demand in an area or distance to the closest provider, are easy measures for spatial accessibility. However the former one does not consider interactions between patients and providers across administrative borders and the latter does not account for the demand side, that is, the competition for the supply. With advancements in GIS, however, better measures of geographic accessibility, variants of a gravity model, have been applied. Among them are (1) a two-step floating catchment area (2SFCA) method and (2) a kernel density (KD) method. This microscopic study compared these two GIS-based measures of accessibility in our case study of dialysis service centers in Chicago. Our comparison study found a significant mismatch of the accessibility ratios between the two methods. Overall, the 2SFCA method produced better accessibility ratios. There is room for further improvement of the 2SFCA method-varying the radius of service area according to the type of provider or the type of neighborhood and determining the appropriate weight equation form-still warrant further study.

Access to microdata on the Internet: Web-based analysis and data subset extraction tools.

The Internet is increasingly being recognized as an invaluable component of education. At the college and university level, online databases and statistical tools for Web-based analysis and data subset extraction have become important instructional resources. These Internet resources enable students to formulate specific research hypotheses, identify relevant variables, and analyze large existing databases. This article describes three of these resources: the Federal Electronic Research and Review Extraction Tool (FERRET) of the U.S. Bureau of the Census, the Survey Documentation and Analysis (SDA) unit at the University of California, Berkley, and the Inter-University Consortium for Political and Social Research (ICPSR), which is housed at the University of Michigan.

Geographic information systems in public health and medicine.

Geographic information systems (GIS) are increasingly being used in public health and medicine. Advances in computer technology, the encouragement of its use by the federal government, and the wide availability of academic and commercial courses on GIS are responsible for its growth. Some view GIS as only a tool for spatial research and policy analysis, while others believe it is part of a larger emerging new science including geography, cartography, geodesy, and remote sensing. The specific advantages and problems of GIS are discussed. The greatest potential of GIS is its ability to clearly show the results of complex analyses through maps. Problems in using GIS include its costs, the need to adequately train staff, the use of appropriate spatial units, and the risk it poses to violating patient confidentiality. Lastly, the fourteen articles in this special issue devoted to GIS are introduced and briefly discussed.