摘要:

This study was designed to identify the relevant components of the organizational culture of medical group practices and to develop an instrument to measure those cultures. Building on the work of industrial psychologists and organizational sociologists, a 35-item instrument was developed through an iterative process with more than 100 medical groups. The final instrument was tested using responses from physicians practicing in two very different medical groups: one a prepaid group practice with salaried physicians and the other, until recently, a fee-for-service practice. Using stepwise discriminant analysis of the responses to this instrument, more than 90% of the physicians were able to be placed in the appropriate practice setting.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Nicotine polacrilex (“nicotine gum”) is effective in helping persons to quit smoking cigarettes. Because many persons try to quit without formal assistance, it may be an appropriate product for over-the-counter (OTC) purchase. Some smokers, however, might use such a product in lieu of more effective methods of cessation, and still others might use it to cope with enforced periods of nicotine abstinence (eg, at the work place) and thereby delay their decision to quit. The study's objective was to assess the public health benefits and risks of OTC availability of nicotine gum.A Markov model was developed and used to contrast two alternative policy scenarios: one in which nicotine gum was assumed to remain available only by prescription, and another in which it was assumed to be made available for OTC purchase. Various data sources were used to estimate the model, including the Health Promotion and Disease Prevention Supplement to the 1991 National Health Interview Survey and the 1986 Adult Use of Tobacco Survey. Primary outcome measures included the numbers of persons who would try to quit smoking, the numbers who would use various methods of smoking cessation, including OTC nicotine gum, and the numbers of current adult smokers who would be abstinent at the end of 10 years.Findings suggest that an average of 3 million persons each year would use OTC nicotine gum. As a consequence of OTC availability, an additional 450,000 smokers would be abstinent at the end of 10 years. These results are sensitive to assumptions regarding the effectiveness of OTC nicotine gum, as well as to the effect of OTC availability on the use of other methods of smoking cessation. The number of persons who would quit smoking, however, increases under a fairly wide range of assumptions. Over-the-counter availability of nicotine gum may confer significant public health benefits.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

In Australia an increasing proportion of active general practitioners (GPs) are women. Overseas research showing differences between male and female GPs in practice style, the reasons patients consult them, or in the nature of the medical conditions they manage has failed to adjust for confounders. In Australia, such differences have never been investigated. This study assessed differences between male and female GPs in terms of their personal characteristics, patient mix, patient reasons for consultation, and the medical conditions they manage. It also considered the extent to which differences are accounted for by the effect of confounders.A secondary analysis was done of data from the Australian Morbidity and Treatment Survey 1990 to 1991 (n = 113,000 general practice encounters). In addition, univariate analysis was followed by multivariate analysis, with adjustments for GP and patient characteristics and (in analysis of conditions managed) for patient reasons for encounter.Significant differences were found in the work patterns and patient mix of male and female GPs. Patients' selectivity in the problems presented to the two groups remained after adjustment for confounders. Female GPs managed more female-specific, endocrine, general, and psychosocial problems even after multivariate adjustment. Although male GPs managed more cardiovascular, musculoskeletal, male genital, skin, and respiratory problems at the univariate level, these differences were no longer apparent after adjustment.Male and female GPs manage different types of medical conditions. Although some differences are due to their patient mix and to patient selectivity, others are inherent to the sex of the physician. Extrapolation of results to Australian general practice suggests that these two groups of GPs could become semispecialized.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The contribution of oral health to health-related quality of life (HQOL) has seldom been examined. This study was designed to develop and validate a measure of oral health-related quality of life (OHQOL), examine relations between OHQOL and HQOL, and explore OHQOL's relation to problem-based dental care utilization in a sample of 1,242 older men, using data gathered by a mail survey. Factor analysis of eight oral health items revealed that three items related to the impact of oral conditions on daily functioning defined a factor labeledOHQOL. Factor analysis of the HQOL items and these three OHQOL items showed that OHQOL represents a separate and independent factor. Correlational analyses supported the construct validity of the OHQOL measure: Men with better OHQOL scores reported less dental pain or discomfort, fewer eating problems, and less problem-based dental care utilization. Logistic regression analysis showed that the measures of dental pain and oral discomfort were related positively to utilization, whereas OHQOL was related negatively. These results suggest that OHQOL represents a separate and distinct facet of HQOL that is associated with dental care utilization. Thus they support the validity of the OHQOL construct and suggest its use in future studies of HQOL.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

This study sought to determine if county-level demographic, health care resource, policy, and competitive factors are associated with the movement of obstetrician-gynecologists (ob-gyns) into and out of rural areas. County-level descriptive data from the Area Resource File, the American Medical Association Physician Masterfile, and the American Hospital Association Guide were used for hospital descriptions. This was a correlational study that measured the association of ecologic indicators of nonmetropolitan counties with indicators of gain or loss of ob-gyns. Descriptive statistics characterize the supply and movement of ob-gyns by size and location of the counties. Multinomial logistic regression models describe the net effect of the ecologic indicators on physician movement. During the period 1985 to 1990, a total of 962 patient care ob-gyns moved out of 531 nonmetropolitan counties, and 979 ob-gyns moved into 528 counties. Counties in the southern Atlantic states experienced the greatest net inflow, whereas Illinois, Missouri, and Texas had the greatest net outflow. Counties that retained ob-gyns during this period were in the mid-range of population. Positive correlates of outward migration were adjacency to a metropolitan county and loss of hospital bed supply; negative correlates with outward migration were the supply of hospital beds and total population. Inward migration was positively correlated with retention or gain of county family physicians and with adjacency; negative correlates were overall population and total family physician supply. The movement of ob-gyns in nonmetropolitan counties is influenced by state policies, local resources, and relative location. No clear evidence shows that there are competitive relations between family physician supply and ob-gyn supply.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Providing National Health Service Corps (NHSC) scholarships to under-represented minorities has been an important federal mechanism to bolster the numbers of minority physicians. Little is known about how minorities fare during their NHSC commitment periods. In 1991, questionnaires were mailed to all primary care physicians placed in rural communities from 1987 through 1990 in the NHSC scholarship program, in a retrospective cohort study. One hundred and twenty-two of the 398 eligible NHSC physician respondents (31%) indicated they were minorities. National Health Service Corps physicians were found to be well matched by race to the sites where they served, and minority NHSC physicians worked in counties and practices with greater proportions of minority inhabitants and patients. Minorities among rural NHSC physicians were less likely to have been raised in rural areas and were less interested in rural practice during medical school and when placed in their rural NHSC sites. The relative urban preferences of minority physicians in large part explains why this group was more dissatisfied with their work and personal lives while serving their obligations. Minority physicians also reported lower satisfaction for their families. Minority and nonminority NHSC physicians reported comparable acceptance by their communities, and demonstrated similarly low retention rates. The NHSC plays a significant role in the careers of many young minority physicians and in promoting the temporary availability of minority physicians for rural health professional shortage areas. However, as of 1991, many minority NHSC physicians placed in rural areas would have preferred urban sites, which resulted in their lower satisfaction.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Although physicians are all too familiar with the psychologic impact of having multiple responsibilities, the associated impact on practice styles has not been examined systematically. To provide some data on the effects of “work dispersion,” we examined the hypothesis that the inpatient resource use of physicians would rise with the number of hospitals in which they work.Data for 1991 from Medicare's National Claims History File were used to profile a sample of attending physicians (n = 33,756) in seven states. The attending physician “profile” was the casemix-adjusted relative value of all physician services (regardless of who delivered them) that were delivered during each patient's hospital stay. Relative value was measured in relative value units, used by Medicare in determining physician payments. The authors then categorized physicians in terms of the number of hospitals to which they admitted patients. Physician profiles were adjusted further to control for geography, physician specialty, and characteristics of the physician's primary (ie, most used) hospital. One third of the physicians in the sample had admissions to more than one hospital. Physicians working in one hospital had inpatient practice profiles 2.1% below the sample mean. Additional hospital affiliations were associated with progressively higher profiles: two hospitals, 2.3% above the mean; three hospitals, 4.5% above; four hospitals, 8.2% above; and five or more hospitals, 11.5% above (allP<0.01).The practice of medicine in more than one hospital is associated with higher inpatient profiles and shows a dose-response relationship. Physicians and policy makers will need to consider carefully whether there are any associated benefits to justify the increased cost.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Studies of total quality management as a means of improving health care quality to date have relied on case studies of individual teams or hospitals. The Total Quality Improvement Registry Project surveyed quality coordinators (n = 36) and quality improvement team leaders (n = 228) to collect both site-level and team-level data on quality improvement in Veterans Health Administration hospitals. Usable responses were received from 100% of quality coordinators and 73.7% (168) of team leaders. Site-level data include hospital structural characteristics and measures of training and commitment, as well as features and activities of the hospital quality councils. Team-level data include size, membership, task, age, activities, and a proxy measure of quality improvement. The authors report on the relations between levels of commitment to total quality management principles, training levels, activities of quality councils, and team formation and success. These data provide support for a model of commitment to quality improvement that involves four realms of influence within the medical centers: (1) management, (2) physician leadership, (3) physician staff and middle management, and (4) nurses and employees. The authors also report on the activities of quality councils and the relation of their activities to commitment and perceived improvement. Using bivariate correlation and multiple regression, the authors found that the age of the quality council, overall facility commitment to total quality management philosophy, and physician commitment are the most critical variables in explaining numbers of teams, training intensity, and total perceived improvement at this sample of medical centers. Specifically, we find that commitment to total quality management philosophy and the number of active teams explains 41% of the observed variation in quality improvement. In future articles, the authors will report details of team activities and the development of teams over time.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Substantial geographic and hospital-based variations have been documented in the use of breast-conserving surgery (BCS) in 1986. The authors studied the patterns of adoption of this procedure from 1986 to 1990. National Medicare inpatient claims were used to study women aged 65 to 79 who underwent an operation for local or regional breast cancer in 1986 (38,679 patients) or 1990 (43,083 patients). Breast-conserving surgery was used for 5,509 (14.1%) of the Medicare patients in 1986 and 6,476 (15.0%) in 1990. The only region with an increase in BCS use from 1986 to 1990 was New England. Many hospitals had low volumes of operations, with a median of six to seven patients annually. Ten percent of the hospitals performed 55% of the conservative operations. Large hospitals, urban hospitals, and those with higher patient volumes or a cancer center were somewhat more likely to have increased use of BCS by 1990. Despite the substantial evidence supporting BCS as an alternative to mastectomy, the overall use of BCS in Medicare inpatients increased minimally from 1986 to 1990. Many patients are treated in hospitals with little experience with BCS. Hospitals using more BCS in 1986 were somewhat more likely to increase the use of BCS by 1990.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The measurement of inpatient complications has received substantial attention in recent years because mortality rates and other outcome measures often appear unable to discriminate superior from inferior hospital care. Complication measurement holds out the promise of being more sensitive to variations in patient care because complications occur more frequently than do mortalities, and because complications are more direct consequences of the process of care.The authors developed a new measure of complications that seeks to give insight into the patient care given by different hospitals or physicians by using commonly available data. Specifically, this measure is based on a decision-theoretic model that estimates the probability of a complication for combinations of admitting and secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnoses. The measure can be evaluated at the patient level, or aggregated and risk-adjusted for the population of a given care provider (eg, physician or hospital). When applied to a set of patient-level UB-82/92§data, this measure estimates the risk of complication for any member of a population, controlling for comorbidity, and hence is designated comorbidity-adjusted complication risk (CACR).The authors describe the development of CACR and its testing and validation using data acquired from the states of Pennsylvania, California, and Florida, as well as facility data obtained directly from hospitals. The data set includes 480,000 patients from 50 Pennsylvania hospitals, 300,000 patients from 33 Florida hospitals, 370,000 patients from 35 California hospitals, and 37,000 patients from six validation hospitals. Comorbidity-adjusted complication risk is constructed from widely available data common to most patient cases. Comorbidity-adjusted complication risk can be adjusted for its case mix, but such risk adjustment has much less effect on CACR than on other adverse outcomes such as mortality and morbidity. Comorbidity-adjusted complication risk varies widely across the hospitals in this sample, yet it is stable across time and is correlated with other known quality outcomes, including such accepted “gold standards” as hospital-documented adverse event rates and chart review determinations of complications.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID