摘要:

Innovation and diffusion of new surgical procedures are limited in Manitoba, Canada by restrictions on which hospitals are allowed to perform particular surgical programs. Programs centralizing performance of certain operations in a few hospitals have the potential for controlling costs and quality of care but may limit access for individuals living in other areas. Such issues are highlighted in this analysis of coronary artery bypass graft surgery in Manitoba. Patterns of growth and access are first examined; then regional variations in rates of bypass surgery are compared with rates for coronary angiography and valve surgery. Physician reluctance to refer patients to Winnipeg appears to be responsible for the lower rates of these procedures in Western Manitoba. The implications for studies of centralization/regionalization of medical services, physician decision-making, and diffusion of technology are explored.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Nurse anesthetists (CRNAs) are a lower cost substitute for anesthesiologists in the delivery of anesthesia services. This article addresses the question of when anesthesiologists delegate in a team approach as opposed to using a solo arrangement. Logistic regression analysis was done using data from the 1986 Anesthesia Practice Survey and revealed that the team approach is more likely in areas with a relatively large supply of CRNAs; in hospitals with large surgical volumes, teaching facilities, and public hospitals; during emergency procedures, more lengthy procedures, and less complex surgeries; and among patients with poorer preoperative physical status. However, as the supply of anesthesiologists increases, the probability of CRNA use declines and in areas outside New England the “solo anesthesiologist” arrangement is significantly more common. Medicare and other third-party payers should eliminate regional variations in provider mix that are due to locational preferences and provider attitudes. Delegation to CRNAs can be encouraged by reducing what anesthesiologists are paid for practicing alone.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

To assess patients' reactions to a mandatory second surgical opinion program and to measure the accuracy of communication between these patients and their physicians, questionnaires were sent to New York City municipal employees, retirees, and dependents who had received second-opinion consultations. The most frequent reactions, among 902 respondents, were that the consultations provided reassurance (59%), helped in deciding whether to proceed with surgery (49%), and provided a chance to ask important questions (29%). Relatively few patients felt that the program caused anxiety (12%) or confusion (5%). Patients were generally pleased with the administrative aspects of the program but less satisfied with the consultant physicians they had seen. Twelve percent of patient-physician pairs disagreed about the advice that had been communicated in their second-opinion consultation visits. Nonconcordance rates varied greatly with the nature and complexity of the advice rendered and were higher among patients who stated that their consultants' explanations were not thorough and understandable. In addition to their cost-containment functions, mandatory surgical second-opinion programs can be supportive and informative. Systematic feedback from patients can be used to enhance these strengths, to correct programmatic deficiencies, and to improve the accuracy of communication.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

This paper examines the causes behind the gender differences in the prescription of psychotropic medications by primary care physicians. The 1985 National Ambulatory Medical Care Survey data were used for the analysis. Women were more likely than men to receive prescriptions for anxiolytics and antidepressants but were equally likely to receive prescriptions for hypnotics/ barbiturates and antipsychotics. Controlling for statistically significant presenting symptoms, physician diagnoses, and sociodemographic and health services factors, women were still more likely to receive a prescription for anxiolytics and antidepressants. The reasons, true and artifactual, for these differences are discussed. It is suggested that the artifactual reasons must be explored through experimental and/or observational research designs and not with cross-sectional data.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Congress exempted certain types of specialty hospitals from the Medicare Prospective Payment System because it was recognized that Diagnosis-Related Groups (DRGs) may not properly define the case mixes in such institutions. This study is part of a larger investigation into case mix and payment in children's hospitals, one category of exempted institutions. A national sample of approximately 500,000 cases was developed with intentional oversampling of children's and university hospitals to allow detection of specialized types of cases. Five case-mix classification schemes—DRGs, Disease Staging, Patient Management Categories, Severity of Illness Score, and Pediatric Diagnosis System groups—were applied to the data set, and data items not included in the Uniform Hospital Discharge Data Set were collected. A set of Children's Diagnosis- Related Groups (CDRGs), based on modification of the current DRG system, resulted from the study. When CDRGs were applied to an independent sample of children's hospital data, length of stay variance was reduced by 47.6% compared with 32.3% for DRGs (length of stay outliers removed). These results suggest that incremental approaches to DRG refinement in other clinical areas where current definitions are inadequate may be better than rejecting the large amounts of statistical and clinical analyses existing in the DRG system. Similar methods can be used to correct problems brought on by changes in medical practice.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Although numerous studies have been made of the determinants of smallarea variation in hospital discharge rates, there is still disagreement about the role of socioeconomic factors. The lack of consensus stems, in part, from the difficulty in comparing results across studies that use different units and methods of analysis. Many of the studies using well-defined hospital service areas did not have the data needed to conduct a controlled analysis of the determinants of hospital utilization. Most of the studies that have performed controlled analyses have relied on larger geopolitical areas, which are not believed to capture self-contained health care systems. The study described here used a consistent set of data, three methods of analysis, and two units of analysis to test the importance of socioeconomic characteristics in explaining the variation in medical and surgical discharge rates in Michigan. Socioeconomic factors are found to be statistically significant determinants of the variation in both medical and surgical discharge rates, whether the method of analysis is simple correlations or multiple regressions, and whether the unit of analysis is the county or a well-designed hospital service area. These results suggest that previous small-area variation studies may have incorrectly concluded that socioeconomic characteristics do not explain differences in utilization rates.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

A research program was undertaken to develop and validate a multidimensional measure of patient satisfaction with pharmacy services. A self-administered questionnaire consisting of 44 Likert-type attitudinal items was adapted from the Patient Satisfaction Questionnaire developed by Ware et al. In an iterative scale development process, the adapted questionnaire and its revisions were evaluated in three successive studies conducted on convenience samples (n = 30,313,489) of individuals in attendance at family practice clinics in a southwestern city. Methods used to construct multi-item scales measuring separate dimensions of service included principal components factor analysis and item analyses. Acquiescent response set (ARS), the tendency to agree with statements of opinion regardless of content, was measured by the method of matched pairs of items. A partial correlation matrix which controlled for ARS was used as the data in a principal components factor analysis in an effort to reduce the biasing effect of ARS on factor analytic outcomes. Dimensions of satisfaction identified were Explanation, Consideration, Technical Competence, Financial Aspects, Accessibility, Drug Efficacy, OTC (over-the-counter) Product Availability, and Quality of the Drug Product. Questionnaire revision is suggested to confirm the validity of the latter two dimensions. Future research should examine the relationship between separate dimensions of satisfaction and other patient attitudes and behaviors, and the convergence between this instrument and other measures of patient satisfaction with pharmacy services.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

This study examined physician test-ordering behavior at a large urban Veterans Administration Medical Center staffed by two medical schools. Patients are assigned randomly to the two schools' wards, which operate independently of each other. The medical records of 119 patients, admitted during a 5-month period, were abstracted for data on the process and outcomes of medical care. Only one statistically significant difference in diagnostic testing practices was revealed by the observation that 12% of patients on one service received another abdominal film, while no patients on the other service did. The implications of studies such as this for small-area analysis are discussed. If variation in the utilization of health services is observed in a geographic region, then a study of physician behavior at a single facility may help to identify the reason for the variation.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

It is generally accepted that diagnosis-related groups (DRGs) for alcohol, drug, and mental disorders are inappropriate for inpatient prospective payment. To address this issue, the Veterans Administration (VA) supported a project to construct alternative classes that are more clinically meaningful, more homogeneous in their resource use, and that account for more variation in resource use among psychiatric and substance use cases than existing DRGs. This paper reports on this project. Using a data set containing universally available discharge data plus behavioral, social, and functional information obtained by a survey of 116,191 discharges from VA psychiatric beds, and with AUTOGRP as the classifying algorithm, a classification system was formed. Twelve psychiatric diagnostic groupings (PDGs) were identified, analogous to major diagnostic groups in the DRG system. Within each PDG, from 4 to 9 terminal groups of Psychiatric Patient Classes (PPCs) were formed and validated. The 12 substance abuse PPCs explain >31% of the variation in length of stay; for the mental disorder PPCs the variance explanation is >11%, a substantial improvement over DRGs that, for the same data set, explain <2 and 3%, respectively. With the addition of only 5 variables beyond those presently included in discharge data sets, greater precision for payment purposes can be achieved. Implications for adoption of this classification system are discussed.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID