摘要:

Objectives.Measures of acquired immunodeficiency syndrome (AIDS)-related knowledge that have good psychometric properties are needed to evaluate the impact of educational interventions, particularly among impoverished populations. Few measures that satisfy these requirements are available. The authors describe the psychometric characteristics and composition of a subset of 21 AIDS knowledge items from the questionnaire used by the National Center for Health Statistics.Methods.The study was conducted with a convenience sample of women and their significant others or close friends in nine homeless shelters and 11 residential drug recovery programs in the skid row area of Los Angeles from 1991 to 1993. Trained nurses and outreach workers collected data from 486 predominately African-American adults before delivery of well-established, culturally sensitive AIDS educational intervention. A subset of 334 participants were re-interviewed 6 months later.Results.A total scale score was calculated from a one-factor solution, and two subscale scores were formed based on a two-factor solution. One subscale was composed of primarily cognitive items, whereas the second subscale contained mainly transmission-related items. The internal consistency reliability of the overall scale was 0.89; the two subscales had alphas of 0.80 and 0.92. The measures have face validity, and support for convergent validity was found. Further, even though AIDS knowledge in the sample was relatively high, all three measures showed marked improvement in the subsample of respondents who were re-interviewed after receiving AIDS-related educational information.Conclusions.These measures show promise for assessing AIDS knowledge and the efficacy of AIDS education programs in vulnerable populations. The findings reported here, however, are preliminary. Test-retest reliability needs to be examined, and additional studies are needed with samples that are more culturally diverse and include socially isolated individuals.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Is discharge destination a determinant of readmission? Studies to date have been inconclusive. The primary purpose of this study was to identify the role of discharge destination in the occurrence of repeat hospitalizations for a national sample of patients discharged from Veterans Health Administration (VHA) hospitals.Methods.The authors studied a 20% random sample of individual patients, 65 years of age or older, with either chronic obstructive pulmonary disease, stroke, or dementia who were discharged from a Veterans Health Administration hospital in 1988. All data for the study were obtained from secondary administrative sources. Multiple sources were used to determine discharge destination. The authors focused on personal home versus nursing home discharge destination. Both VHA and Medicare discharge data were used to track hospital readmissions. Proportional hazards regression models were used to examine the independent association of discharge destination with time to readmission within 30 days, 6 months, 1 year, and 2 years of discharge, adjusting for severity, other clinical and demographic characteristics, and censoring deaths.Results.After adjustment and including out-of-system (Medicare) use, we found that patients with chronic obstructive pulmonary disease and patients with dementia who were discharged to nursing homes (community and Veterans Health Administration, respectively) were less likely to be readmitted within 30 days after discharge than patients discharged to personal homes.Conclusions.These findings have important implications for adjusting hospital performance profiles based on discharge destination and for focussing efforts to reduce the frequency and associated costs of hospital readmissions.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Adverse outcome rates are increasingly used as yardsticks for the quality of hospital care. However, the validity of many outcome studies has been undermined by the application of one outcome to all patients in large, diagnostically diverse populations, many of which lack evidence of a link between antecedent process of care and the rate of the outcome, the underlying assumption of the analysis.Methods.To address this analytic problem, the authors developed a model that improves the ability to identify quality problems because it selects diseases for which there are processes of care known to affect the outcome of interest. Thus, for these diseases, the outcome is most likely to be causally related to the antecedent care. In this study of hospital readmissions, risk-adjusted models were created for 17 disease categories with strong links between process and outcome. Using these models, we identified outlier hospitals.Results.The authors hypothesized that if the model improved on identifying hospitals with quality of care problems, then outlier status would not be random. That is, hospitals found to have extreme rates in one year would be more likely to have extreme rates in subsequent years, and hospitals with extreme rates in one condition would be more likely to have extreme rates in related disease categories. It was hypothesized further that the correlation of outlier status across time and across diseases would be stronger in the 17 disease categories selected by the model than in 10 comparison disease categories with weak links between process and outcome.Conclusions.The findings support all these hypotheses. Although the present study shows that the model selects disease-outcome pairs where hospital outlier status is not random, the causal factors leading to outlier status could include (1) systematic unmeasured patient variation, (2) practice pattern variation that, although stable with time, is not indicative of substandard care, or (3) true quality-of-care problems. Primary data collection must be done to determine which of these three factors is most causally related to hospital outlier status.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Although race is recognized as an important variable in health status and medical care, the conditions of African-American and white elders have not been studied sufficiently as they enter home care after hospital discharge. This study tests hypotheses that African-American elders enter home care sicker, more dependent, and cognitively impaired.Methods.Hypotheses were tested in two independent studies, both conducted in a Midwestern city. Study 1 compares the physical and cognitive conditions of 208 African-Americans and white elders discharged home after hospitalization for congestive heart failure. Data were obtained from medical records and from patient interviews. Study 2 compares the physical and cognitive conditions of 212 African-Americans and white elders discharged home after hospitalization for hip fracture, cerebral vascular accident, and congestive heart failure. Data were obtained from medical records and interviews with patients' discharge planners.Results.African-Americans were found to go home more sick, more dependent, and more cognitively impaired, although no race difference was found in instability at discharge.Conclusions.These findings raise concerns about African-American elders' access to care in community settings, given their greater needs at discharge.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.A decision support tool for psychiatric hospital admissions was developed and validated to provide reliable, clinically relevant information to providers and case managers.Methods.Using the Severity of Psychiatric Illness rating system, an empirical model of psychiatric emergency decision-making was constructed and validated on a spilt sample of 254 crisis cases.Results.Three dimensions of the Severity of Psychiatric Illness system-Suicide Potential, Danger to Others, and Severity of Symptoms-were used to construct a model that successfully predicted 73% of decisions about level of care (inpatient or outpatient). Clear misses, patients with a 0.20 probability of being hospitalized who were admitted, and patients with an 0.80 probability or greater of being hospitalized who were not admitted were reviewed to allow for utilization review. This decision support tool then was validated by predicting hospital outcomes in two additional samples. First, a random sample of consecutive admissions to a not-for-profit psychiatric hospital were studied. Second, a panel of admissions from a large managed care firm were evaluated.Conclusions.Results demonstrate that the decision to hospitalize patients in psychiatric hospitals is rational and that models predicting admission also can predict in-hospital outcomes.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.This study investigates the degree of substitutability of adult foster care for nursing home care in Oregon.Methods.Using three tests, the authors determined (1) the extent to which an additional adult foster care resident in a county reduces the number of nursing home residents in that county, (2) which characteristics of residents and facilities are important in sorting residents into either nursing homes or adult foster care facilities, and (3) the price elasticity of demand for adult foster care, using the county as the unit of observation.Results.It was found that for every additional foster care resident in a county, a nursing home loses 0.85 residents-almost a one-to-one substitution ratio.Conclusions.Despite the high degree of substitutability, residents perceive important differences in the characteristics of the two forms of care. Indeed, private residents are, on average, willing to pay twice as much for nursing home care as for adult foster care, suggesting that these differences are important. Finally, private consumers are sensitive to price differences among adult foster care facilities. The implications for policy are discussed.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The authors explore the determinants of having a regular source of care in a community-based probability sample of homeless adults in Los Angeles. Results from this study should be more representative than those from previous studies of the homeless that are clinic- or shelter-based. In addition to those factors found to be barriers to regular sources of care in the general population, we hypothesized that psychosocial characteristics of the homeless and the homeless lifestyle would negatively impact their likelihood of having a regular source of care.Methods.The authors conducted a multiple logistic regression to predict regular source of care among the homeless, using an adaptation of the Behavioral Model of health services utilization as an analytic framework.Results.Fifty-seven percent of the sample reported that they had a regular source of care. Of those with a source of care, 30% reported a hospital outpatient department; 25% reported a community or homeless clinic; 23% reported a hospital emergency room; 14% reported a government clinic; and 9% reported a private physician's office as their source of care. Some factors found to be barriers to having a regular source of care in the general population (male, Hispanic, young age) also were barriers among homeless adults. Additional barriers in this sample included homelessness-related characteristics such as competing needs, long-term homelessness, and social isolation. Chronic mental illness and chronic substance dependence were not related to having a source of care among the homeless. Characteristics that increased the likelihood of having a regular source of care in the general population (poor health status, Medicaid) were not related to having a regular source of care among the homeless.Conclusions.In a context of limited resources, the distribution of regular source of care among the homeless appears to be highly inequitable. Although some of the characteristics identifying those with a regular source of care suggest differential patterns of behavior across subgroups, others suggest differential advantage in access to care and a lack of fit between the needs of the homeless and the organization of health services.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The authors examine whether physician education has enduring effects on treatment of depression.Methods.Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes.Results.No lasting educational effect was observed consistently in any of the outcomes measured.Conclusions.There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Analyses were performed to reproduce and examine the sensitivity of the cross-specialty linkage algorithm used by Hsiao et al1to obtain the currently implemented resource-based relative value scale for Medicare physician reimbursement.Methods.The cross-specialty linkage procedure designed and implemented in Hsiao et al is an important component of the resource-based relative value scale underlying current Medicare Fee Schedule. This linkage procedure aligns independent intraspecialty relative value scales onto a common scale, and therefore determines the level of reimbursement accruing to each specialty. The complexity of the algorithm to perform this alignment has prevented critical review of the methodology. The authors examine the statistical properties of the algorithm, and diagnose its sensitivity from changes in the data and small modifications to the numerical procedure.Results.Our examination of the linkage algorithm uncovered some issues requiring further consideration. These include the questions raised about the use of "biweighting," and about the benefits of incorporating correlation information into the analysis. Moreover, simulation analyses demonstrate that the existing relative value scale is sensitive to changes in the input data and methodology. Certain specialties' reimbursement can shift by as much as 32% using Hsiao's algorithm. Most importantly, the interspecialty linkage algorithm underlying the current fee schedule downweights pairs of linked services even when such links are deemed more important from a clinical point of view. As a result, in some cases clinically superior links received little or no importance in the algorithm.Conclusions.The cross-specialty linkage procedure described in Hsiao et al may not adequately perform the task of aligning intraspecialty relative value scales onto a common scale because of the sensitivity of the algorithm and the choice of statistical methodology. The authors suggest improvements to Hsiao's method resulting from our analyses. If widespread adoption of the Medicare Fee Schedule is a component of health care reform, reconsideration of the process determining each specialty's payment level assumes new importance.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID