ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Previous studies relating the incidence of negligent medical care to malpractice lawsuits in the United States may not be generalizable. These studies are based on data from 2 of the most populous states (California and New York), collected more than a decade ago, during volatile periods in the history of malpractice litigation.Objectives.The study objectives were (1) to calculate how frequently negligent and non-negligent management of patients in Utah and Colorado in 1992 led to malpractice claims and (2) to understand the characteristics of victims of negligent care who do not or cannot obtain compensation for their injuries from the medical malpractice system.Design.We linked medical malpractice claims data from Utah and Colorado with clinical data from a review of 14,700 medical records. We then analyzed characteristics of claimants and nonclaimants using evidence from their medical records about whether they had experienced a negligent adverse event.Measures.The study measures were negligent adverse events and medical malpractice claims.Results.Eighteen patients from our study sample filed claims: 14 were made in the absence of discernible negligence and 10 were made in the absence of any adverse event. Of the patients who suffered negligent injury in our study sample, 97% did not sue. Compared with patients who did sue for negligence occurring in 1992, these nonclaimants were more likely to be Medicare recipients (odds ratio [OR], 3.5; 95% CI [CI], 1.3 to 9.6), Medicaid recipients (OR, 3.6; 95% CI, 1.4 to 9.0), ≥75 years of age (OR, 7.0; 95% CI, 1.7 to 29.6), and low income earners (OR, 1.9; 95% CI, 0.9 to 4.2) and to have suffered minor disability as a result of their injury (OR, 6.3; 95% CI, 2.7 to 14.9).Conclusions.The poor correlation between medical negligence and malpractice claims that was present in New York in 1984 is also present in Utah and Colorado in 1992. Paradoxically, the incidence of negligent adverse events exceeds the incidence of malpractice claims but when a physician is sued, there is a high probability that it will be for rendering nonnegligent care. The elderly and the poor are particularly likely to be among those who suffer negligence and do not sue, perhaps because their socioeconomic status inhibits opportunities to secure legal representation.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.The ongoing debate on the incidence and types of iatrogenic injuries in American hospitals has been informed primarily by the Harvard Medical Practice Study, which analyzed hospitalizations in New York in 1984. The generalizability of these findings is unknown and has been questioned by other studies.Objective.We used methods similar to the Harvard Medical Practice Study to estimate the incidence and types of adverse events and negligent adverse events in Utah and Colorado in 1992.Design and Subjects.We selected a representative sample of hospitals from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric 1992 discharges. Each record was screened by a trained nurse-reviewer for 1 of 18 criteria associated with adverse events. If ≥1 criteria were present, the record was reviewed by a trained physician to determine whether an adverse event or negligent adverse event occurred and to classify the type of adverse event.Measures.The measures were adverse events and negligent adverse events.Results.Adverse events occurred in 2.9±0.2% (mean±SD) of hospitalizations in each state. In Utah, 32.6±4% of adverse events were due to negligence; in Colorado, 27.4±2.4%. Death occurred in 6.6±1.2% of adverse events and 8.8±2.5% of negligent adverse events. Operative adverse events comprised 44.9% of all adverse events; 16.9% were negligent, and 16.6% resulted in permanent disability. Adverse drug events were the leading cause of nonoperative adverse events (19.3% of all adverse events; 35.1% were negligent, and 9.7% caused permanent disability). Most adverse events were attributed to surgeons (46.1%, 22.3% negligent) and internists (23.2%, 44.9% negligent).Conclusions.The incidence and types of adverse events in Utah and Colorado in 1992 were similar to those in New York State in 1984. Iatrogenic injury continues to be a significant public health problem. Improving systems of surgical care and drug delivery could substantially reduce the burden of iatrogenic injury.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Tolerance of uncertainty is believed to be an important attribute of practicing physicians. This study attempts to (1) estimate how medical students perceive physicians' tolerance of uncertainty and (2) measure the tolerance of uncertainty of practicing physicians.Research Design.Cross-sectional.Setting and Subjects.Medical students (n = 113) and practicing physicians (n = 151) at the Faculty of Health Sciences, Ben-Gurion University, Israel.Measures.A self-administered, Hebrew version of an instrument developed in the United States.Independent Variables.Age, gender, seniority (year of study for students or years in practice for physicians), country of birth for students or of graduation for physicians, and physicians' specialty.Dependent Variables.Two dimensions, which were identified by factor analysis: reluctance to disclose uncertainty and stress from uncertainty.Results.The estimates of physicians' stress from uncertainty by first-year students aged <22 years were higher than those by first-year students aged ≥22 years. There were no significant differences in the way junior and senior medical students perceived physicians' tolerance of uncertainty. Stress from uncertainty was higher in female physicians (P= 0.028) and in graduates of the former Soviet Union (P= 0.044) than among male physicians and Israeli graduates, respectively. Reluctance to disclose uncertainty was higher among graduates of the former Soviet Union (P= 0.003) and among psychiatrists (P= 0.021) than among Israeli graduates and other specialties, respectively.Conclusions.The reliability and factor structure of the instrument were replicated. The previously reported differences in tolerance of uncertainty between women and men and between local and foreign graduates were confirmed. Physicians' tolerance of uncertainty appeared to be higher than that attributed to them by students. The expected age-related differences in perception of clinical uncertainty were not detected between junior and senior medical students.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Annual mammography is recommended for all breast cancer survivors.Objectives.To elucidate mammography use among older survivors of breast cancer and to explore determinants of such use.Research Design.Retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare claims.Subjects.A cohort of 3885 breast cancer survivors aged ≥65 years diagnosed with early-stage breast cancer in the United States in 1991.Measures.Medicare mammogram claims during the 2-year period following initial breast cancer treatment.Results.Overall, 62% of the cohort underwent annual mammography, 23% underwent mammography in 1 of 2 years, and 15% had no mammography claim in the 2 years evaluated. Twenty-two percent of the women who underwent breast-conserving surgery (BCS) without radiotherapy had no mammogram in the 2-year period evaluated, compared with 17% of those who underwent mastectomy and 4% of those who underwent BCS with radiotherapy. In multivariate analyses controlling for age, cancer stage, and other patient factors, the use of annual mammography was significantly lower among women treated with mastectomy or BCS without radiotherapy than among women treated with BCS with radiotherapy.Conclusions.Mammography is underused in the follow-up care of older breast cancer survivors. Underuse is of particular concern in women treated with BCS without radiotherapy because of the high risk of local disease recurrence. It is unknown whether poorer follow-up care contributes to the previously described lower rate of long-term survival among women who received this therapy.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.The Health Utilities Index Mark 3 (HUI3) is a comprehensive, compact health status classification and health state preference system. The HUI3 system has been included in 4 Canadian population health surveys and numerous clinical trials.Objectives.To evaluate the construct validity of the HUI3 for the measurement of health-related quality of life (HRQL) and attribute-specific morbidity in respondents to the 1990 Ontario Health Survey reported to have arthritis or stroke. The authors assessed (1) whether those with stroke, arthritis, and both conditions had lower HRQL scores than those with neither condition and (2) whether HUI3 detects morbidity in specific health attributes affected by arthritis and stroke. Stroke (but not arthritis) were expected to affect speech and cognition; arthritis (but not stroke) to affect pain; both to affect mobility, dexterity, and emotion; and neither to affect vision and hearing.Research Design.Linear regression models of HRQL and attribute-specific utilities were estimated as a function of 3 indicator variables of health problem (stroke only, arthritis only, both) and variables included to reduce confounding.Results.Subjects with stroke, arthritis, and both conditions had substantially lower HRQL than those with neither condition. Stroke subjects had greater morbidity in speech and cognition than arthritis subjects; somewhat surprisingly, pain morbidity was only slightly higher among arthritis subjects; neither condition affected vision or hearing. These associations were robust to various model specifications.Conclusions.The HUI3 system appears valid for measuring health status and HRQL for stroke and arthritis in the context of a noninstitutionalized population health survey.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Few studies have investigated the influence of race and/or ethnicity on patients' ratings of quality of care. None have incorporated patients' values and beliefs regarding medical care in assessing these possible differences.Objectives.We explored whether patients' values, ratings, and reports regarding physicians' primary care performance differed by race and/or ethnicity.Research Design.This was a cross-sectional, mailed patient survey.Subjects.The study subjects were adult primary care patients in a large health maintenance population (7,747 whites, 836 blacks, 710 Latinos, and 1,007 Asians).Measures and Methods.Ratings of the following dimensions of primary care were measured: technical competence, communication, accessibility, prevention and health promotion, and overall satisfaction. Patients' values regarding these dimensions and their confidence in medical care were measured. Multivariate analyses yielded associations of race/ethnicity with satisfaction and with reports of prevention services received.Results.For 7 of the 10 dimensions of primary care measured, Asians rated physician performance significantly less favorably than did whites, including differences among Asian ethnic subgroups. Latinos rated physicians' accessibility less favorably than did whites. Blacks rated physicians' psychosocial and lifestyle health promotion practices higher than did whites. No differences were found in patient reports of prevention services received, except Pacific Islanders reported receiving significantly more prevention services than whites.Conclusions.In a large HMO population, significant differences were found by race and ethnicity, and among Asian ethnic subgroups, in levels of patient satisfaction with primary care. These findings may represent actual differences in quality of care or variations in patient perceptions, patient expectations, and/or questionnaire response styles. More research is needed to assess, in accurate and culturally appropriate ways, whether health plans are meeting the needs of all enrollees.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Capitation holds health providers fiscally responsible for the services they deliver or arrange and thus provides strong motivation for physicians and hospitals to integrate activities and reduce costs of care.Objectives.The objective of this study was to assess 2 potential effects of capitation: (1) its effects on the integration of functional, financial, and clinical processes between hospitals and physicians and (2) its effects, in conjunction with process integration, on hospital costs.Study Design.We studied a 1995 American Hospital Association (AHA) special survey that has information on 44 different physician-hospital integrative activities and on global capitation contracts held by management service organizations, physician-hospital organizations, and other similar entities. These data were combined with the AHA's Annual Survey of Hospitals, InterStudy HMO data, the area resource file, and state regulation data. Multivariate analysis was used to assess the relationship between capitation and integration and then to examine the influence of these factors and others on hospital costs. We studied 319 urban hospitals with complete data.Findings.Provider capitation was found to promote integration between hospitals and physicians in relation to administrative/practice management, physician financial risk sharing, joint ventures to create new services, computer linkages, and an overall measure of physician-hospital integration. However, anticipated effects of integration and capitation on hospital costs were not evident.Conclusions.Global capitation is motivating tighter integration between physicians and hospitals in a number of respects. Although capitation is currently having the intermediate effect of encouraging process integration, it is not yet having the ultimate anticipated effect of lowering hospital costs.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.There are a growing number of efforts to compare the service quality of health care organizations on the basis of patient satisfaction data. Such efforts inevitably raise questions about the fairness of the comparisons. Fair comparisons presumably should not penalize (or reward) health care organizations for factors that influence satisfaction scores but are not within the control of managers or clinicians. On the basis of previous research, these factors might include the demographic characteristics of patients (eg, age) and the institutional characteristics (eg, size) of the health care organizations where care was received.Objectives.The goal of this study was to examine the extent to which a patient's satisfaction scores are related to both his/her demographic characteristics and the institutional characteristics of the health care organization where care was received.Methods.We conducted an analysis of secondary data from the Veterans Health Administration (VHA), US Department of Veterans Affairs. The database contained patient responses to self-administered satisfaction questionnaires and information about demographic characteristics. Additional data from VHA were obtained regarding the institutional characteristics of the hospitals where patients received their care.Results.Among demographic characteristics, age, health status, and race consistently had a statistically significant effect on satisfaction scores. Among the institutional characteristics, hospital size consistently had a significant effect on patient satisfaction scores.Conclusions.Study results can be interpreted as justifying the need to adjust patient satisfaction scores for differences in patient population among health care organizations. However, from a policy perspective, such adjustments may ultimately create a disincentive for health care organizations to customize their care.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives.To identify the determinants of patient preferences for participation in medical decision making.Methods.Data were analyzed for 2,197 patients from the Medical Outcomes Study, a 4-year observational study of patients with chronic disease (hypertension, diabetes, myocardial infarction, congestive heart failure, and depression). Multivariate logistic regression models estimated the effects of patients' sociodemographic, clinical, psychosocial, and lifestyle characteristics on their decision-making preferences.Results.A majority of the patients (69%) preferred to leave their medical decisions to their physicians. The odds for preferring an active role significantly decreased with age and increased with education. Women were more likely to be active than men (odds ratio [OR] = 1.44,P< 0.001). Compared with patients who only suffered with unsevere hypertension, those with severe diabetes (OR = 0.62,P= 0.04) and unsevere heart disease (OR = 0.45,P= 0.02) were less likely to prefer an active role. Patients with clinical depression were more likely to be active (OR = 1.64,P= 0.01). Patients pursuing active coping strategies had higher odds for an active role than "passive" copers, while those who placed higher value on their health were less likely to be active than those with low health value (OR = 0.59,P< 0.001).Conclusions.Although a majority of patients prefer to delegate decision making to physicians, preferences vary significantly by patient characteristics. Approaches to enhancing patient involvement will need to be flexible and accommodating to individual preferences in order to maximize the benefits of patient participation on health outcomes.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID