[Organization of psychiatric assistance to pensioners of the Ministry of internal affairs of Russia.]

For the purpose of systematization of the directions of rendering psychiatric help to pensioners of law-enforcement bodies (OVD) of the Russian Federation with mental disorders, the analysis of the existing normative legal acts regulating psychiatric examination of employees of Department of internal Affairs of the Russian Federation at dismissal on retirement and attachment on medical care in departmental healthcare institutions is carried out. It is shown that the provision of specialized psychiatric and psychotherapeutic assistance to pensioners of internal Affairs of the Russian Federation is carried out mainly in the municipal health care system, there is no monitoring of the mental state of pensioners of internal Affairs of the Russian Federation, including combatants with post-stress disorders. Within the framework of the project Of the concept of development of the psychiatric service of the Ministry of internal Affairs of Russia, it is proposed to systematize approaches to the organization of psychiatric care for pensioners of the Ministry of internal Affairs of the Russian Federation with mental disorders in the structure of departmental health care, with the improvement of the regulatory legal framework for the organization of psychiatric care, which will ensure the provision of high-quality psychiatric care.

Views of the chairs of Scottish health boards on engagement with quality management and comparisons with English trusts

OBJECTIVE

To describe the views of the chairs of Scottish health boards on the engagement of their boards with healthcare quality and to compare them with the views of the chairs of boards of English acute trusts. The focus of the Scottish Health Boards is on providing and commissioning care, while in England the acute trusts only provide care.

METHODS

We mailed a questionnaire, based on one used in England, to the 14 health board chairs in NHS Scotland in January 2011. The results were compared with the results of a similar questionnaire given to English acute trust chairs in 2009.

RESULTS

Most chairs in Scotland (67%) prioritised oversight of quality. Quality is considered at most Board meetings (92%), taking over 20% of time for 69% of chairs. Most boards have local quality targets and feedback quality data to staff. Compared with England, boards in Scotland meet less frequently and focus less on quality (shorter discussions, less frequent data review, fewer local targets) but they are more optimistic about their board's performance.

CONCLUSIONS

Although most chairs of Scottish boards view quality as a priority, they pay less attention to it than chairs in England, possibly due to their additional role in commissioning care.

Racial disparity in influenza vaccination: does managed care narrow the gap between African Americans and whites?

CONTEXT

Substantial racial disparities exist in use of some health services. Whether managed care could reduce racial disparities in the use of preventive services is not known.

OBJECTIVE

To determine whether the magnitude of racial disparity in influenza vaccination is smaller among managed care enrollees than among those with fee-for-service insurance.

DESIGN, SETTING, AND PARTICIPANTS

The 1996 Medicare Current Beneficiary Survey of a US cohort of 13 674 African American and white Medicare beneficiaries with managed care and fee-for-service insurance.

MAIN OUTCOME MEASURES

Percentage of respondents (adjusted for sociodemographic characteristics, clinical comorbid conditions, and care-seeking attitudes) who received influenza vaccination and magnitude of racial disparity in influenza vaccination, compared among those with managed care and fee-for-service insurance.

RESULTS

Eight percent of the beneficiaries were African American and 11% were enrolled in managed care. Overall, 65.8% received influenza vaccination. Whites were substantially more likely to be vaccinated than African Americans (67.7% vs 46.1%; absolute disparity, 21.6%; 95% confidence interval [CI], 18.2%-25.0%). Managed care enrollees were more likely than those with fee-for-service insurance to receive influenza vaccination (71.2% vs 65.4%; difference, 5.8%; 95% CI, 3.6%-8.3%). The adjusted racial disparity in fee-for-service was 24.9% (95% CI, 19.6%-30.1%) and in managed care was 18.6% (95% CI, 9.8%-27.4%). These adjusted racial disparities were both statistically significant, but the absolute percentage point difference in racial disparity between the 2 insurance groups (6.3%; 95% CI, -4.6% to 17.2%) was not.

CONCLUSION

Managed care is associated with higher rates of influenza vaccination for both whites and African Americans, but racial disparity in vaccination is not reduced in managed care. Our results suggest that additional efforts are needed to adequately address this disparity.

Racial differences in cardiac revascularization rates: does "overuse" explain higher rates among white patients?

BACKGROUND

Coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) are well-established treatments for symptomatic coronary artery disease. Previous studies have documented racial differences in rates of use of these cardiac revascularization procedures. Other studies suggest that these procedures are overused: that is, they are done for patients with clinically inappropriate indications.

OBJECTIVE

To test the hypothesis that the higher rate of cardiac revascularization among white patients is associated with a higher prevalence of overuse (revascularization for clinically inappropriate indications) among white patients than among African-American patients.

DESIGN

Observational cohort study using Medicare claims and medical record review.

SETTING

173 hospitals in five U.S. states.

PARTICIPANTS

A stratified, weighted, random sample of 3960 Medicare beneficiaries who underwent coronary angiography during 1991 and 1992; 1692 of these patients underwent 1711 revascularization procedures within 90 days.

MEASUREMENTS

The proportion of CABG and PTCA procedures rated appropriate, uncertain, and inappropriate according to RAND criteria, and the multivariate odds of undergoing inappropriate revascularization among African-American patients and white patients.

RESULTS

After angiography, rates of PTCA (23% vs. 19%) and CABG surgery (29% vs. 17%) were significantly higher among white patients than among African-American patients. The respective rates of inappropriate PTCA and CABG surgery were 14% and 10%. Among the study states, rates of inappropriate use ranged from 4% to 24% for PTCA and 0% to 14% for CABG surgery. White patients were more likely than African-American patients to receive inappropriate PTCA (15% vs. 9%; difference, 6 percentage points [95% CI, -0.4 to 12.7 percentage points]), and difference by race was statistically significant among men (20% vs. 8%; difference, 12 percentage points [CI, 1.2 to 21.7 percentage points]). Rates of inappropriate CABG surgery did not differ by race (10% in both groups).

CONCLUSIONS

Among a large and diverse sample of Medicare beneficiaries in five U.S. states, overuse of PTCA was greater among white men than among other groups, but this difference did not fully account for racial disparities in revascularization. Overuse of cardiac revascularization varied significantly by geographic region.

Scale and structure of capitated physician organizations in California

Physician organizations in California broke new ground in the 1980s by accepting capitated contracts and taking on utilization management functions. In this paper we present new data that document the scale, structure, and vertical affiliations of physician organizations that accept capitation in California. We provide information on capitated enrollment, the share of revenue derived by physician organizations from capitation contracts, and the scope of risk sharing with health maintenance organizations (HMOs). Capitation contracts and risk sharing dominate payment arrangements with HMOs. Physician organizations appear to have responded to capitation by affiliating with hospitals and management companies, adopting hybrid organizational structures, and consolidating into larger entities.

For-profit and not-for-profit health plans participating in Medicaid

The proliferation of for-profit health plans has heightened concerns about quality of care, particularly with respect to Medicaid. We undertook this study to compare for-profit and not-for-profit health plans that participate in Medicaid, examining processes of care and the organizational characteristics related to utilization management, financial incentives, and quality of care. Our findings demonstrate that for-profit and not-for-profit plans appear to be more similar than dissimilar in many areas of management, although for-profit plans are more likely to use aggressive utilization review and have slightly less developed quality management systems. On balance, these findings should reassure critics of for-profit health care.

Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse?

BACKGROUND

Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care.

METHODS

We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race.

RESULTS

Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons).

CONCLUSIONS

Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.

The role of quality measurement in a competitive marketplace

Quality measurement is not a new idea. However, in recent years, several new trends have gained prominence: greater interest in publicly reported information on quality of care, access to care, and patient satisfaction; an increased focus on health plans and integrated systems of care rather than on institutional providers and practitioners as the unit of observation; wide adoption of the techniques of continuous quality improvement within the health care sector; increased use of clinical practice guidelines to improve care for a broad range of medical conditions; incorporation of computer technology into the clinical setting; and greater appreciation for health outcomes as a measure of quality of care. This chapter first reviews the changes in the medical landscape that have seeded these trends and the distinction between quality assurance and quality improvement. It then focuses on public policy concerns, in particular on the emergence of publicly disseminated information about quality of care, now often called "quality report cards." The major prototypes of these reports developed to date, the responses to quality reporting by different members of the delivery system, and the major criticisms of this approach are reviewed. The chapter concludes by predicting probable developments and the strategies most likely to move health care forward in a productive direction.

Impact of sociodemographic case mix on the HEDIS measures of health plan quality

BACKGROUND

The widely used Health Plan Employer Data and Information Set (HEDIS) measures may be affected by differences among plans in sociodemographic characteristics of members.

OBJECTIVE

The objective of this study was to estimate effects of geographically linked patient sociodemographic characteristics on differential performance within and among plans on HEDIS measures.

RESEARCH DESIGN

Using logistic regression, we modeled associations between age, sex, and residential area characteristics of health plan members and results on HEDIS measures. We then calculated the impact of adjusting for these associations on plan-level measures.

SUBJECTS

This study included 92,232 commercially insured members with individual-level HEDIS data and an additional 20,615 members whose geographic distribution was provided.

MEASURES

This study used 7 measures of screening and preventive services.

RESULTS

Performance was negatively associated with percent receiving public assistance in the local area (6 of 7 measures), percent black (5 measures), and percent Hispanic (2 measures) and positively associated with percent college educated (6 measures), percent urban (2 measures), and percent Asian (1 measure) after controlling for plan and product type. These effects were generally consistent across plans. When measures were adjusted for these characteristics, rates for most plans changed by less than 5 percentage points. The largest change in the difference between plans ranged from 1.5% for retinal exams for people with diabetes to 20.2% for immunization of adolescents.

CONCLUSIONS

Performance on quality indicators for individual members is associated with sociodemographic context. Adjustment has little impact on the measured performance of most plans but a substantial impact on a few. Further study with more plans is required to determine the appropriateness and feasibility of adjustment.

Providing consumers with information about the quality of health plans: the Consumer Assessment of Health Plans demonstration in Washington State

BACKGROUND

In 1995 the Agency for Health Care Policy and Research began a five-year project, Consumer Assessment of Health Plans (CAHPS), to create instruments to collect data from consumers about their health care experiences, to develop sophisticated methods to convey these data to consumers, and to evaluate the value of these data to consumers who are selecting health plans. Results were obtained from one of the first CAHPS demonstration sites, the Washington State Health Care Authority.

METHODS

The survey was distributed in May-June 1997 to 15,885 enrollees in 20 health plans; 8,204 (51.6%) surveys were completed. Survey results were summarized in a report that described the performance of plans, which was distributed to 97,000 enrollees, and reactions to the report were obtained from more than 1,500 individuals.

RESULTS

Nearly everyone who was mailed the report said they saw it. A large proportion said they read most or all of it, and most thought the report was easy to understand, contained information needed to rate plans, and was helpful to learning about differences between plans. Those who used the CAHPS performance report were more likely to switch plans and to report that they were confident they had selected the best plan for their situation.

DISCUSSION

The study was unique in that it attempted to evaluate whether employees read the performance report, how they reacted to it, and whether reading it influenced their decision to switch plans or their confidence that they had selected a suitable plan. Choosing a new plan probably stimulated more intense scrutiny of the report than not anticipating switching.

Quality of care by race and gender for congestive heart failure and pneumonia

BACKGROUND

Variations in the rates of major procedures by race and gender are well described, but few studies have assessed the quality of care by race and gender for basic hospital services.

OBJECTIVE

To assess quality of care by race and gender.

RESEARCH DESIGN

Retrospective review of medical records.

SUBJECTS

Stratified random sample of 2,175 Medicare beneficiaries hospitalized for congestive heart failure or pneumonia in Illinois, New York, and Pennsylvania during 1991 and 1992.

MEASURES

Explicit process criteria and implicit review by physicians.

RESULTS

In adjusted analyses, black patients with congestive heart failure or pneumonia received lower quality of care overall than other patients with these conditions by both explicit process criteria and implicit review (P < 0.05). On explicit measures, overall quality of care did not differ by gender for either condition, but significant differences were noted on explicit subscales. Women received worse cognitive care than men from physicians for both conditions, better cognitive care from nurses for pneumonia, and better therapeutic care for congestive heart failure (P < 0.05). Women received worse quality of care than men by implicit review (P = 0.03) for congestive heart failure but not pneumonia.

CONCLUSIONS

Consistent racial differences in quality of care persist in basic hospital services for two common medical conditions. Physicians, nurses, and policy makers should strive to eliminate these differences. Gender differences in quality of care are less pronounced and may vary by condition and type of provider or service.

The effect of patients' preferences on racial differences in access to renal transplantation

BACKGROUND

In the United States, black patients undergo renal transplantation less often than white patients, but few studies have directly assessed the association between race and patients' preferences with respect to transplantation.

METHODS

To assess preferences with respect to transplantation and experiences with medical care, we interviewed 1392 (82.9 percent) of 1679 eligible patients with end-stage renal disease (age range, 18 to 54 years) approximately 10 months after they had begun maintenance treatment with dialysis. Participants were selected from a stratified random sample of patients undergoing dialysis in four regions of the United States (Alabama, southern California, Michigan, and the mid-Atlantic region of Maryland, Virginia, and the District of Columbia) in 1996 and 1997. Patients were followed until March 1999.

RESULTS

The interviews were conducted with 384 black women, 354 white women, 337 black men, and 317 white men. Black patients were less likely than white patients to want a transplant (76.3 percent of black women reported such a preference, vs. 79.3 percent of white women, and 80.7 percent of black men vs. 85.5 percent of white men), and they were less likely to be very certain about this preference (58.3 percent vs. 65.3 percent and 64.1 percent vs. 75.7 percent, respectively; P<0.01 for each comparison with both sexes combined). However, much larger differences were evident in rates of referral for evaluation at a transplantation center (50.4 percent for black women vs. 70.5 percent for white women, and 53.9 percent for black men vs. 76.2 percent for white men; P<0.001 for each comparison) and placement on a waiting list or transplantation within 18 months after the start of dialysis therapy (31.3 percent for black women vs. 56.5 percent for white women, and 35.3 percent for black men vs. 60.6 percent for white men; P<0.001). These racial differences remained significant after adjustment for patients' preferences and expectations about transplantation, sociodemographic characteristics, the type of dialysis facility, perceptions of care, health status, the cause of renal failure, and the presence or absence of coexisting illnesses.

CONCLUSIONS

In the United States, the preferences and expectations with respect to renal transplantation among patients with end-stage renal disease differ according to race. These differences, however, explain only a small fraction of the substantial racial differences in access to transplantation. Physicians should ensure that black patients who desire renal transplantation are fully informed about it and are referred for evaluation.

Quality management practices in Medicaid managed care: a national survey of Medicaid and commercial health plans participating in the Medicaid program

CONTEXT

Rapid expansion of Medicaid managed care has raised concerns about the capacity and willingness of health plans enrolling Medicaid beneficiaries to provide high-quality care. Recently, legislation has facilitated market entry of Medicaid plans, health plans that draw most of their enrollment from the Medicaid population.

OBJECTIVE

To characterize and compare the organizational characteristics and programs related to quality of care of commercial and Medicaid health plans that participate in the Medicaid program.

DESIGN

Cross-sectional survey conducted September 1997 to April 1998.

SETTING

The Medicaid program in 11 states and the District of Columbia.

PARTICIPANTS

All 154 health plans in these localities that provided prepaid general medical care to Medicaid beneficiaries during June 1997, of which 130 (84%) responded to the survey.

MAIN OUTCOME MEASURES

Health plan reports of structural characteristics, services offered, performance measurement and feedback, disease management programs, information systems capabilities, and provider network composition and relationships.

RESULTS

Half of the respondents were Medicaid plans, with 75% or more of enrollees drawn from the Medicaid population. Medicaid plans tended to be smaller and newer than commercial plans that also served the Medicaid population and had more enabling programs targeting the special needs of the Medicaid population, such as inadequate transportation (85% of Medicaid plans vs 62% of commercial plans; P = .003) and illiteracy (66% vs 38%, respectively; P = .002). Overall, 71% of Medicaid plans vs 43% of commercial plans had enabling programs targeted at 6 or more of the 8 special needs we specified (P = .001). While commercial plans had a higher proportion of board-certified primary care physicians (81% vs 73%; P = .01), we found no major differences between Medicaid plans and commercial plans in collection and dissemination of performance measures, designation of specific areas for quality improvement, or use of disease management programs targeted at conditions prevalent in the Medicaid population. Neither commercial nor Medicaid plans reported high success in improving quality of care.

CONCLUSIONS

Based on our survey, while Medicaid plans resemble commercial plans serving the Medicaid population in many aspects of quality management, they are more likely to target programs directed to the specific needs of the Medicaid population. Neither commercial nor Medicaid plans have notably strong records in actual quality improvement.

Hospital readmissions and quality of care

BACKGROUND

Readmission rates are often proposed as markers for quality of care. However, a consistent link between readmissions and quality has not been established.

OBJECTIVE

To test the relation of readmission to quality and the utility of readmissions as hospital quality measures.

SUBJECTS

One thousand, seven hundred and fifty-eight Medicare patients hospitalized in four states between 1991 to 1992 with pneumonia or congestive heart failure (CHF).

DESIGN

Case control.

MEASURES

Related adverse readmissions (RARs), defined as readmissions that indicate potentially sub-optimal care during initial hospitalization, were identified from administrative data using readmission diagnoses and intervening time periods designated by physician panels. We used linear regression to estimate the association between implicit and explicit quality measures and readmission status (RARs, non-RAR readmissions, and nonreadmissions), adjusting for severity. We tested whether RARs were associated with inferior care and performed simulations to determine whether RARs discriminated between hospitals on the basis of quality.

RESULTS

Compared with nonreadmitted pneumonia patients, patients with RARs had lower adjusted quality measured both by explicit (0.25 standardized units, P = 0.004) and implicit methods (0.17, P = 0.047). Adjusted differences for CHF patients were 0.17 (P = 0.048) and 0.20 (P = 0.017), respectively. In some analyses, patients with non-RAR readmissions also experienced lower quality. However, rates of inferior quality care did not differ significantly by readmission status, and simulations identified no meaningful relationship between RARs and hospital quality of care.

CONCLUSIONS

RARs are statistically associated with lower quality of care. However, neither RARs nor other readmissions appear to be useful tools for identifying patients who experience inferior care or for comparing quality among hospitals.

Quality of care for two common illnesses in teaching and nonteaching hospitals

Teaching hospitals are recognized for treating rare diseases, but their value in caring for common illnesses is less clear. To assess quality of care for congestive heart failure and pneumonia, we reviewed the medical records of Medicare beneficiaries in major teaching, other teaching, and nonteaching hospitals in four states. Overall quality was rated better in major and other teaching hospitals than in nonteaching hospitals by physician reviewers and explicit process criteria, but the results varied for different subsets of explicit measures. Future studies should assess whether outcomes differ between teaching and nonteaching hospitals.

Rolling down the runway: the challenges ahead for quality report cards

Today, steadily increasing numbers of hospitals and health plans are publicly releasing performance reports on the quality of care to permit comparisons across different providers. Our experience in recent years has provided important new evidence of what public quality reporting can accomplish and the difficulties it faces. Several years ago, the most important impediments to quality reporting may have been the availability of acceptable quality indicators and the feasibility of voluntary, standardized data collection by health plans. We have made strides in these areas. The Health Employer Data and Information Set (HEDIS) has expanded, and there have been new innovations in collecting data on quality from both patients and physicians. Hundreds of health plans have begun to report standardized quality data on a routine basis either voluntarily or in response to requirements from the Health Care Financing Administration, state Medicaid agencies, or private payers. Now, the more formidable barriers to the use of quality report cards may relate to the ways we report the data and use it. We need to find acceptable middle ground for those who believe information on individual physicians is critical and those who believe it is harmful. We need to reap the advantages in different modalities of data collection and different tools for quality management. Most of all, we need to find better ways to use quality reporting to empower purchasers and consumers and improve quality of care.

Use of public performance reports: a survey of patients undergoing cardiac surgery

CONTEXT

Publicly released performance reports ("report cards") are expected to foster competition on the basis of quality. Proponents frequently cite the need to inform patient choice of physicians and hospitals as a central element of this strategy.

OBJECTIVE

To examine the awareness and use of a statewide consumer guide that provides risk-adjusted, in-hospital mortality ratings of hospitals that provide cardiac surgery.

DESIGN

Telephone survey conducted in 1996.

SETTING

Pennsylvania, where since 1992, the Pennsylvania Consumer Guide to Coronary Artery Bypass Graft [CABG] Surgery has provided risk-adjusted mortality ratings of all cardiac surgeons and hospitals in the state.

PARTICIPANTS

A total of 474 (70%) of 673 eligible patients who had undergone CABG surgery during the previous year at 1 of 4 hospitals listed in the Consumer Guide as having average mortality rates between 1% and 5% were successfully contacted.

MAIN OUTCOME MEASURES

Patients' awareness of the Consumer Guide, their knowledge of its ratings, their degree of interest in the report, and barriers to its use.

RESULTS

Ninety-three patients (20%) were aware of the Consumer Guide, but only 56 (12%) knew about it before surgery. Among these 56 patients, 18 reported knowing the hospital rating and 7 reported knowing the surgeon rating, 11 said hospital and/or surgeon ratings had a moderate or major impact on their decision making, but only 4 were able to specify either or both correctly. When the Consumer Guide was described to all patients, 264 (56%) were "very" or "somewhat" interested in seeing a copy, and 273 (58%) reported that they probably or definitely would change surgeons if they learned that their surgeon had a higher than expected mortality rate in the previous year. A short time window for decision making and a limited awareness of alternative hospitals within a reasonable distance of home were identified as important barriers to use.

CONCLUSIONS

Only 12% of patients surveyed reported awareness of a prominent report on cardiac surgery mortality before undergoing cardiac surgery. Fewer than 1% knew the correct rating of their surgeon or hospital and reported that it had a moderate or major impact on their selection of provider. Efforts to aid patient decision making with performance reports are unlikely to succeed without a tailored and intensive program for dissemination and patient education.

Quality management by state Medicaid agencies converting to managed care: plans and current practice

CONTEXT

Enrollment in Medicaid managed care plans has increased more than 5-fold in this decade, but how states monitor and encourage quality of care in these programs is not known.

OBJECTIVE

To characterize the quality monitoring and assurance activities of state Medicaid agencies for Medicaid beneficiaries enrolled in comprehensive prepaid managed care programs.

DESIGN

Structured telephone survey conducted between October 1996 and January 1997.

SETTING

State Medicaid agencies.

PARTICIPANTS

Representatives from all state Medicaid agencies, including the District of Columbia, with beneficiaries enrolled in comprehensive prepaid managed care plans as of July 1, 1996.

MAIN OUTCOME MEASURES

Proportion of states with specific quality monitoring and assurance activities for Medicaid managed care.

RESULTS

We surveyed all 34 states enrolling beneficiaries in comprehensive managed care programs. In 1996, all 34 states enrolled the population receiving assistance from the Aid to Families With Dependent Children (AFDC) program, while only 21 (62%) and 15 (44%) enrolled the disabled and elderly populations, respectively. In the period 1995 to 1996, 19 states (63%) collected data on satisfaction with care, and 25 states (83%) collected data on childhood immunizations. No more than half of the states collected data on other selected measures of access and quality, but a substantial number planned to collect such data in 1997. While at most 37% of states were providing comparative data to health plans, up to 80% were planning to provide such information in 1997. Similarly, while at most 10% of states provided beneficiaries with such information, up to 38% planned to do so in 1997. The breadth of contracting requirements designed to assure quality varied substantially across states.

CONCLUSIONS

State Medicaid agencies have already begun adapting to their new roles as purchasers of health care. Continued monitoring is essential to ensure that state agencies implement planned programs and that quality of care for Medicaid enrollees is preserved or improved.

Mitogen-activated protein kinase activation: an alternate signaling pathway for sustained vascular smooth muscle contraction

PURPOSE

The vascular smooth muscle determines the dynamic caliber of the blood vessel and hence is the final effector cell in modulating vasomotor tone. Although considerable information is available regarding the physiologic agonists that induce contraction, less is known about the cellular signaling events that lead to long-lasting contractions or vasospasm. We examined the hypothesis that activation of mitogen-activated protein (MAP) kinase may be associated with sustained smooth muscle contractions.

METHODS

Physiologic contractile responses were determined in intact bovine carotid artery smooth muscles in a muscle bath. Corresponding signaling events were determined with immunoblots using antiphosphotyrosine antibodies or immunoprecipitation of whole-cell phosphorylated strips of muscle.

RESULTS

The tyrosine kinase inhibitor, genestein, significantly inhibited the magnitude of contractions induced by phorbol ester, endothelin, angiotensin, and serotonin. In addition, genestein inhibited the sustained phase of contractions induced by serotonin. Serotonin-induced vascular smooth muscle contractions were temporally associated with an increase in the phosphorylation of MAP kinase.

CONCLUSIONS

These data suggest that the activation of MAP kinase is associated with sustained vascular smooth muscle contractions. Pharmacologic manipulation of MAP kinase activation may lead to new approaches to treat pathologic circumstances of increased vasomotor tone such as vasospasm.

Attitudes about treatment of coronary heart disease among women and men presenting for exercise testing

To assess attitudes that could contribute to gender differences in the use of coronary procedures, we surveyed 322 patients presenting for exercise testing at a major teaching hospital. Adjusting for sociodemographic and clinical factors, women and men did not differ significantly in their willingness to seek a second opinion, reduce physical activity, or take drugs to avoid major cardiac surgery, but men were more likely than women to describe themselves as risk takers on a three-item personality measure (adjusted odds ratio 2.5; 95% confidence interval 1.4-4.6). Patients' attitudes about risk should be explored further in studies of gender differences in the use of coronary procedures.

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument

OBJECTIVES

This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival.

METHODS

Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained.

RESULTS

Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61).

CONCLUSIONS

Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study

OBJECTIVES

The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS).

METHODS

A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model.

RESULTS

Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days.

CONCLUSIONS

The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Influence of cardiac-surgery performance reports on referral practices and access to care. A survey of cardiovascular specialists

BACKGROUND

Reports on the comparative performance of physicians are becoming increasingly common. Little is known, however, about the credibility of these reports with target audiences or their influence on the delivery of medical services.

METHODS

Since 1992, Pennsylvania has published the Consumer Guide to Coronary Artery Bypass Graft Surgery, which lists annual risk-adjusted mortality rates for all hospitals and surgeons providing such surgery in the state. In 1995, we surveyed a randomly selected sample of 50 percent of Pennsylvania cardiologists and cardiac surgeons to find out whether they were aware of the guide and, if so, to determine their views on its usefulness, limitations, and influence on providers.

RESULTS

Eighty-two percent of the cardiologists and all the cardiac surgeons were aware of the guide. Only 10 percent of these respondents reported that its mortality rates were "very important" in assessing the performance of a cardiothoracic surgeon. Less than 10 percent reported discussing the guide with more than 10 percent of their patients who were candidates for a coronary-artery bypass graft (CABG). Eighty-seven percent of the cardiologists reported that the guide had a minimal influence or none on their referral recommendations. For both groups, the most important limitations of the guide were the absence of indicators of quality other than mortality (cited by 78 percent), inadequate risk adjustment (79 percent), and the unreliability of data provided by hospitals and surgeons (53 percent). Fifty-nine percent of the cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery in severely ill patients who required it, and 63 percent of the cardiac surgeons reported that they were less willing to operate on such patients.

CONCLUSIONS

The Consumer Guide to Coronary Artery Bypass Graft Surgery has limited credibility among cardiovascular specialists. It has little influence on referral recommendations and may introduce a barrier to care for severely ill patients. If publicly released performance reports are intended to guide the choice of providers without impeding access to medical care, a collaborative process involving physicians may enhance the credibility and usefulness of the reports.

Cholesterol-reduction intervention study (CRIS): a randomized trial to assess effectiveness and costs in clinical practice

BACKGROUND

The 1988 US National Cholesterol Education Program Expert Panel Report recommended initial treatment with niacin or bile acid sequestrants, followed by other agents if needed, to lower low-density lipoprotein cholesterol (LDL-C) levels in hypercholesterolemic patients who require drug therapy. It is unknown how the effectiveness and costs of such an approach ("stepped care") compare in typical clinical practice to those of initial therapy with lovastatin.

PATIENTS AND METHODS

We randomly assigned 612 patients, aged 20 to 70 years, who met 1988 National Cholesterol Education Program guidelines for drug treatment of elevated LDL-C level and had not previously used cholesterol-lowering medication, to either a stepped-care regimen or initial therapy with lovastatin (both n=306). The study, conducted at Southern California Kaiser Permanente, was designed to approximate typical practice: provider compliance with treatment plans was encouraged but not enforced, and patients paid for medication as they customarily would.

RESULTS

At 1 year, the decline in mean LDL-C level was significantly greater among patients assigned to initial treatment with lovastatin (22% vs 15% for stepped care; P<.001), as was the number who attained goal LDL-C level (</= 4.14 mmol/L [</= 160 mg/dL], or </= 3.36 mmol/L [</= 130 mg/dL] if coronary heart disease or two or more risk factors were present) (40% vs 24%; P<.001). The increase in mean high-density lipoprotein cholesterol levels was significantly greater in the stepped-care group, however (8% vs 1% for lovastatin; P<.001). Patients who were randomized to stepped care were more likely to report substantial bother caused by side effects (30% vs 16% for lovastatin; P<.001) and discontinuation of therapy at 1 year (28% vs 18%, respectively; P<.01). Costs of care were $333 higher per patient in the lovastatin group ($786 vs $453; P<.001).

CONCLUSIONS

A stepped-care regimen beginning with niacin is less costly than initial therapy with lovastatin, but also less effective in lowering LDL-C level. While it is more effective in increasing high-density lipoprotein cholesterol levels, the tolerability of such a regimen may be a problem.

Variations in the utilization of coronary angiography for elderly patients with an acute myocardial infarction. An analysis using hierarchical logistic regression

This article reports a study of variations in the utilization of angiography for Medicare recipients who had an acute myocardial infarction. The study cohort consisted of 1987 Medicare beneficiaries who had a recent acute myocardial infarction. Variations were examined from three perspectives: patient characteristics, regional practice patterns, and on-site availability of the procedure. Factors associated with variation within and among states were incorporated into the analysis using hierarchical logistic regression models. The probability of angiography during the first 90 days after an acute myocardial infarction was estimated as a function of patient age, gender, race, and comorbidity for patients in 51 states (including the District of Columbia). Interstate differences were examined in relation to geographic region and on-site availability of angiography. Observed rates of angiography ranged between 13.8% and 38.3% (median, 24.7%). Variation was nearly threefold based on estimated state probabilities of angiography for a patient with characteristics set at the national average. Observed and estimated rates were lower in northeastern states than in other parts of the United States. States with more extensive onsite availability of angiography tended to have higher angiography rates after adjusting for patient characteristics and geographic region. Adjusted angiography rates were on average higher for younger patients, males, and nonblacks. There was substantial interstate variation in race differences, with states in the Southeast generally having the largest differences. The adjusted black-to-nonblack odds ratio ranged from a low of 0.41 to a high of 0.94. Interstate variation in age and gender differences was moderate. The work reported in this article illustrates the potential of hierarchical regression modeling as a framework for the analysis of variations and some methodologic issues connected with its implementation. Our results show that large variations in the utilization of procedures can exist, despite uniform insurance coverage and a relatively homogeneous patient cohort. Aggressive use of angiography was highly variable across states as was the degree of access to the procedure for blacks and nonblacks. The state rate of on-site availability of angiography facilities was an important predictor of utilization. Increased on-site availability of angiography, however, was not associated with a reduction of differences in access to the procedure.

Development and validation of a claims based index for adjusting for risk of mortality: the case of acute myocardial infarction

We developed a comorbidity index on a cohort of 162,699 Medicare beneficiaries who had an acute myocardial infarction (AMI) in 1987 and validate it on two national cohorts: (1) a cohort of 164,427 Medicare beneficiaries who had an AMI in 1988 and (2) a cohort of 10,466 patients admitted to Veterans Administration Hospitals (VAH) for AMI in 1988-1991. The impact of each sensitivity was expressed as; (1) the risk of mortality for those with the comorbidity, (2) the adjustment to the log odds for 2 year mortality and (3) the age-based likelihood of 2 year mortality. Models were validated by calculated the area under an ROC curve obtained by fitting a logistic regression model to each validation population. The two year mortality rate for 30-day survivors was approximately 30% in each of the 3 cohorts. The 5 most prevlent comorbidities coded in the developmental cohort were heart failure (34%), chronic angina (27%), minor arrythmias (25%) and uncomplicated hypertension (18%). Cancer was the most powerful predictor of 2 year mortality, impacting mortality the same as a 18.3 year age increase. Saturation (having all secondary diagnoses in the discharge summary filled) resulted in a 9.2 year age increase. Validation in the 1988 Medicare and in the Veterans Administration Hospitals cohorts resulted in areas of 73% and 72% under the respective ROC curves. Our methods can serve as a prototype for others wishing to assess comorbidity in other targeted subgroups.

Correlates of employment after AIDS diagnosis in the Boston Health Study

OBJECTIVES

The purpose of this study was to determine the impact of personal and job characteristics on the time to employment loss after diagnosis of the acquired immunodeficiency syndrome (AIDS) and to examine how job loss affects patients' income.

METHODS

Data were collected from 305 patients with AIDS at three sites in Boston, Mass, between February 1990 and July 1991. Life-table methods were used to estimate the number of months employed after diagnosis. A Cox proportional hazards model was used to estimate the effect of risk factors on the probability of ceasing employment in a month.

RESULTS

Seventy-six percent of respondents were working at the time of diagnosis; 53% still had a job at the time of the baseline interview, which averaged 16 months later, but about one in three was on sick or disability leave. Mental and physical demands of jobs significantly influenced the likelihood of employment loss. The loss of earnings reduced monthly income by 75%.

CONCLUSIONS

Job characteristics affect the likelihood of employment loss, which in turn has a deleterious effect on income. Programs supporting persons with AIDS during the transition out of work or enabling them to modify their job demands may also reduce these problems.

Changes in insurance status and access to care for persons with AIDS in the Boston Health Study

The purpose of this study was to measure unmet needs and changes in insurance status for persons with acquired immunodeficiency syndrome (AIDS). Thirty-six percent of the study's Boston-area respondents (n = 305) had a change in insurance coverage between AIDS diagnosis and interview. Medicaid coverage increased from 14% to 41%. Pneumocystis carinii pneumonia prophylaxis was nearly universal. Only 5% did not receive zidovudine, and intravenous drug users were at higher risk. Approximately 14% to 15% of patients reported problems in obtaining medical and dental services; Blacks, homeless persons, and those who were not high school graduates were at higher risk. Use of selected treatments for which there were clear clinical guidelines was adequate, yet disadvantaged groups were more likely than other persons with AIDS to face obstacles to other services.

Cost-effectiveness of ticlopidine in preventing stroke in high-risk patients

BACKGROUND

Ticlopidine, an antiplatelet agent, when compared with aspirin has been found to reduce the risk of stroke in high-risk patients, ie, those with recent transient ischemic attack, reversible ischemic neurological deficit, amaurosis fugax, or minor stroke. Its cost-effectiveness in such use, however, is unknown.

METHODS

We developed a model of primary stroke prevention in which a hypothetical cohort of 100 high-risk men and women 65 years of age was assumed to receive either ticlopidine (500 mg daily) or aspirin (1300 mg daily). Using published data, we estimated lifetime incidence of stroke, life expectancy (unadjusted and adjusted for changes in quality of life), and lifetime medical care costs associated with each therapy.

RESULTS

Patients who receive ticlopidine would experience two fewer initial strokes per hundred than those treated with aspirin. Life expectancy would be extended by approximately one-half month, and lifetime medical care costs (discounted at 5%) would increase by about $2300. The cost-effectiveness of ticlopidine, compared with aspirin, is estimated to range from $31,200 to $55,500 per quality-adjusted life-year gained as the utility of life after nonfatal stroke is assumed to vary from 0.75 to 0.95.

CONCLUSIONS

Ticlopidine therapy to prevent stroke in high-risk patients is cost-effective by current standards of medical practice.

Physician discretion and racial variation in the use of surgical procedures

BACKGROUND

Racial variation in the use of surgical procedures raises concern about equitable access. The goal of our study was to examine racial differences in utilization across a broad range of procedures in Massachusetts and to assess whether racial variation is related to physician discretion.

METHODS

We obtained fiscal year 1988 hospital discharge data for all Massachusetts residents, identified 10 clinically important surgical procedures, and calculated age- and sex-adjusted rate ratios for white and black patients. Level of discretion was determined by using a modified Delphi technique.

RESULTS

Whites had higher rates for eight procedures (abdominal aortic aneurysm repair, appendectomy, cardiac valve replacement, carotid endarterectomy, cholecystectomy, lumbar disk procedures, open reduction/internal fixation of the femur, and tonsillectomy) and lower rates for two procedures, hysterectomy and prostatectomy. Of the eight procedures for which utilization was higher among whites, four were ranked as moderate- or high-discretion procedures and four were ranked as low-discretion procedures. Hysterectomy, the only procedure for which utilization was substantially higher among blacks (white:black rate ratio < 0.90), was ranked as a high-discretion procedure.

CONCLUSIONS

With the exception of hysterectomy and prostatectomy, procedure rates for whites were greater than those for blacks for a wide range of surgical procedures. Racial variation exists for low-discretion procedures as well as for those associated with moderate and high discretion. Variation among low-discretion procedures that is not explained by medical need suggests the possibility of race-related differences in access to care or in the way patients and physicians make clinical decisions.

Trends in the use of drug therapies in patients with acute myocardial infarction: 1988 to 1992

OBJECTIVES

In this study, we investigated the use of thrombolytic agents and other cardiac drugs in a national cohort of patients with acute myocardial infarction and assessed the influence of large clinical studies on types of thrombolytic therapy prescribed.

BACKGROUND

Information about usage patterns for these drugs is unavailable, and little is known about the impact of large clinical trials on their use.

METHODS

We conducted a retrospective cohort study of 65,011 patients who were treated for acute myocardial infarction during fiscal years 1988 to 1992 (October 1, 1987 to September 30, 1992) in hospitals participating in the SMS Corporation's on-line data pool.

RESULTS

The overall thrombolysis rate for patients with acute myocardial infarction increased from 11% in fiscal year 1988 to 18% in fiscal year 1990 and has remained approximately at that level since then. In mid-1989, tissue plasminogen activator was used in 90% of the patients receiving thrombolysis, whereas streptokinase was used in only 10%. Since 1991, tissue plasminogen activator has been used in 60% of patients and streptokinase in almost 30%. Much of this change came after presentation and publication of results of the Second Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico (GISSI-2) and the Third International Study of Infarct Survival (ISIS-3) trials. Over these 5 years, use of beta-adrenergic blocking agents increased steadily, and use of calcium-channel blocking agents declined steadily.

CONCLUSIONS

Current usage rates of thrombolytic therapy are lower than expected, but trends in usage rates for beta-blockers and calcium channel blockers reflect their increasing and decreasing approval, respectively. Presentation and publication of results from the Third International Study of Infarct Survival and the Second Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico trials appear to have influenced the type of thrombolytic agent prescribed.

The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma

OBJECTIVES

To examine whether differences in intensities of care by socioeconomic status and race result in worse health among adults with asthma post-hospital discharge.

DESIGN

Patients were enrolled during hospitalization and recontacted three months after discharge.

PATIENTS

Those aged 18-55 years, with a primary diagnosis of asthma (n = 97).

MAIN OUTCOME MEASURES

Regular source of care, "intensive" therapy (use of an anti-inflammatory agent, pulmonary function testing, or an asthma specialist), and patient-reported (Intermediate Activities of Daily Living Scale [IADL] score, dyspnea) and performance-based (peak flow rate) measures of health status post-discharge.

RESULTS

28% of patients with a yearly income less than $16,000 had no regular source of care, compared with 11% of those with an income from $16,000 to $29,999 and no patient with an income of at least $30,000 (p = 0.003). Similarly, intensive therapy was received by 40%, 67%, and 81% of these groups (p = 0.005). Education had similar associations. Patients with no regular source of care or who did not receive intensive therapy had significantly worse health. Patients of lower socioeconomic status had health outcomes that were up to 25% lower than those of patients of higher socioeconomic status (p < 0.05 for differences in LADL score, dyspnea, and peak flow by educational levels and for differences in dyspnea by income levels), after adjustment for age, gender, race, insurance status, and baseline health. After further adjustment for source of care and intensity of therapy, differences in health outcomes by socioeconomic status uniformly decreased in magnitude and only the differences in LADL scores and dyspnea by educational levels remained statistically significant. Although nonwhite patients were less likely to have a regular source of care or to receive intensive therapy, there was no difference in health outcomes by race.

CONCLUSIONS

Patients of lower socioeconomic status who have asthma have worse health outcomes post-hospital discharge, which appear to be due in part to less continuous and less intensive treatment.

The relation between health insurance coverage and clinical outcomes among women with breast cancer

BACKGROUND

Women without private health insurance are less likely than privately insured women to be screened for breast cancer, and their treatment may differ after cancer is diagnosed. In this study we addressed two related questions: Do uninsured patients and those covered by Medicaid have more advanced breast cancer than privately insured patients when the disease is initially diagnosed? And, for each stage of disease, do uninsured patients and patients covered by Medicaid die sooner after breast cancer is diagnosed than privately insured patients?

METHODS

We studied 4675 women, 35 to 64 years of age, in whom invasive breast cancer was diagnosed from 1985 through 1987, by linking New Jersey State Cancer Registry records to hospital-discharge data. We compared the stage of disease and stage-specific survival among women with private insurance, no insurance, and Medicaid coverage through June 1992. We also estimated the adjusted risk of death for these groups, using proportional-hazards regression analysis to control for age, race, marital status, household income, coexisting diagnoses, and disease stage.

RESULTS

Uninsured patients and those covered by Medicaid presented with more advanced disease than did privately insured patients (P < 0.001 and P = 0.01, respectively). Survival was worse for uninsured patients and those with Medicaid coverage than for privately insured patients with local disease (P < 0.001 for both comparisons) and regional disease (P < 0.001 for both comparisons), but not distant metastases. The adjusted risk of death was 49 percent higher (95 percent confidence interval, 20 to 84 percent) for uninsured patients and 40 percent higher (95 percent confidence interval, 4 to 89 percent) for Medicaid patients than for privately insured patients during the 54 to 89 months after diagnosis.

CONCLUSIONS

The more frequent adverse outcomes of breast cancer among women without private health insurance suggest that such women would benefit from improved access to screening and optimal therapy.

The effect of health coverage for uninsured pregnant women on maternal health and the use of cesarean section

OBJECTIVES

Although there has been substantial policy interest in interventions to improve the neonatal outcomes of disadvantaged women, little attention has been paid to the health status of pregnant women themselves. We therefore examined whether the provision of health coverage to uninsured low-income pregnant women affects maternal health status or the use of cesarean section.

DESIGN

Natural experiment in Massachusetts.

PATIENTS

All in-hospital, single-gestation births in 1984 (N = 57,257) and 1987 (N = 64,346).

INTERVENTION

Healthy Start is a statewide health coverage program for uninsured pregnant women. In 1985, it covered women with incomes below 185% of the federal poverty level.

MAIN OUTCOME MEASURES

Rates of adverse maternal outcome (severe pregnancy-related hypertension, placental abruption, and a length of stay at least 1 day longer than infants' stay) and cesarean section for uninsured women, and for two concurrent control groups, women with Medicaid and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. We then examined the change in these interpayer differences in rates between 1984 and 1987 to measure the effect of Healthy Start.

MAIN RESULTS

In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% vs 5.1%, respectively; interpayer difference, 0.4%) and received fewer cesarean sections (17.2% vs 23.0%; interpayer difference, -5.8%). Between 1984 and 1987 there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. However, the interpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% confidence interval [CI], +0.4% to +4.2%), although the uninsured continued to undergo fewer cesarean sections (22.4% vs 25.9%). Similar results were observed when the uninsured women were compared with women with Medicaid.

CONCLUSIONS

The provision of health insurance alone to low-income pregnant women may not be associated with an improvement in maternal health. Expanded coverage was associated, however, with an increase in the rate of cesarean section.

Physicians' liking for their patients: more evidence for the role of affect in medical care

Correlates of physicians' liking for their patients were examined among 17 internists at a health maintenance organization and 530 of their patients 70 years of age and older. Analyses were conducted for the entire sample as well as for individual physicians, whose results were combined by meta-analysis. Both kinds of analysis showed that patients were more liked when they were in better health (based on psychometric measures of social, emotional, functional, and overall self-rated health) and when they were more satisfied with their care. In addition, male patients were liked more than female patients, and physicians who were female and less experienced liked their patients more.

The effects of intravenous drug use and gender on the cost of hospitalization for patients with AIDS

At present limited data exist describing the hospital use patterns of intravenous drug users (IVDUs) and women with AIDS. Our objective was to determine if frequency of hospitalization, length of stay (LOS), and cost per hospitalization varied by risk status and gender, controlling for a variety of confounders, including severity of illness as measured by the Turner-Kelly-Ball and Justice AIDS severity of illness systems. We performed a population-based cohort study that compared all women (n = 69) and male IVDUs (n = 74) with AIDS diagnosed in Massachusetts in 1987 with a random sample of all male, nonintravenous drug-using patients diagnosed in that year (n = 148). Frequency of hospitalization, LOS, and cost of hospital care were obtained from hospital billing records for 1987 and 1988. Regression analysis showed 42% longer lengths of stay (p < or = 0.001) and 38% higher cost (p < or = 0.001) per hospitalization for IVDUs with AIDS compared with non-IVDU homosexual AIDS patients. No statistically significant differences by gender were observed. Our results suggest that hospital care for IVDUs is likely to be more expensive. Policymakers should incorporate these data when planning for AIDS care. In addition, instruments to assess severity of illness should incorporate information on intravenous drug use.

Racial differences in the use of revascularization procedures after coronary angiography

OBJECTIVE

To assess whether rates of coronary revascularization procedures differ between blacks and whites after coronary angiography is performed and to assess the relationship of these rates to hospital characteristics.

DESIGN

A retrospective cohort study using 1987 and 1988 data on hospital claims and characteristics from the Health Care Financing Administration.

SETTING

One thousand four hundred twenty-nine acute care hospitals that provide coronary angiography in the United States.

PATIENTS

A national sample of 27,485 Medicare Part A enrollees, aged 65 to 74 years, who underwent inpatient angiography for coronary heart disease in 1987.

MAIN OUTCOME MEASURE

The adjusted odds of revascularization with either coronary angioplasty or bypass graft surgery within 90 days of angiography for whites relative to blacks, controlling for age, sex, region, Medicaid eligibility, principal diagnosis, comorbid diagnoses, and hospital characteristics of ownership, teaching status, urban/suburban or rural location, and availability of revascularization procedures.

RESULTS

White men and women were significantly more likely than black men and women, respectively, to receive a revascularization procedure after coronary angiography (57% and 50% vs 40% and 34%, both P < .001). The adjusted odds of receiving a revascularization procedure after coronary angiography were 78% higher for whites than blacks (95% confidence interval for odds ratio, 1.56 to 2.03). Statistically significant racial differences in the adjusted odds of receiving a revascularization procedure were present in all types of hospitals except rural hospitals, and these differences did not vary significantly by any of the four hospital characteristics (all P > .20 for interaction terms).

CONCLUSIONS

Among Medicare enrollees, whites are more likely than blacks to receive revascularization procedures after coronary angiography. Racial differences of similar magnitude occur in all types of hospitals. These differences may reflect overuse in whites or underuse in blacks, but they are unlikely to reflect access to cardiologists or hospitals that perform revascularization procedures. Potential explanations include unmeasured clinical or socioeconomic factors, differing patient preferences, and racial bias at the hospitals performing angiography.

Discussion of preferences for life-sustaining care by persons with AIDS. Predictors of failure in patient-physician communication

OBJECTIVES

To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician.

DESIGN AND SETTING

Structured patient interview at a staff-model health maintenance organization (HMO), an internal medicine group practice at a private teaching hospital, and an AIDS clinic at a public hospital.

PATIENTS

289 persons with AIDS.

MAIN RESULTS

Only 38% of patients had discussed their preferences for resuscitation with their physician. Using logistic regression, we found that patients were less likely to have discussed resuscitation with their physician if they were nonwhite (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24 to 0.99), had never been hospitalized (OR, 0.52; 95% CI, 0.27 to 0.99), or were cared for in the HMO (OR, 0.44 relative to the private teaching hospital; 95% CI, 0.23 to 0.82). Patients were more likely to have discussed their preferences if they were not currently taking zidovudine (OR, 1.76; 95% CI, 1.02 to 3.03) and if they had decided to defer life-sustaining therapy (OR, 2.30; 95% CI, 1.35 to 3.91). Among nonwhites, those with a nonwhite physician were more likely to have discussed resuscitation (OR, 4.38; 95% CI, 1.13 to 16.93). Of patients who had not discussed their preferences for life-sustaining care, 72% wanted to do so. Patient desire for discussion of this issue did not vary by race, severity of illness, hospitalization status, use of zidovudine, or site of care.

CONCLUSIONS

A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.

Physicians' liking for their patients: more evidence for the role of affect in medical care

Correlates of physicians' liking for their patients were examined among 17 internists at a health maintenance organization and 530 of their patients 70 years of age and older. Analyses were conducted for the entire sample as well as for individual physicians, whose results were combined by meta-analysis. Both kinds of analysis showed that patients were more liked when they were in better health (based on psychometric measures of social, emotional, functional, and overall self-rated health) and when they were more satisfied with their care. In addition, male patients were liked more than female patients, and physicians who were female and less experienced liked their patients more.

The effect of providing health coverage to poor uninsured pregnant women in Massachusetts

OBJECTIVES

There has been substantial policy interest in whether the provision of health coverage to poor uninsured pregnant women affects access to prenatal care and birth outcomes. We therefore examined whether the statewide provision of health coverage to uninsured low-income pregnant women affects access to prenatal care and infant birth outcomes.

DESIGN

Natural experiment.

PATIENTS

All in-hospital, single-gestation live births in 1984 (N = 57,257) and 1987 (N = 64,346).

INTERVENTION

In 1985, Massachusetts instituted Healthy Start, a program providing health coverage to uninsured pregnant women with incomes below 185% of the federal poverty level.

MAIN OUTCOME MEASURES

Rates of satisfactory prenatal care, care initiated before the third trimester, and adverse infant outcome for uninsured women and for two concurrent control groups, women with Medicaid, and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. To assess the effect of the program, we examined the change in these interpayer differences in rates between 1984 and 1987.

MAIN RESULTS

Between 1984 and 1987, the rate of satisfactory prenatal care declined from 96.4% to 93.8% for all women in Massachusetts (P < .001). There was no statewide change in the overall incidence of adverse birth outcome (6.6% in both years). In 1984, uninsured women were less likely than privately insured women to receive satisfactory prenatal care (90.5% and 98.1%, respectively; interpayer difference, -7.6%) and to initiate care before the third trimester (94.2% and 99.1%; interpayer difference, -4.9%), and were more likely to suffer an adverse birth outcome (7.1% and 5.8%; interpayer difference, 1.3%). Between 1984 and 1987, there were no statistically significant changes in the interpayer differences in rates for any of the outcome measures relative to either control group.

CONCLUSIONS

Our findings suggest that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987. In the setting of this statewide decline in access, the expansion of health coverage to uninsured low-income pregnant women was not associated with an improvement in access to prenatal care or birth outcomes.